Preface

Pleural pathology covers a wide range of benign and malignant thoracic diseases that may require invasive approaches for their diagnosis and treatment.

Advances made in the field of thoracic surgery go hand in hand with inexorable technological achievements, which have greatly improved the standards of diagnosis and treatment in patients undergoing thoracic surgery for benign and malignant diseases by increasing procedural safety, improving prognosis, and reducing potential peri-and postoperative complications.

This book examines pleural pathology from a surgical point of view, starting from the historical aspects, which are a reminder of where we were and where we presently stand in the management of pleural disease. It discusses in detail, and according to the most recent guidelines, the surgical aspects and management of pleural infection (empyema) and complications that may arise following lung surgery for cancer (i.e., bronchopleural fistula). One section covers all the aspects related to pneumothorax, with a special focus on secondary pneumothorax and pneumothoraces in children. Chapters deal with the indications, positioning techniques, and management of chest drains and indwelling catheters, which are commonly utilized in daily clinical practice for the management of pleural disease (pleural effusion, pneumothorax).

I am deeply grateful to the chapter authors for their contributions to this project, which I am sure will be much appreciated by the thoracic community worldwide.

> **Alberto Sandri** Thoracic Surgery Division, San Luigi Hospital, University of Torino, Orbassano (TO), Italy

Section 1 Introduction

#### **Chapter 1**

## Introductory Chapter: Pleura, A Surgical Perspective

*Alberto Sandri and Francesco Leo*

#### **1. Introduction: a surgical perspective through the centuries**

Pleural pathology covers a vast chapter of benign and malignant thoracic diseases which may require invasive approaches for their diagnosis and treatment.

However, the present role of the thoracic surgeon in the management of pleural/ thoracic disease is the tip of the iceberg of a very long journey which dates back thousands of years. It is a journey that starts with no knowledge of the human anatomy, physiology and basic medical sciences and where mistakes, attempts, improvements and eventually successes were the fundamentals of the present medicine and surgery.

The very first pathologies related to the chest and pleura reported in history relate majorly to thoracic traumas and thoracic wounds (e.g., penetrating injuries), caused accidentally or during fights/wars, and infections (e.g., empyema). Their treatment was the cornerstone for the present modern thoracic surgery.

#### **2. Early reports of thoracic wounds and infections**

The first historical reports of chest wounds and infections treated by doctors are described in the Edwin Smith papyrus, during the Ancient Egyptian Era.

Other reports of chest injuries and attempts at their treatment have been reported and described in several historical books, in which it is clear how the limited knowledge of the human anatomy and physiology and the total absence of basic infection management because of the then ignored micro-bacterial world were causes of almost certain death.

The "*Iliad*" by Homer, copiously report wounds and infections during the Trojan War [1, 2], as well as the French knight saga *Chanson de Roland* (Song of Roland), provides a long list of usually deathly chest wounds, in which the clear description proves that contemporary witnesses, including barber-surgeons, were already aware of this kind of injuries and their poor prognosis despite the treatments available in those times.

#### **3. Empyema and surgery**

Thoracic empyema is defined as the collection of pus in the pleural cavity and it is one of the very first pathologies on the scene of history of surgically treated chest diseases [3, 4]. The first recorded descriptions of invasive approaches to the chest cavity are found in the medical texts of ancient Greece in regards to the treatment of empyema as suggested by Hippocrates of Kos, whose teaching *ubi pus (ivi) evacua* has remained relevant throughout the ages. Hippocrates' first treatment attempt

#### was a conservative one, based upon herbal medications and physiotherapy. If the patient did not improve, open evacuation of the empyema was then undertaken [5].

*'First, cut the skin between the ribs with a bellied scalpel; then wrap a lancet with a piece of cloth, leaving the point of the blade exposed a length equal to the nail of your thumb, and insert it. When you have removed as much pus as you think appropriate, plug the wound with a tent of raw linen, and tie it with a cord; draw off pus once a day; on the tenth day, draw all of the pus, and plug the wound with linen. Then make an infusion of warm wine and oil with a tube, in order that the lung, accustomed to being soaked in pus, will not be suddenly dried out. When the pus is thin like water, sticky when touched with a finger, and small in amount, insert a hollow tin drainage tube. When the cavity is completely dried out, cut off the tube little by little, and let the ulcer unite before you remove the tube [6]'.*

Sequelae of chest injuries and post-pneumonic empyemas (unidentified until percussion and auscultations were introduced in the mid-nineteenth century) are reported in ancient medical sources. The great Roman doctor Galen of Pergamon (*Aelius Galenus* or *Claudius Galenus*) advised the usage of metallic tubes in order to drain an empyema cavity [7], a teaching that did not change significantly through the Christian and Muslim medical practices of the Middle Ages [8]. Barber surgeons like *Pietro d'Argellata* refined and improved the chest drain insertion and thoracic irrigation to wash out the purulent fluids from the chest cavity. In this context, further improvements were adopted in time, such as a thoracentesis syringe and cannula for the irrigation of empyema [9, 10]. Permanent windows of the chest wall was a competing way of treating empyemas, with modern surgeons such as Joseph Lister and Charles M.E. Chassaignc who refined the technique. Excision of a segment of the rib was endeavoured by German, French and English surgeons, such as Paget in his book Surgery of the Chest [11]. The challenge of empyema, usually tuberculous in origin, led to the emergence of chest surgery in the late decades of the nineteenth century. Basic treatment for empyema consisted of rib resection and loose tamponade of the chest cavity with a gauze soaked in antiseptic (mercury/iodine). Between 15 and 20% of post-traumatic patients need surgery (rib resection and debridement), with a mortality comprised between 20 and 50%, likely related to streptococcal superinfections [12]. As depicted later in this chapter, the belief of a transcostal approach (chest tube) for the treatment of empyema lasted until long after the first World War.

As a matter of fact, thoracostomy, i.e., the externalisation of the empyema cavity by unroofing, was another option that went through several modifications in the years, starting from the Eloesser flap introduced in 1935 [13] to the Clagett procedure which required daily packings [14, 15]. George R. Fowler and Edmond Delorme pioneered the exeresis of the thick visceral pleura (decortication) in 1894–95 [16]. It was Lilienthal who reintroduced lung decortication for early-stage empyema on the basis of his experiences in the American Expeditionary Force in Europe [17]. Debridement and decortication became an option as soon as general anaesthesia and intubation were established during and after the Second World War. Such surgical improvements along with the introduction in the 1930s of Sulphonamides and later on, in 1943, of Penicillin, drastically revolutionised the treatment of thoracic empyema and their outcomes [18].

