581

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Review Article

Interventional Radiology of the Chest: Image-Guided

Percutaneous Drainage of Pleural Effusions, Lung Abscess,
and Pneumothorax
Jeffrey S. Klein1, Scott Schultz2, John E. Heffner3

Percutaneous catheter drainage of intrathoracic collections fluid with a positive Gram’s stain or cultures for pathogens. Still
has developed as a natural extension of similar interventional other effusions, characterized by presence of an exudative
radiologic procedures in the abdomen. The advent of CT and parapneumonic effusion with a low pH (<7.20), elevated LDH
sonography, which allow detection and characterization of (>1000 lU/I), or low glucose (<40 mg/dI), indicate collections
pleural and parenchymal collections, combined with advances
unlikely to resolve with antibiotic therapy alone that may
in drainage catheter design and interventional techniques,
progress as a complicated effusion through a fibrinopurulent
have made imaging-guided management of intrathoracic col-
lections a safe and effective alternative to traditional surgical
stage to an organized stage within days to weeks if left un-
therapy. This article begins with a review of the etiology, patho- drained [2]. Anaerobic and mixed aerobic-anaerobic infections
physiology, diagnosis, and treatment of parapneumonic pleural have become the most common cause of complicated para-
effusion, which remains the most common Indication for pneumonic effusions in the last two decades as a result of the
image-guided percutaneous drainage. Subsequent sections widespread use of broad-spectrum antistaphylococcal and
consider issues related to percutaneous drainage of malignant antistreptococcal antibiotics [3].
pleural effusion, lung abscess, and pneumothorax. Diagnosis of a parapneumonic fluid collection is usually
suggested by typical findings on conventional chest radio-
graphs. Posteroanterior, lateral, and decubitus (ipsilateral
Parapneumonic EffusionslEmpyemas
and contralateral) chest radiographs estimate overall size,
Infected pleural fluid collections most often develop as a extent, and laterality of the pleural process. Whenever a
complication of pulmonary infection, chest trauma, or recent parapneumonic effusion is suspected, these radiographs
surgery, or as secondary infection of a preexisting hydrothorax should be obtained to diagnose free-flowing or loculated
or hemothorax [1]. A parapneumonic pleural effusion develops pleural collections and to provide a baseline examination for
in approximately 40% of patients with community-acquired gauging treatment efficacy. The contralateral decubitus view
pneumonia [2]. Most of these collections resolve with appro- may reveal parenchymal lesions previously obscured by effu-
priate antibiotic therapy directed toward the causative organ- sions on posteroanterior views. CT is useful for more specific
ism. Effusions that require drainage for definitive treatment are characterization of complex pleural-parenchymal processes.
termed “complicated” parapneumonic effusions. Some compli- External drainage of infected pleural fluid collections has
cated parapneumonic effusions can be further described as been the mainstay of treatment for centuries. However, the
an “empyema.” Most clinicians define empyema as frank pleu- optimal method of establishing external drainage remains
ral pus, although some extend the definition to include pleural controversial [4]. Therapeutic options include thoracentesis

Received June 30, 1994; accepted after revision September 16, 1994.
1Department of Radiology, St. Joseph’s Hospital and Medical Center, 350 W. Thomas Ad., Phoenix, AZ 85013. Address correspondence to J. S. Klein.
2Department of Radiology, University of California Medical Center, San Francisco, CA 94143-0628.
3Department of Medicine, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013.
AJR 1995;164:581-588 0361-803X195/1643-581 © American Roentgen Ray Society
 582 KLEIN ET AL. AJR:164, March 1995

[5], image-guided catheter drainage [6], surgical thoracos- accessing large free-flowing or loculated collections in supine
tomy tube placement [7], thoracotomy with debridement and patients. Continuous monitoring of the course of the needle,
directed chest tube placement [8], open pleural decortication guidewire, and catheter is a distinct advantage of fluoroscopy.
[9], and, more recently, video-assisted thoracoscopic pleural The procedure is best performed in an interventional radiology
surgery [10]. External drainage procedures should be chosen suite, where immediate access to biplane fluoroscopy and to
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case by case. any necessary wires and catheters is available.

Image-guided percutaneous transthoracic drainage of Sonography is the technique of choice to guide thoracen-
infected pleural collections is indicated in patients who have a tesis and pleural drainage. Its advantages include absence
diagnostic thoracentesis showing frank empyema or a compli- of ionizing radiation, portability, and real-time capabilities
cated parapneumonic effusion by measurement of pleural fluid [1 3]. Patients with free-flowing pleural fluid who can sit
pH, LDH, glucose, and protein. As with surgically placed thora- upright or those with loculated collections that contact the
costomy tubes, radiologic drainage is most effective in patients chest wall are easily accessed by sonography. Needle
with short duration of symptoms, free-flowing or unilocular guides that attach to the ultrasound transducer and dedi-
parapneumonic effusions,
absence of a thick pleural peel on cated biopsy probes with central needle ports allow real-time
CT scans, and fluid that can be aspirated easily by needle. monitoring of initial needle placement. Pleural drainage can
Postoperative empyemas, particularly those associated with also be performed at the bedside using sonographic guid-
bronchopleural fistulae, respond poorly to closed thoracostomy ance in critically ill, hemodynamically unstable patients.
tube drainage and usually require an open surgical procedure CT is best used to detect loculated pleural collections associ-
[ii]. An algorithm illustrating our approach to parapneumonic ated with underlying parenchymal consolidation. It can visualize
or infected pleural fluid collections is shown in Figure 1. the selected external drainage pathway to allow safe catheter
Fluoroscopy, sonography, CT, or any combination of these placement into the collection. Drainage can be performed
techniques can accurately guide drainage catheter placement immediately following the diagnostic CT examination. Multiple
[12]. Image guidance is selected by: (1) availability and conve- locules of pleural fluid, which require multiple drainage catheters
nience of the various techniques, (2) size and position of the or open surgical drainage, are best seen by CT. Rescanning
collection, (3) the patient’s condition, and (4) the radiologist’s can assess accuracy of catheter placement into the dependent
preference. Fluoroscopy is readily available and is used for portion of the collection and drainage adequacy (Fig. 2).

