Pleural space infections are associated with considerable morbidity, mortality, and health care resource use (Table 58.1). Drainage of the pleural space is the key component of care; however, the modality and extent of drainage and debridement has long been debated. Options include nonoperative (thoracentesis and tube thoracostomy with or without intrapleural thrombolytic therapy) and operative (thoracotomy or VATS) intervention. The approach to pleural space infection varies significantly between physicians reflecting differences in specialization, access to thoracic surgeons, and conventional wisdom and training.

The usual argument against the use of chest tubes for pleural space infection was the high incidence of loculation within the pleural space that usually impairs chest tube drainage and prevents complete evacuation of the pleural space. However, with image-guided SBCCs, this argument may not stand anymore. SBCCs offer many advantages over the traditional chest tubes for the management of pleural space infection. First, in case of loculated pleural effusion, SBCCs can be accurately placed exactly in the desired fluid pocket. Second, in the presence of multiple loculations, several SBCCs can be placed in the same setting. Finally, in the case of numerous loculations, the use of intrapleural thrombolytic agents might be useful to break the loculation and improve the drainage.

It is unclear how the growing availability of new management options for pleural drainage has affected clinical practice in the community at large.

Malignant pleural effusions (MPE) develop in patients with a variety of malignancies with lung and breast carcinomas and lymphomas accounting for about 70 % of all malignant effusions. Several management options exist for patients with MPEs and depend on how symptomatic the patient is, the rate of fluid reaccumulation, the presence of trapped lung, patient’s prognosis, and anticipated tumor response to the available treatment. Asymptomatic patients with slowly reaccumulating pleural effusions may benefit from repeated thoracentesis. However, for a patient in whom the pleural effusions reaccumulate rapidly, this option might be bothersome. In such patients, insertion of SBCC serves several purposes. It helps to completely drain the effusions, which is important to assess the lung expansion and to rule out lung entrapment that will affect the decision for further long-term management plans. If lung entrapment is ruled out, then pleurodesis is an effective method for long-term control of the effusion. Conventional large-bore chest tubes (24–32 F) have been traditionally employed in most studies involving sclerosing agents because they are thought to be less prone to obstruction by clots. However, their placement is perceived to be associated with significant discomfort. SBCCs offer similar efficacy and less pain and discomfort to the patients. Studies using SBCCs with commonly used sclerosants have reported similar success rates to large-bore chest tubes.

Pneumothorax can be classified as spontaneous or iatrogenic. Spontaneous pneumothorax can be subdivided into primary, in patients with no underlying lung disease, or secondary, which is associated with parenchymal lung disease. Traumatic pneumothorax results from chest trauma or as an iatrogenic complication of thoracentesis, transthoracic needle lung biopsy, transbronchial lung biopsy, or central venous line insertion.

The optimal size for chest tube needed for pleural aspiration in cases of pneumothorax is usually determined by the rate of air leak. In patients who are not at risk for large air leak (e.g., spontaneous and iatrogenic pneumothorax), SBCCs may be sufficient to maintain adequate air evacuation. However, patient with impending tension pneumothorax, underlying severe lung disease, receiving mechanical ventilation, or in cases of traumatic pneumothorax especially in combination with hemothorax, larger conventional chest tubes may be required for adequate evacuation of the pleural space.

In general, large-bore chest tubes are the preferred approach in the management of hemothorax in the acute phase. However, after the acute phase has resolved, septation may form and prevent complete evacuation of the pleural space by the chest tube. In such conditions, SBCCs may be inserted under image guidance into the specific pockets and may avoid patients from further surgical intervention. In case where mature blood clots form, however, surgical intervention might be the only option to completely evacuate the pleural space.

With the traditional large-bore chest tubes, most clinicians insert the chest tube via an incision at the fourth or fifth intercostal space in the anterior axillary or midaxillary line where the tube then advanced blindly either apically or posteriorly depending on the underlying nature of the pleural disease. With this method, tube malposition can occur, especially in cases of loculated collections. Image-guided SBCCs overcome this problem by allowing the physician to accurately place the catheter exactly into the pleural collection (Table 58.2).

A thorough examination of the chest with an appropriate imaging modality (usually US) is first performed. In cases of free-flowing effusion, the entry site is preferred to be as lateral as possible to avoid patient discomfort and tube dislodgement when the patient lies supine. In addition, the entry site is preferred to be as inferior as possible and then advanced posteriorly to the most gravity-dependant region of the pleural space to allow for maximum drainage. Insertion of catheters medial to the scapula is discouraged unless absolutely necessary because it carries the risk of catheter dislodgement with scapula movement. However, in cases of loculated collections, the entry site should be marked exactly at the site of the collection (preferably at the inferior border of the collection) seen on the US. In cases of pneumothorax, the entry site is usually chosen in the anterior chest wall, usually in the second intercostal space.

Many SBCC kits are commercially available. When choosing an SBCC kit, several things should be considered. The catheter should be made of soft and flexible material to allow for easy navigation and placement through the intercostal space and to minimize pain and discomfort to the patients. Catheters with coiled ends (pigtail configuration) are preferred for prolonged drainage of pleural effusion (e.g., malignant effusions and parapneumonic effusions) as they provide an additional locking mechanism that minimizes the chance of catheter dislodgement (Fig. 58.2). The catheter should be radiopaque, so it can be easily identified on chest radiographs. Finally, catheters should have sufficient side holes to allow for adequate drainage and minimize catheter blockage.

In general, most of SBCCs used for pleural effusions are inserted with the Seldinger technique. However, for small pneumothoraces with small air leak, a compact, one-piece pneumothorax drainage system is available (Tru-Close Thoracic Vent. UreSil, Skokie, IL). This unit is composed of a 12- or 13-French, 10-cm-long catheter connected to a rectangular chamber that contains a self-sealing aspiration port, a red signal diaphragm indicating entry into the pleural space, and a flutter valve (Fig.58.5).

As most of the currently available kits fulfill all of the above criteria, one should choose the kit that he is most comfortable with. Using multiple kits usually cause confusion and may prolong procedure time especially in cases of emergencies.

Prior to SBCC placement, all available imaging should be carefully reviewed. This allows the operator to have an idea about the pleural space anatomy and the expected size and location of the pleural collection. In addition, one should insure presence of enough pleural space for a safe insertion of the catheter using the Seldinger technique without injuring the lung parenchyma.

Patient is then placed in the desired position which varies among clinicians. However, most interventionists prefer to place the patient in the supine position with the ipsilateral arm over the head. Sometimes, a lateral decubitus position is necessary to gain access to a posteromedial fluid collection. In patients with a collapsed lung with pleural effusion or pneumothorax, this positioning usually entails placing the patient with the healthy lung down. This can lead to hypoventilation in the normal lung and potentially dangerous hypoxemia.