#### **4. Tuberculosis, artificial pneumothorax and surgery**

Tuberculosis has been known since the Old Testament [19], properly defined clinical and pathologic features depicted in detail in the mid-nineteenth century [20]. In 1882, Robert Koch identified the organism responsible for tuberculosis, proving the *sine qua non* cause of the disease. Remedies for phthisis comprised supportive care provided mostly by sanatoriums and Carlo Fontanini's artificial pneumothorax.

#### **4.1 Carlo Fontanini's artificial pneumothorax**

During his entire professional career, Carlo Fontanini from Pavia, Italy, devoted a great deal of time and effort to the study of tuberculosis contributing extensively to the medical literature on this subject. Forlanini's epoch-making treatise on the rationale of artificial pneumothorax was printed in the *Gazzetta degli Ospedali & delle Cliniche di Milano, Volume 3, No. 68, Page 537, August 23*. His reasoning was based on the observations of other clinicians as well as of his own, noticing that spontaneous pneumothorax, with or without pleural effusion, had a favourable effect on the course of pulmonary tuberculosis [21]. His apparatus introduced nitrogen into the pleural cavity through a large hypodermic needle, and in doing so, produced a pneumothorax. However, an artificial pneumothorax was frequently unsuccessful as a therapy for tuberculosis because of the presence of pleuropulmonary adhesions. This complication was accounted for with the use of the thoracoscope, firstly utilised by HANS Christian Jacobaeus from Stockholm in 1910, who is considered the father of the thoracoscope. The thoracoscope favoured the identification and clearance of adhesions through their digital manipulation setting the basis, in due time, for minimally invasive thoracic surgery [22, 23].

However, Forlanini's artificial pneumothorax was challenged by another attempt of treating tuberculosis; in fact, in 1937, at the Brompton Hospital in London, James E.H. Roberts reported 33 operations of extrapleural pneumothorax, which is the collection of air in the space between parietal pleura and endothoracic fascia.

#### **4.2 Thoracoplasties as a surgical treatment for tuberculosis**

Extrapleural thoracoplasties, in those times, was preferred because of the lack of safe anaesthesia; this surgical procedure aims at definitely resecting the pleural space with ribs and periosteum, intercostal neurovascular bundles and intercostal muscles.

Several surgeons in the years modified the technique, even by performing them in several stages. In fact, by the 1920s, staged operations became favoured as a result of the publication of Ernst F. Sauerbruch, André Maurer (Paris) and Walther Graf (Dresden) [24]. Those procedures were performed either under local anaesthesia or ether/chloroform masks narcosis, in spontaneous breathing.

Sauerbruch added drainage to the cavity and performed it in two-three stages to avoid mediastinal shift.

Remodelling the chest wall following thoracoplasty was achieved by means of omentum or muscle apposition in the years to come. By the early 1950s, thoracoplasty plombage with or without pneumoperitoneum had replaced artificial pneumothorax as the primary procedure.

Caverna treatment was another pressing problem due to deadly haemoptysis. It was Vincenzo Monaldi who refined staged transmural drainage as a very safe procedure (1939). Following a partial rib resection as a first step, he obtained a debridement of parietal-visceral adhesions through the instillation of irritative agents and, after 7–10 days, he inserted a tube through the area of the adhesions into the cavity, creating a real cavernostomy [25, 26].

It was only in 1936 that the first successful pulmonary lobectomy and pneumonectomy for tuberculosis were performed. In those days, post-lobectomy and post-pneumonectomy mortality for the treatment of tuberculosis was 20–25% for the former and up to 40–50% for the latter [24].

#### **5. Chest wounds, penetrating chest injuries, gunshot wounds**

In 1395, *Guy de Chauliac*, a leading physician-surgeon of the French medieval times, completed the most important surgical book of that time, *Chirurgia Magna*. In the second Doctrine of *Chirurgia Magna,* there are several comments regarding the lack of ancient writings on thoracic wounds and their treatment, acknowledging then non-linear treatment strategies between his contemporaries.

Basically, there were two schools of thought regarding the treatment of chest wounds, one advocated the open treatment of penetrating thoracic wounds using tents and drains to allow food and pus to escape the pleural cavity, the other, instead, advocated the immediate closure of the wound to prevent the entry of cold air and loss of heat [27]. This debate persisted for centuries.

Chest injuries developed a decisively worse prognosis as the more fatal gunshot wounds dominated from the sixteenth century onwards [28]. Giovanni da Vigo, an Italian surgeon and physician of Pope Julius II, was one of the first surgeons to explore firearm wounds, including those to the chest, in Practica Copiosa of 1514 [27].

In accordance with Guy de Chauliac, Vigo too points out the dilemma of the "open" vs. "closed" treatment of penetrating thoracic injuries, among which he was more inclined to the latter. Vigos's work was accredited by a French military surgeon, Ambroise Paré, in the attempt of establishing guidelines to determine whether to choose an open or a closed treatment for penetrating thoracic wounds [29].

#### **5.1 The introduction of aspiration to a chest drain**

In 1707, Dominique Anel described a method for sucking wounds with a silver tube attached to a piston syringe which replaced a human mouth, a practice which was very common in those days, to such an extent that nobles and upper-class men would bring wound suckers with them when they had to fight duels [29, 30]. Following such invention, the surgical procedure now consisted of a cannula which allowed a catheter to be introduced into the pleural space, not only to the margins of the wound, and by applying an aspiration to it. In 1771, Adamus Birkholz added a reservoir container into Anel's suction line, creating an early Potain aspiration [29]. In the following years, despite the advances made, there was still a lack of consensus on the optimal treatment management of chest wounds, comprising different techniques, ranging from the hypothetical necessity of closing at first the wound to avoid blood loss from the lung but making a counter opening which would evacuate the retained blood, as Valentine did in 1772, to Gurthrie's method (early 1800s), which encompassed closing the wounds of the chest and watching for an increase in serous effusion for few days after the injury, indicating that the bleeding had likely stopped for, then, evacuating the blood with a trocar and cannula through a new opening or by reopening the original wound [31].

Larrey, a surgeon who treated Napoleon, believed that there was a danger of renewed bleeding if attempts were made to evacuate effused blood less than nine days from the initial injury [29].

It is therefore clear that, to this point of history, the only commonly accepted step forward in the management of penetrating injuries to the chest and consequent chest infections was to drain them. Regarding the how, that was still a dilemma.

