How to prevent empyema in a patient with residual haemothorax and a chest tube in place?

Prevention of Empyema in Patients with Residual Hemothorax and Chest Tube

Placement of a second chest tube is the most effective intervention to prevent empyema in patients with residual hemothorax despite an existing chest tube. 1, 2

Understanding the Risk

Residual hemothorax after initial chest tube placement significantly increases the risk of empyema:

• Patients with residual hemothorax have a 33% risk of developing empyema compared to only 2% in those without residual collections 1
• Retained hemothorax is a well-established risk factor for developing both pneumonia and empyema 2
• Post-traumatic empyema rates vary from 2-25%, with Staphylococcus aureus responsible for 35-75% of these infections 2

Management Algorithm for Residual Hemothorax

Step 1: Evaluate the Existing Chest Tube

• Check for tube patency - if the tube is blocked or drainage has ceased:
  • Flush with 20-50ml normal saline to ensure patency 2
  • Perform imaging (chest X-ray or CT scan) to check tube position and identify undrained locules 2

Step 2: Address Inadequate Drainage

• If poor drainage persists despite a patent tube, imaging should be performed to:
  • Check tube position and distortion
  • Identify undrained locules that may require additional drainage 2
  • Contrast-enhanced CT is the most useful imaging modality for patients failing chest tube drainage 2

Step 3: Definitive Management

• Place a second chest tube for residual collections 1, 3

  • This is the most effective intervention to prevent progression to empyema
  • Tube thoracostomy effectively evacuates the content of the thoracic cavity, reducing the incidence of subsequent empyema 2

• Consider additional interventions if second tube fails:

  • Intrapleural fibrinolytic therapy (streptokinase 250,000 IU twice daily for 3 days or urokinase 100,000 IU once daily for 3 days) 2
  • Early surgical consultation for video-assisted thoracoscopic surgery (VATS) if medical management fails 3, 4

Role of Antibiotics

While antibiotics have a role in certain situations, they are not the primary intervention for preventing empyema in residual hemothorax:

• Antibiotic prophylaxis has shown benefit primarily in penetrating thoracic injuries, not in blunt trauma 2
• In isolated chest trauma, antibiotics (particularly first-generation cephalosporins) may reduce empyema incidence as an adjunctive measure, not as primary management 5
• The British Thoracic Society guidelines do not recommend routine antibiotic prophylaxis as the primary intervention for residual hemothorax 2

Importance of Complete Drainage

• Incomplete drainage of the pleural cavity leads to empyema development with long-term morbidity 6
• Early identification of patients needing additional intervention minimizes hospital stay and complications associated with residual blood in the pleural cavity 6
• Protocols focusing on complete evacuation of hemothorax show very acceptable results in preventing empyema 6

Common Pitfalls to Avoid

• Delaying additional drainage when the initial chest tube is inadequate 1
• Relying solely on antibiotics without addressing the mechanical problem of residual fluid 2
• Using needle thoracentesis, which is inadequate for complete evacuation of viscous blood collections 3
• Clamping a bubbling chest tube, which should never be done as it may lead to tension pneumothorax 2

In conclusion, while antibiotic therapy has a role in certain situations, placement of a second chest tube is the most effective intervention to prevent empyema in patients with residual hemothorax despite an existing chest tube.