Percutaneous Drainage of a Chest Abcess

Michael P. D'Alessandro, M.D.
Peer Review Status: Internally Peer Reviewed

Contrast:
None

Technique:
Medias Abscess
Drain under CT
Use ant or post approach - don't traverse lung

Lung Abscess
Indication: sepsis refractory to abx and postural drainage, large collections, pts who Can't cough or who have obstructed bronchi
Contraindic: uncorrectable coagulopathy/uncooperative pt
Access via contiguous abnormal pleura to decrease risk of bronchopleuralfistula
Guide via fluoro/CT - place needles and cath above rib
Check PT, PTT, plt, Hgb
Clear liquids p MN
Cover patient with broad spectrum Abx
22G needle bx -> send for gm stain and culture
Put cath in via trocar - 12-16 Fr locking pig [16-24 Fr Malecot if very thick pus]
Evacuate cavity
Gently lavage cavity with saline which activates cough reflex
Don't normally need abscessogram
If abscess is in lower lobes - put patient prone and put cath in via post axillary
line so patient will not lie on it when supine
Put patient supine or prone when doing proc-> never lat b/c it can cause spillover of bugs into clean lung
Should be in about 10 days

Empyema Drainage
Relative contraindic: coagulopathy/TCP
Check PT, PTT, plt, Hgb
Clear liquids p MN
Cover patient with broad spectrum Abx
Do diagnostic tap under US with 20-22G and drain if infected
For free flowing collections use 6th-8th intercostal space in post axillary line
Place catheter via Seldinger or Trocar
Catheter choice - use single lumen with multiple large sideholes and have pig or curved tip - if serous use 8-10 Fr - if thick pus use 12-14 Fr
Drain infected collections completely
Large (>1500 cc) chronic and noninfected collections should be drained slowly
over 24-48 hrs to avoid development of reexpansion pulmonary edema
Catheter is attached to Pleurevac with (-20) cm suction, secure all connections with tape and put petroleum gauze around cath entry site
After 1st cath is placed you must re CT to check for loculations which must be drained separately
On daily rounds check patient condition, tmax, WBC ct, cultures, amt and character of drainage, catheter insertion site for drainage/infection/hematoma Avg drainage takes about 7 days
Flush cath q shift
When to remove catheter: drainage < 10 cc in 24 hrs, patient clinically improving with no Fever and normalWBC, CXR looks OK

Views to Take:
Not applicable

References:
See References Chapter.

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