During the American Civil War war, surgeons started to insert trocars in the chest to drain fluid retained in the pleural space while, in the same period, the Union forces were experimenting the use of airtight seals to impede airflow in open chest wounds. It is on Playfair, in 1873, the attribution to applying a water-sealed

chest drainage system for the first time, as a successful treatment of a child with thoracic empyema [32]. Until that time, scarce information was known in regards of the intrapleural negative pressure, the reason why the management of chest traumas was only just successful until then.

#### **5.2 The first closed water-seal chest drain**

In 1875, Gotthard Bülau applied a closed water-seal chest drainage to treat an empyema, as an alternative to the standard rib resection and open tube drainage in the acute phase or rib excision in the chronic phase [33]. In contrast to the popular opinion of the surgeons of that time, Bülau was the first to understand the importance of negative intrapleural pressure to obtain the re-expansion of a collapsed lung subsequent to thoracic empyema.

His method consisted in puncturing the pleural space and introducing a rubber catheter with a clamp inside the chest. The part of the drain outside the chest was then immersed in a bottle filled for one third with an antiseptic solution and unclamped, creating a siphon drainage which allowed pus to flow out from the chest [33–35]. The nineteenth century marked the advent of rubber tubes and the invention of standardised syringes and needles changed and improved the practice of chest tube thoracostomy.

During World War I, despite the above-mentioned improvements and treatment options (needle drainage of hemothorax, wound exploration and debridement, wound exploration for foreign body removal and closure of open pneumothorax with sutures), mortality was still high, estimated to be around 55% [36]. Furthermore, during World War I, recently invented tampons and Morelli's occlusive rubber cuffs, which allowed for closure and simultaneous suction drainage, were in use in the control of airflow in open chest wounds [29]. Also, by that time, post-thoracotomy evacuation of fluid in the pleural cavity was recognised as an important way to avoid infection, and the concept of a flutter valve for uni-directional air movement within a drainage tube was spreading, but tube thoracostomy was not widely used yet for treating hemothoraces or pneumothoraces [31].

During World War II, it was clear to the surgeons that lung function restoration was the primary goal of treatment, with emphasis on wound debridement and pleural cavity drainage [37]. The modern three-chamber thoracic drainage system was first described by Howe in 1952 and in the Korean War (1950–1953), mortality decreased to 0.6–1.9% of major thoracic trauma patients who survived to be evacuated and treated. Also, the frequency of empyema due to penetrating chest wounds was reported to be 25–30%, decreased to 9% as hemothorax was approached with a more aggressive attitude [38–41].

During the years, tube thoracostomy was finally accepted as the standard of care at the time of the Vietnam War. A significant improvement was developed by Heimlich in 1968, who designed a flutter valve to attach to catheters and replace the underwater drain bottles. Its advantages included sterility, disposability, simplicity, safety in the event of disconnection, and allowance for patient ambulation [42].

#### **6. Conclusions**

Thoracic surgery is a multi-fathered speciality, which gained recognition as a distinct surgical entity only in the 1950s. The development of such a specialistic surgery was possible because of the knowledge gained through, attempts, mistakes, improvements and eventually successes over hundreds of years. The post-war effect on the development of thoracic surgery was enormous. In the first decade after the

war, thoracoplasties and empyema treatments for tuberculosis dominated thoracic surgery, but it was in the 1930s that small but decisive steps were taken in the direction of lung parenchymal resection. It was right in those days that oncological cases became a priority over the tubercular ones because of the introduction of new medical treatments available, (i.e., streptomycin, 4-aminosalicylic acid, isoniazid, pyrazinamide, cycloserine, ethambutol and rifampicin 1963).

The contribution to the development of a dedicated thoracic anaesthesia was a cornerstone in consolidating the results of thoracic surgery, especially with the achievement and standardisation of the single lung ventilation through a doublelumen endotracheal tube.

Another crucial step was the establishment of thoracic societies in the world by the earliest pioneers in thoracic surgery, such as the American Association of Thoracic Surgeons (AATS) in 1917 and the Society of Cardiothoracic Surgeons of Great Britain and Ireland (SCTS) in 1934. The role of the Societies helped, in the beginning, through sharing surgical experiences and results to, then, cooperating in improving and standardising operating techniques, indications and treatments through an evidence-based methodology and teaching.

Such advances go hand in hand with the inexorable technological achievements in the thoracic surgery field, which greatly improved the standards of diagnosis and treatment in patients undergoing thoracic surgery for benign and malignant diseases, by increasing procedural safety, improving prognosis and reducing potential peri and post-operative complications.

#### **Author details**

Alberto Sandri\* and Francesco Leo Thoracic Surgery Division, San Luigi Hospital, University of Torino, Orbassano (To), Italy

\*Address all correspondence to: alberto.sandri@icloud.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Introductory Chapter: Pleura, A Surgical Perspective DOI: http://dx.doi.org/10.5772/intechopen.102049*

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### Section 2

## Surgical Management of Pleural Infection

#### **Chapter 2**

## Surgical Management of Pleural Space Infection

*Alessandro Maraschi and Andrea Billè*

#### **Abstract**

Pleural space infections are a common clinical entity affecting a large number of patients. These are associated with considerable morbidity and mortality rate and they require significant healthcare resources. In this chapter, we discuss the disease characteristics with regards to the etiology (primary and secondary), clinical presentation, radiological findings, different stages of the condition and treatment options according to stage at presentation. Conservative management (medical treatment, pleural drainage, with or without intrapleural fibrinolytic) may be effective in management of simple pleural space infections, but surgical management may be required in loculated complex empyema to prevent acute sepsis, deterioration and trapped lung. Surgical treatment of complicated pleural infections either by VATS or thoracotomy will be discussed in order to understand when to perform debridement/decortication of the pleural cavity or less frequently a thoracostomy.

**Keywords:** Pleura, Empyema thoracic, Pneumoniae, Thoracoscopic debridement, Decortication

#### **1. Introduction**

Pleural infections are a frequent clinical entity which affect a large number of patients. The annual incidence in the UK and USA combined is up to 80,000 cases. The overall incidence worldwide is increasing both in the adult and pediatric population [1].

Infection of the pleural space remains a serious condition which continues to be associated with high morbidity and mortality rate. The outcome is poor and it is reported to have one-year mortality of 20%, which rises up to 30% in the elderly population. Approximately 20% of patients with pleural space infection will require surgical treatment due to a failure in the conservative management [2, 3].

Pleural infections consist in a continuum spectrum of evolving disease through 3 different stages, starting from an uncomplicated pleural effusion to a complicated effusion and eventually established empyema.

