From the Research
Blood in the pleural space may resolve on its own without intervention in small amounts, but larger collections typically require drainage to prevent complications and improve patient outcomes in terms of morbidity, mortality, and quality of life. The management of hemothorax depends on the volume of blood, the patient's symptoms, oxygen requirements, and whether the bleeding has stopped 1. Small hemothoraces of less than 300-400 mL that are stable and not causing significant symptoms can be managed conservatively with close monitoring, including serial imaging with chest X-rays or ultrasound to assess the resolution of the hemothorax and the patient's clinical status 2. However, moderate to large hemothoraces (>500 mL) generally require drainage via thoracentesis or chest tube placement to prevent complications such as respiratory compromise, infection (empyema), or fibrothorax (permanent scarring and lung restriction) 3, 1.
The decision to intervene should be based on the patient's individual clinical presentation and the potential risks and benefits of drainage versus conservative management. In patients with retained hemothorax, thoracoscopic assisted drainage (VATS) is conditionally recommended over thrombolytic therapy, and early VATS (≤4 days) is recommended over late VATS (>4 days) 1. The use of intrapleural fibrinolytic therapy, such as alteplase, has also been shown to be effective in resolving retained hemothorax in some cases, with minimal risk of bleeding complications 4.
Key considerations in the management of hemothorax include:
- The volume of blood in the pleural space and the patient's symptoms
- The patient's oxygen requirements and whether the bleeding has stopped
- The potential risks and benefits of drainage versus conservative management
- The use of serial imaging to monitor the resolution of the hemothorax and the patient's clinical status
- The consideration of thoracoscopic assisted drainage (VATS) or intrapleural fibrinolytic therapy in patients with retained hemothorax.