What are the guidelines for pleural lavage in loculated empyema management?

Pleural Lavage Guidelines for Loculated Empyema

Primary Management Strategy

When a chest tube becomes blocked or drainage ceases in loculated empyema, flush the tube with 20-50 ml normal saline to restore patency, and if poor drainage persists despite flushing, obtain imaging (ultrasound or CT) to assess tube position and identify undrained locules. 1

Algorithmic Approach to Drain Management

Initial Response to Cessation of Drainage

• Check for mechanical obstruction first: Inspect for kinking at the skin level, particularly with smaller drains, which can be repositioned and redressed 1
• Flush with saline: Use 20-50 ml normal saline to ensure patency when blockage is suspected 1
• In pediatric patients: When sudden cessation occurs, immediately check for obstruction by flushing 1

Imaging After Failed Flushing

• Obtain contrast-enhanced CT scanning: This is the most useful imaging modality to provide anatomical detail of locules and ensure accurate chest tube placement 1
• Ultrasound is highly sensitive: For identifying septations (sensitivity 81-88%, specificity 83-96%) and should guide interventions in loculated collections 1
• CT limitations: Cannot accurately differentiate early versus late fibrinopurulent stage disease, and pleural thickness does not predict drainage outcome 1

Intrapleural Fibrinolytic Therapy (Not Simple Lavage)

Adult Dosing

• Streptokinase: 250,000 IU twice daily for 3 days 1
• Urokinase: 100,000 IU once daily for 3 days 1
• These agents improve radiological outcome and current best evidence recommends their use, though it remains unknown if they reduce mortality or need for surgery 1

Pediatric Dosing

• Urokinase is the recommended agent (only fibrinolytic studied in randomized controlled trials in children) 1, 2
• For children ≥10 kg: 40,000 units in 40 ml 0.9% saline twice daily for 3 days (6 doses total) 1, 2
• For children <10 kg: 10,000 units in 10 ml 0.9% saline twice daily for 3 days 1, 2
• Fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion with loculations or empyema 1, 2

When to Replace or Reposition Drains

• If permanently blocked: Remove the tube and insert a new chest tube if significant pleural fluid remains 1
• In children: A drain that cannot be unblocked should be removed and replaced if significant pleural fluid persists 1
• Use ultrasound guidance: To determine optimal site for any new drain insertion 1

Surgical Escalation Criteria

• Early surgical consultation when chest tube drainage, antibiotics, and fibrinolytics fail 1, 2, 3
• Specific indications for surgery: Persisting sepsis with persistent pleural collection despite drainage and antibiotics 1, 2, 3
• Organized empyema: Symptomatic patients with thick pleural peel require formal thoracotomy and decortication 1, 2, 3
• Video-assisted thoracoscopic surgery (VATS): Can be effective for early intervention and breaking up septations under direct vision 1, 3

Critical Safety Considerations

• Never clamp a bubbling chest drain 1
• If clamped drain causes symptoms: Immediately unclamp if patient complains of breathlessness or chest pain 1
• Streptokinase exposure: Patients receiving intrapleural streptokinase should receive a streptokinase exposure card and use urokinase or tissue plasminogen activator for subsequent indications (e.g., MI, PE) 1
• Bleeding risk: Isolated reports exist of local pleural hemorrhage and systemic bleeding with intrapleural fibrinolytics, though two studies suggest no systemic fibrinolysis up to 1.5 million IU cumulative dose 1

Important Distinction

The term "pleural lavage" typically refers to simple saline flushing for mechanical patency (20-50 ml), not therapeutic irrigation. For loculated empyema requiring more than mechanical flushing, the evidence-based approach is intrapleural fibrinolytic therapy with specific dosing protocols, not continuous or large-volume lavage 1, 2, 3.