The diagnosis can be obtained with a detailed anamnesis, biochemical analysis and radiological test, such as ultrasound or computed tomography.

The treatment choice is based on patient condition and disease stage at presentation. The treatment can be either conservative or surgical.

#### **2. Pleural space infection - etiopathogenesis**

Pneumoniae is an infectious process resulting from invasion and proliferation of microorganisms which elude the host defenses within the lung parenchyma and cause the production of intra-alveolar exudates. Pneumonia may cause the development of parapneumonic effusion followed by an empyema. A parapneumonic effusion occurs in 35–40% of hospitalized cases of pneumoniae, empyema only develops in 20% of these.

The pleural space infection and the subsequent empyema can be classified as primary or secondary:


Patients with risk factors have an increased risk of developing a pleural infection. The most common risk factors are:


Other risk factors for the development of lung infection and therefore, to the development of pleural infection, are: underlying lung disease (COPD, emphysema, interstitial lung disease, deficiency/aberrant alveolar surfactant), tracheal intubation and antibiotic treatment.

Pediatric and elderly population patients affected by chronic diseases are more susceptible to developing lung infection.

Smokers are also included in the high-risk category due to the impact of the smoke on the airway defense mechanism in clearing secretions (thick secretions and impaired ciliary motility) and increased susceptibility.

Patients in the community and patients hospitalized present different risk factors. Impaired conscious levels and higher risk of aspiration is far more common in hospitalized patients, which explains the higher rate of gram-negative gut bacteria.

These present relatively later in the infection with pneumonitis involving the superior segment of a lower lobe or posterior segment or an upper lobe.

The evolution from the simple pleural effusion to the complicated empyema usually occurs following three well defined stages.

1.**Exudative stage** (uncomplicated or simple parapneumonic effusion)

This first stage of the disease is characterized by a simple pleural effusion with clear, free-floating fluid and usually too small to be sampled within the pleural cavity. The fluid is exudative, therefore, following the Light's Criteria:


The fluid is a neutrophil-rich effusion and is the result of an increased pulmonary permeability in response to the inflammation associated with the infection.

The balance between production and reabsorption of the pleural fluid is impaired due to the inflammatory process, which causes increased vascular permeability and neutrophil chemotaxis.

The fluid is sterile and the glucose and pH level are maintained within the physiological range. No microorganisms are seen in Gram stain culture.

This stage occurs between 2 and 5 days from the onset of the pneumonia.

#### 2.**Fibrinopurulent stage** (complicated parapneumonic effusion)

This stage is characterized by the colonization of the microorganisms of the pleural fluid. The fibrin deposition causes loculation and pleural thickening, activation of the coagulation cascade and downregulation of fibrinolytic pathways. This process can create a uni-loculated or multi-loculated collection consistent in a separate pocket of infected viscous fluid within the pleural space. Bacterial invasion is often present, but Gram stain culture of the fluid may remain sterile due to the rapid bacterial clearance from the pleural space. The fluid is characterized by pH < 7.2, LDH > 1,000 U/L and a decreased glucose level (< 60 mg/dL). Bacterial infection increases the immune response, attracting more neutrophils which by killing the microorganisms increases the CO2 and lactate levels in the effusion, producing a self-maintaining process.

This stage occurs approximately 5–10 days after the pneumonia onset.

#### 3.**Organizing stage** (pleural empyema)

In the final stage the pleural fluid begins to organize. Thick and viscous pus created by fibroblast chemotaxis, accumulates within the pleural space and creates a thick fibrinous rind (fibrous peel) covering the lung surface encasing the organ and preventing the re-expansion (trapped lung). The trapped lung causes decreased ventilation leading to a perfusion-ventilation mismatch, which causes a restrictive syndrome. Microorganisms are normally present in the pus and the disease at this stage is non-reversible.

Findings in analysis of pleural fluid include a pH < 7.2, glucose <50 mg/dL, LDH > 1,000 IU/L.

Even after eradication of the infection a functional impairment will persist. This stage occurs after 2–3 weeks from the onset of the disease.

#### **3. Microbiology**

Numerous microorganisms may be involved in pleural space infections. The incidence of these pathogens varies widely according to several factors including the source of infection (haematogenous diffusion, following invasive procedure in the chest cavity, such as, thoracic surgery procedures), community or hospital acquired infections, geographic location and age group.

Parapneumonic pleural infections secondary to community acquired pneumonia (CAP) tend to be caused by the same organisms responsible for the pneumonia. CAP is defined as a low respiratory tract infection (LRTI) in a patient who has not been hospitalized in the previous 14 days from the diagnosis. This can be classified as typical and atypical.

Although a causative organism is not always isolated, the most common pathogens responsible for typical CAP, accounting for 85% of cases are:


Atypical CAP is most commonly caused by:


Hospital-acquired pneumoniae (HAP) is defined as a LRTI with the onset 48–72 hours after admission to hospital. In the context of hospital acquired infections (HAP) the most common species of bacteria isolated are:


Parapneumonic pleural infections that result from aspiration are often caused by several pathogens (polymicrobial) mainly including oral streptococci (S. anginosus, S. intermedius, S. constellatus) and anaerobes, which colonize the oropharynx.

Staphylococcus aureus methicillin-resistant is present in 25.8% of the CAP infections and 68.8% in HAP infections [4, 5].

The prevalence of the pathogens is also related to the selected patients. For instance, patients affected by diabetes mellitus have increased risk of empyema secondary to Klebsiella pneumoniae [6].

Mycobacterial infections are far less common than bacterial infections. Tuberculous pleural effusion must always be investigated in areas where tuberculosis is endemic and in patients who have risk factors for TB. Tuberculous pleural effusion is the second most common form of extrapulmonary tuberculosis (after lymphatic involvement). Tuberculous empyema needs to be differentiated from tuberculous pleurisy. In the former, the mycobacterium can be found by stain or culture in the effusion, while in the latter, a lymphocytic effusion is caused by the immunologic response to proteins released by the mycobacterium and TB organisms, which are scarce in the effusion.

This can occur as reactivation disease or primary tuberculosis whereas in children represents mostly a primary disease and in adults occur mainly due to a reactivation process [7, 8].

#### **4. Presentation**

As previously discussed most cases of parapneumonic effusion and empyema follow a previous case of pneumonia, with typical symptoms including productive cough, pleuritic chest pain, dyspnoea and fever.

The presentation may be insidious, with non-specific and delayed symptoms, especially when related to anaerobic infections. Some patients can present with loss of appetite and weight loss over a period of a few weeks to several months. Aerobic infections usually present with more acute onset.

The persistence of fever for more than 3 days following the initiation of adequate antibiotic treatment may indicate progression to pleural involvement and a necessity of more aggressive management.

Patients with empyema present with persistent fever and malaise for several days compared with those with pneumoniae alone or pneumoniae with simple parapneumonic effusion.

On physical examination decreased fremitus, dullness on percussion and decreased breath sounds related to the presence of pleural effusion are representative signs of pleural effusion. In case of overt empyema patients present with fever, tachypnoea and tachycardia, in combination with the above described findings of a pleural effusion.

Laboratory blood tests are nonspecific for parapneumonic pleural effusion and these usually are the common findings in an infection, such as, leukocytosis and elevated C-reactive protein.

The main markers for the diagnosis are pH, LDH and glucose in the pleural effusion, along with the symptoms and clinical presentation. The normal pleural fluid is clear with pH ranges between 7.60 and 7.64. It contains a similar amount of glucose to that of plasma, LDH < 50% of plasmatic concentration, white blood cells <1,000/ mm3 and scarce amount of protein (less than 2%, 1–2 g/dL).

However, since these are non-specific and require invasive test to be analyzed, numerous studies have investigated different biomarkers, inflammatory cytokines and enzymes to enhance and expedite the diagnostic process of empyema. These have not proven any diagnostic advancement compared to the traditional analysis [9–13].

A recent study by Wu et al. assesses the performance of four proteins (BPI, NGAL, AZU1 and calprotectin) in the diagnosis of complicated parapneumonic effusions. This study highlighted the superiority of BPI (bactericidal permeabilityincreasing protein) compared to LDH, glucose and pH in the diagnosis of complicated parapneumonic effusion [14].

#### **5. Radiological findings of parapneumonic effusion and empyema**

Chest radiography, ultrasonography (US) and computed tomography are paramount in the diagnosis and management of parapneumonic effusion and empyema, as well as, in their post-treatment and post-operative monitoring.

All patients diagnosed with pneumoniae should undergo new imaging considering the chest radiography as the first step in the diagnosis process to show presence of pleural effusion.

CT is generally performed when loculations are demonstrated or suspected at the US and also, when a surgical procedure is planned.

Magnetic Resonance Imaging (MRI) and positron emission tomographic scanning are not useful and they do not usually have a role in the diagnostic and management process of pleural effusions.

Occasionally, if esophageal perforation or intra-abdominal processes, such as, liver abscesses are suspected, contrast imaging may be required. Specifically, to identify an esophageal perforation: fluoroscopy with a low-osmolar water-soluble agent like barium for esophageal perforation; CT scan with water-soluble oral contrast administered 20 minutes before scanning to demonstrate extraluminal contrast leak and intravenous contrast to delineate the esophageal wall.

#### **5.1 Chest radiography**

Uncomplicated parapneumonic effusions are characterized by:


Free-flowing fluid collects in the dependent areas of the chest cavity. To measure with good approximation the amount of fluid in the chest cavity with a radiography, the following details can be noted:


A pleural fluid depth ≥ 10 mm from the chest wall on the chest X-ray suggests sufficient fluid is present to perform diagnostic pleural aspiration. Complicated parapneumonic effusions (**Figures 1-3**) are characterized by:

	- Pleural opacity in a non-dependent area
	- Linear densities in the pleura
	- No changes or minor changes in the imaging comparing erect and decubitus radiographs

#### **Figure 1.**

*Chest radiograph of a patient with complicated parapneumonic effusion, demonstrated by restricted expansion of the underlying lung in the right hemithorax. Guy's and St. Thomas' Thoracic Surgery NHS Foundation Trust.*

#### **Figure 2.**

*Chest radiograph of a patient with empyema, demonstrated by lenticular opacity in the pleural cavity of the right hemithorax. Guy's and St. Thomas' Thoracic Surgery NHS Foundation Trust.*

#### **Figure 3.**

*Chest radiograph of a patient with empyema, demonstrated by lenticular opacity in the pleural cavity of the left hemithorax. Guy's and St. Thomas' Thoracic Surgery NHS Foundation Trust.*

Empyema is characterized by:


#### **5.2 Ultrasound scan features of a parapneumonic effusion and empyema**

US is reported to be superior to radiography and computed tomography to identify the presence of septations. It is also more sensitive than decubitus radiography in detection of the amount of fluid being capable of detecting a minimum of 5 ml of

#### *Surgical Management of Pleural Space Infection DOI: http://dx.doi.org/10.5772/intechopen.99879*

fluid. Sonography has been reported having a sensitivity of 93% and a specificity of 96% in the diagnosis of pleural effusion [15].

Moreover, the US is particularly useful in critically ill patients allowing supine examinations when the patient cannot be mobilized [16].

It is also valuable in confirming the presence and size of pleural effusion and allows to determine the precise location of the fluid for needle-guided aspiration and drainage.

Tu and colleagues demonstrated the utility of the portable sonography in Emergency Departments and Intensive Care Units in critically ill patients. This allowed, based on the ultrasound features of the effusion, to indicate whether or not thoracentesis was necessary or could safely be deferred [17].

Four different patterns of imaging can be described in sonography evaluation, accordingly to the stage disease: [18].


#### **5.3 Computed tomography features of a parapneumonic effusion and empyema**

Chest CT is considered the gold standard to assess a complex pleural effusion. It is better performed with medium contrast in order to better identify the pleural membranes. This is the most sensitive method for detecting a small amount of fluid (limit of resolution 2 ml).

Computed tomography allows:


Specific findings of an empyema include:


#### **Figure 4.**

*Lung window computed tomography representative of a loculated left empyema. Guy's and St. Thomas' Thoracic Surgery NHS Foundation Trust.*

#### **Figure 5.**

*Mediastinal window computed tomography representative of a loculated left empyema. Guy's and St. Thomas' Thoracic Surgery NHS Foundation Trust*

Although pleural thickening is found in both parapneumonic effusion and empyema, the pleural thickness is greater in purulent effusions, with the absence of pleural thickening suggesting an uncomplicated parapneumonic effusion (**Figures 4** and **5**).

#### **6. Principles of management for parapneumonic effusion/empyema**

Our Unit follows the guidelines of the British Thoracic Society, which are in accordance with the American College of Chest Physician guidelines.

The parapneumonic effusion and empyema are categorized according to radiological, biochemical and microbiological criteria. The staging of the disease based upon these criteria guides the management (**Figure 6**).

Patients can be divided in four categories which require different management: **Category 1**: includes uncomplicated parapneumonic effusion with minimal

free-flowing fluid (< 10 mm at the chest X-ray) and undetermined microbiology

#### **Figure 6.**

*Management of pleural infection in adults: British Thoracic Society pleural disease guidelines 2010, © British Thoracic Society, 2010.*

and biochemistry. Patients in this category can be treated with antibiotics only for the underlying pneumoniae.

**Category 2**: includes uncomplicated parapneumonic effusion with small to moderate free-flowing fluid (more than 10 mm of collection on the radiography). These patients have a negative culture and Gram stain. pH ≥ 7.2 and glucose ≥3.4 mmol/L.

Patients in this category are treated with antibiotics regimens as the previous category with an addition of a thoracocentesis (to determine the fluid quality) and a chest drain insertion if the effusion is large and the patient is symptomatic.

**Category 3**: includes complicated parapneumonic effusion with large or loculated collection and thickened parietal pleura. The cultures or Gram stains are positive. Acidotic effusion (pH < 7.2) and glucose level < 3.4 mmol/L.

These patients require, as the previous categories, antibiotic treatment, thoracocentesis followed by chest drain insertion in symptomatic cases.

In presence of a pH < 7.2 a chest drain insertion is mandatory.

Multi-loculated effusions may require multiple chest drains and/or intrapleural thrombolysis.

Early surgical intervention with video-assisted thoracoscopic surgery (VATS) is recommended for evacuation of pleural fluid, debridement with the disruption of the loculations and decortication in presence of an immature pleural cortex. Early surgical intervention can minimize the impact of the lung restriction in long term effects, allowing a better and faster resolution of the infection and can also reduce the mortality.

**Category 4**: presence of frank pus which determines empyema. Also, radiological evidence of empyema on the CT scan.

These patients require antibiotic treatment of the underlying pneumoniae, chest tube insertion followed by surgical washout, debridement and decortication aiming for the re-expansion of the underlying lung.

#### **7. Conservative management**

When the patient presents in stage I, in most cases, uncomplicated parapneumonic effusions resolve with appropriate antibiotic therapy and drainage is not generally necessary.

It is important to strictly monitor the clinical and radiological evolution to decide if the patient does not respond to conservative treatment. Further pleural fluid sample should be taken to test possible resistance to antibiotics and further imaging considered.

For most community acquired complicated parapneumonic effusions and empyema an empiric intravenous antibiotic regimen that cover S. pneumoniae and the oropharynx pathogens including microaerophilic streptococci and anaerobic bacteria is instituted.

This consists in a third-generation cephalosporin associated with metronidazole or a combination beta-lactam/beta-lactamase inhibitor (amoxicillin-clavulanate, ampicillin-sulbactam).

In case of penicillin hypersensitivity who cannot have cephalosporin, options include carbapenem in single therapy, combination therapy with fluoroquinolone and metronidazole or a monobactam with metronidazole.

Clindamycin has been used for treatment of anaerobic lung infections, however, the increasing rates of resistance among anaerobes makes this antibiotic no longer routinely used for empiric treatment of anaerobic infections.

In case of hospital acquired parapneumonic effusions and empyema the empiric IV antibiotic regimen targets MRSA, gram-negative bacteria (including Pseudomonas spp) and anaerobic bacteria. Vancomycin with metronidazole associated with an antipseudomonal cephalosporin is appropriate. A combination of vancomycin and beta-lactam/beta-lactamase inhibitor is an alternative. However, since the combination of vancomycin and piperacillin-tazobactam is highly nephrotoxic, sometimes linezolid is used in place of vancomycin when piperacillin-tazobactam is used.

In case of penicillin allergy, an appropriate protocol can be vancomycin with metronidazole and an antipseudomonal fluoroquinolone or an antipseudomonal carbapenem.

While most uncomplicated effusions respond well to antibiotic treatment alone, there may be an indication for drainage in selected circumstances: in symptomatic and frail patients early drainage can be considered.

*Surgical Management of Pleural Space Infection DOI: http://dx.doi.org/10.5772/intechopen.99879*

After the establishment of an appropriate antibiotic regimen, a good clinical response with improvement of signs and symptoms is expected. The antibiotic course is usually maintained for at least 7 days and in most of the times the coverage for the anaerobic species is not needed.

Radiographic improvement usually requires 2 to 4 days, especially with no chest drain inserted.

As a general principle, for self-resolving uncomplicated bacterial parapneumonic effusions, the antibiotic therapy can be protracted with good results and resolution, up to 1–2 weeks. Complicated parapneumonic effusions and empyema usually request longer treatment ranging from 3 weeks for a complicated effusion and 4–6 weeks for empyema.

The initial IV antibiotic regimen can be switched to an oral regimen with similar spectrum when the clinical response is clear, and more invasive procedures such as drainage are no longer needed. There is no demonstrated optimal duration of therapy. The duration of treatment is individualized and it is based upon the type of effusion, the adequacy of drainage, clinical and radiographic response to treatment. On top of that, the immune status and efficacy of immune response of the patient plays a primary role in the duration and efficacy of treatment.

#### **7.1 Intrapleural fibrinolytics**

In case of complicated parapneumonic effusions (stage 2) which demonstrate difficult resolution with the sole drainage and antibiotics, including circumstances when septations are proven at the imaging, intrapleural t-PA/DNase can be considered.

These are also a valid option in patients not fit for surgery.

These agents are not exempt from side effects, these include chest pain, fever, allergic reactions (more frequently with streptokinase) and pleural hemorrhage (the risk is increased in presence of renal failure, thrombocytopenia, anticoagulation).

Fibrinolytics are neutralized (usually within an hour) by plasminogen activator inhibitors that are increased during pleural infection.

The first Multicenter Intrapleural Sepsis Trial (MIST1), a double-blind prospective and randomized controlled trial of patients with pleural infection randomized in 2 groups


demonstrated no significant difference between the two groups for mortality percentage requiring surgery, radiological outcomes and lengthy hospital stay; therefore, reporting no benefit of the use of intrapleural streptokinase [19].

7% of patients in the treatment group reported serious adverse effects (chest pain, fever, allergy), compared to 3% in the placebo group.

The median length of stay in the streptokinase group was 13 days while in the control group was 12 days, reporting no significant difference.

Death and the need for surgical intervention data were analyzed separately and no difference was found between the groups at 3 or 12 months.

MIST2 analyzed 210 patients with pleural infection assigned randomly to four groups to receive: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo.

However, the MIST2 trial found that the intrapleural use of tissue plasminogen activator (t-PA) and DNase improved the drainage of infected fluid in patients affected by pleural infections [20].

This study reported that combination of TPA and DNase improves the drainage of empyema reducing the length of hospital stay (6.7 days less than the placebo groups) and the need for surgery (4% of surgical referrals at 3 months in the double treatment group, compared to 16% of surgical referrals at 3 months in the placebo arm).

#### **8. Surgical treatment**

Surgical treatment is often indicated in patients with stage III empyema with cortex encasing the lung or empyema that fails to resolve with antibiotics, chest drain insertion and if indicated t-PA/DNase (stage II) or in symptomatic patients despite control of infection and sepsis.

Failure of resolution of the pleural effusion and the sepsis within 5–7 days despite drainage (+/− t-PA/DNase) and antibiotics is indication for surgical treatment.

This involves minimally invasive approach or thoracotomy according to the stage of the disease. VATS is preferred as first approach. Thoracotomy and thoracostomy remain valid alternatives in patients with advanced staged empyema.

#### **8.1 VATS/thoracotomy debridement and decortication**

Thoracoscopy has been proven an effective procedure for the treatment of pleural infection and reporting high successful rate around 91% with few complications compared to thoracotomy.

In their study, Brutsche et al. [21] analyzed a retrospective series of 127 patients over a period of 4 years affected by empyema and treated with medical thoracoscopy.

Empyema was defined by frank pus on thoracocentesis or by pH < 7.2 with signs of infection. Chest radiography and CT scan were used to confirm the diagnosis.

Thoracoscopy was performed with a zero-degree scope through a 7 mm trocar.

Post-operative active suction of minus 20 cm H2O was applied together with IV antibiotics for at least one week. They reported 9% of complications (surgical emphysema and prolonged air leak). No mortality was observed. 6% of cases required a thoracotomy and pleurectomy post thoracoscopy.

In a single centre, prospective study, Wait et al. [22] considered stage 2 empyema only. 20 patients were randomized to undergo either video-assisted thoracoscopic surgical decortication (11 patients) or chest tube drainage with streptokinase (9 patients). The VATS group reported higher treatment success (10/11, 91% vs. 4/9, 44%), lower chest tube duration (5.8 ± 1.1 vs. 9.8 ± 1.3 days), and decreased total hospital days (8.7 ± 0.9 vs. 12.8 ± 1.1 days). One death was reported in each group.

The authors concluded that VATS was the preferred primary approach for complex fibrinopurulent parapneumonic empyema.

In a recent Cochrane review, the authors [23] compared surgical with nonsurgical treatment for pleural empyema.

The study included eight randomized controlled trials for a total of 391 participants comparing open thoracotomy versus drainage.

Six trials were focused on children and two on adults comparing tube thoracostomy drainage with or without intrapleural fibrinolytics, to either VATS or thoracotomy.

#### *Surgical Management of Pleural Space Infection DOI: http://dx.doi.org/10.5772/intechopen.99879*

Of note, one trial, in children, showed a statistically significant reduction in mean hospital stay of 5.90 days (mean hospital stay of the control group was 15.4 days) and in complications for those treated with primary thoracotomy.

Seven studies were focused on the comparison between VATS versus thoracostomy drainage. No significant difference in mortality or complications between groups for both adults and children, with or without fibrinolysis, were reported. There was a significant reduction in mean length of hospital stay for patients who underwent VATS, 2.5 days less than the thoracostomy group.

A meta-analysis [24] based on 14 papers comparing VATS to traditional thoracotomy to perform decortication for the treatment of persistent pleural collections, in adults, demonstrated the superiority of VATS in terms of postoperative morbidity, complications and length of hospital stay, and gave equivalent resolution when compared with thoracotomy and decortication.

In 2005, Luh et al. [25] in a retrospective single centre study compared VATS decortication in the treatment of complicated parapneumonic effusion (stage 2) in 145 patients and loculated empyema (stage 3) in 89 patients, over a period of 8 years. Those with empyema had a conversion rate to thoracotomy and decortication of 21.3% compared with 3.5% with complicated effusion. The study reported also a significant reduction in postoperative length of stay on patients with complicated effusion (9.1 days) compared to patients with empyema (18.5 days). Reported perioperative morbidity; effusion group 6.2% vs. empyema group 11.2%. Perioperative mortality: effusion 2.1% and empyema 5.6%.

6.8% needed further surgery for empyema and 9 patients required open drainage or thoracoplasty, 7 patients needed re-decortication or repair of bronchopleural fistula.

Shahin et al. [26] in their single centre study over a period of 3 years reported a 3.5% conversion rate from VATS to thoracotomy to perform a decortication of 3.5% in patients with fibrinopurulent empyema (stage 2) and 19% in those with advanced organized empyema. Postoperative stay was shorter with VATS than thoracotomy (5 vs. 8 days) and no mortality was reported in both groups.

The authors conclude that we should consider VATS debridement and decortication as a first-choice treatment for primary empyema.

Another single centre study [27] analyzed a 10 years-experience comparing VATS decortication in 326 patients and 94 patients after thoracotomy and decortication. 11.4% of VATS cases were converted to thoracotomy. The VATS group reported reduced median post-operative hospital stays (7 vs. 10 days) and significantly reduced postoperative complications (atelectasis, prolonged air-leak, reintubation, ventilator dependence, need for tracheostomy, blood transfusion, sepsis,) and 30-day mortality. The mean operative time was VATS-thoracotomy 97 min – 155 min.

The study concluded that VATS approach is an effective and reasonable first-line option for most patients with complex pleural effusions and empyema.

Cardillo et al. [28] reported for VATS (185 patients) better results than thoracotomy decortication (123 patients) in terms of operative time, pain, postoperative air-leak, hospital stay and time to return to work. Conversion rate to open surgery was 11/185 (5.9%). Empyema recurred only in VATS group 3/185 (1.6%). The analysis of postoperative pain at six months follow-up showed no significant differences.

In conclusion, VATS and thoracotomy (open surgery) show similar postoperative outcomes, however, in terms of morbidity and hospital length of stay VATS is superior to open surgery. Therefore, when possible, VATS is preferred over the thoracotomy approach.

In advanced stage empyema open decortication should be considered: patients with stage III empyema or previous VATS procedures with still trapped lung or symptoms.

#### *8.1.1 Our data*

In our Institution regarding a single surgeon experience 103 patients were treated for empyema from August 2015 to May 2021: 33 were female and 70 males, with a median age of 58 years.

34 thoracotomies (33%) and 69 VATS were performed (28 decortications and 75 washout and debridement), Between VATS cases. The average operating time was 82 minutes. The average blood loss was 250 ml, ranging from 0 ml to 2500 ml. We reported 3 (4.3%) conversions for bleeding (one from parenchymal abscess and 2 from the lung surface).

The Median length of chest drain was 4 days and median length of hospital stay of 9 days (range 2 to 38 days): 8 and 9 days in the VATS and thoracotomy group respectively. Postoperative in-hospital mortality was 4.8% (n = 5): One COVID-related and one for progression of malignancy. One intraoperative mortality was due to bilateral PE.

9.7% of patients presented with postoperative complications: pneumoniae, bleeding (one required re-intervention), prolonged air leak, chylothorax and respiratory arrest due to mucus plug. Five patients were re-admitted within the first 30 days post discharge: 3 recurrent chest infections, one PE and one wound infection.

#### *8.1.2 VATS washout and debridement technique*

The main goal of the surgery is to achieve an adequate drainage of empyema and full re-expansion of the lung. This is easier if early intervention and adequate antibiotic treatment is undertaken.

Thoracoscopic debridement allows direct vision of the chest cavity facilitating the drainage. Usually the thoracoscope introduction is best performed after opening the pleura under direct vision.

Often, the best place to insert the first port is the intercostal space from which a needle exploration is positive for pleural fluid/pus. Alternatively, the creation of a pleural window by open dissection is requested, in presence of thickened pleural rinds. Subsequently, the port is inserted through the incision.

The risk of blind insertion of a thoracoscopic port in absence of confirmatory exploratory aspiration is to enter into the adherent lung parenchyma with a subsequent damage to the lung surface which will result in a postoperative air leak. Hence, blind port insertion should be avoided.

Following the first port insertion the pleural space is debrided, a second port can be inserted in order to achieve the complete debridement of the chest cavity. With the use of Yohan forceps, endoscopic ring-grasper or the swiping action of the scope itself, all the adhesions and loculations are separated and dissected in order to create space and have a clear vision of the chest cavity.

Repeated warm saline irrigations help loosen adhesions as well as improve vision by sucking and draining blood and purulent material.

A helpful maneuver to release adhesions is the use of endoscopic instruments to hold the membrane and twisting it from outside the port, which allows to peel the fibrinopurulent membrane effectively.

Most of the time, two ports are sufficient in case of early intervention, to clear the cavity. In presence of thick membranes, a third port may be required in order to achieve complete release of the trapped lung.

When satisfied with the debridement and subsequent lung re-expansion, port sites are closed and chest drain is inserted in the pleural cavity.

These procedures are often related to considerable bleeding related to the inflammatory state of the tissues. This generally stops following lung re-expansion. However, bleeding from intercostal vessels need to be controlled with coagulation

#### *Surgical Management of Pleural Space Infection DOI: http://dx.doi.org/10.5772/intechopen.99879*

diathermy, endoclip or bipolar diathermy device. Arterial bleeding needs careful identification and control before intercostal drain insertion and ports closure.

It is generally preferred to start with a keyhole approach and then convert to an open thoracotomy if required by emergency or impossibility to complete the debridement/decortication.

Conversion to open thoracotomy is also appropriate in patients who do not tolerate single lung ventilation, uncontrollable bleeding or damaged structures not accessible by VATS.

Timing is crucial when surgery is discussed in the management on stage II or III empyema. Decortication is associated with prolonged hospital stay, bleeding, bacteremia and hypotension. The need of decortication may be less than expected if early treatment is started with antibiotics and VATS debridement of the pleural space. Na open decortication should be probably deferred when infective process is resolved and natural remodeling of the pleural space is completed. An open decortication in presence of chest infection and not defined cortex can cause worse sepsis, prolonged air leak and poor lung re expansion.

Aquamantys © bipolar sealer uses radiofrequency energy and saline simultaneously to provide hemostasis and it is useful to control bleeding from the chest wall surface, as well as, from the lung parenchyma. It is provided with endoscopic handpiece and can be used in keyhole surgery, such as, VATS.

#### **8.2 Thoracostomy**

Rarely, when all the other interventions fail (antibiotics, tube thoracostomy, fibrinolytic therapy) and in patients not fit for major surgery with advanced stage empyema with thick cortex, an open thoracostomy should be considered, this can be obtained with a small rib resection and creation of thoracostomy. The empyema resolving process takes approximately 60–90 days.

The stoma needs multiple daily dressing changes, sometimes, a wound vacuumassisted closure (VAC) device facilitate drainage of the empyema. However, this device can facilitate or worsen the creation of a bronchopleural fistula.

When compared with conventional management of open window thoracostomy, VAC therapy accelerates wound healing and improves re-expansion of residual lung.

Palmen et al. [29] retrospectively analyzed all 242 patients with empyema in a 19.5 years' experience. 19 patients had a recurrence of empyema, which required a thoracostomy. 11 patients were treated with VAC therapy in addition.

The non-VAC group consisted in 8 patients.

Thoracostomy-only group received saline-soaked gauzes application in the cavity, with daily dressing changes.

The total duration of open window thoracostomy and the duration of VAC therapy were 39 ± 17 and 31 ± 19 days, respectively.

All 11 patients were amenable for subsequent closure using pedicled muscular flaps. In 2 patients, VAC therapy alone resulted in complete closure of the thoracostomy.

Four patients died from complications (1 bleeding, 3 recurrent infections) during follow-up. The average duration of OWT was 933 ± 1,422 days.

#### **9. Conclusion**

Parapneumonic effusion stage I can be managed conservatively with antibiotics treatment and chest drain insertion, in stage II VATS debridement and fibrinolytics are recommended, in stage III VATS decortication should be considered the first treatment option considering better outcomes compared to thoracotomy. In case of septic patients or severely trapped lung open decortication should be considered. The preference is to delay the open decortication at a later phase if VATS failed to reduce the risk related to open decortication: bleeding, prolonged air leak and worsening sepsis.

### **Conflict of interest**

The authors declare no conflict of interest.

### **Author details**

Alessandro Maraschi\* and Andrea Billè Thoracic Surgery, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom

\*Address all correspondence to: alessandro.maraschi@gmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Surgical Management of Pleural Space Infection DOI: http://dx.doi.org/10.5772/intechopen.99879*

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Section 3