Suspected parapneumoruc pleural effusion Figure 1

Management of parapneumonic pleural effuiiono

PA/lateral/decubitus chest radiograpbs

No free fluid or level < 1 cm Suspected loculated collection Effusion> I cm thick or loculated collection

Loculated thud not suspected

/
Computed tomography/ultrasound

No loculationsV

Thick pleural peel, symptoms Loculated fluid collection(s)

Antibiotics. f/u hlms >3 weeks

Surgical drainage

Diagnostic lhoracentesis

Pus Non purulent Unable to aspirate

Gram stain/culture positive Exudate

pH < 7.20. LDH > 1000 IU/L

Observation
or glucose 40 mg/dl

48 hours
Transcatheter drainage Persistent sepsis. fluid

Clinical/radiographic
I __________________
1
resotution Intrapleural urokinase

Catheter removal Lack of improvemen

Sureical drainare

Fig. 1 .-Algorithm for approach to parapneumonlc and infected pleural fluid collections.
 AJR:164, March 1995 IMAGE-GUIDED THORACIC FLUID DRAINAGE 583

Fig. 2.-CT-guided empyema drainage In 32-

year-old male with anaerobic empyema.
A, Contrast-enhanced CT scan shows poste-
riorly loculated pleural fluid collection with en-
hancing pleural surfaces consistent with
empyema.
B, CT scan obtained following CT-guided
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drainage of 350 ml of purulent fluid performed

with patient In right lateral decubitus position;
catheter (arrows) is seen posteriorly within
obliterated pleural space. (Image rotated for
comparison with A.)

Catheters ranging from 8-30-French in outer diameter may through the lumen of the stiffening inner cannula, and fluid is
be placed under imaging guidance. A single-lumen catheter aspirated to confirm accurate catheter placement. The cathe-
should be used to prevent air entry into the pleural space, which ter is then advanced off the cannula into the collection.
would impair lung reexpansion and obliteration ofthe empyema Once the catheter has been placed into the dependent por-
cavity. For serous collections, a 10- or 12-French catheter pro- tion of the collection, fluid is manually aspirated until mild resis-
vides adequate drainage; thick collections of purulent or bloody tance is encountered. A repeat sonogram or CT scan through
material may require catheters 24-28-French in diameter, such the area of interest can assess drainage adequacy. If there are
as the ThaI-Quick chest tube (Cook, Bloomington, IN). Most undrained locules, additional catheters are placed. Catheters
empyema drainage tubes have large round or oval side holes to are then affixed to the skin and attached via an adapter to a
promote drainage of particulate matter. The catheter tip may be suction device, such as a Pleur-evac (Deknatel, Fall River, MA).
a pigtail for retention purposes or gently curved to conform to The patient is visited daily to assess therapeutic response
the inner concavity of the pleural space. and catheter patency maintained by flushing the catheter with
Successful pleural space drainage requires careful attention small amounts of sterile saline. Response to tube drainage is
to technique and familiarity with drainage devices. In a patient monitored by daily review of temperatures and peripheral
with suspected pleural space infection, a diagnostic thoracente- WBC counts. Drainage amount is followed most easily by
sis is performed initially under sonographic or CT guidance. marking fluid level in the collection chamber of the drainage
Once the puncture site has been stenlely prepared and anesthe- apparatus after each nursing shift. Daily chest radiographs
tized, an 18-gauge trocar needle is placed through the chest wall assess size of the residual collection and determine need for
into the thickest part of the collection. Care is taken to place the additional manipulations or alternative therapies [14].
needle over an underlying nb to avoid injury to the intercostal Duration of catheter drainage following image-guided place-
vessels and nerve. After removal of the sharp-tipped trocar, fluid ment ranges from 1-45 days, with most requiring 5-10 days of
is aspirated through the needle. lffrank pus is obtained, a drain- treatment [6, 13, 15]. The drainage catheter should be
age catheter is placed. Iffluid cannot be easily aspirated through removed when drainage has diminished to less than 10 ml
an 18-gauge needle confirmed to be within the collection, simple daily, the patient’s fever and WBC count have diminished, and
closed drainage with a thoracostomy tube is unlikely to be suc- radiographic resolution of the pleural collection has occurred.
cessful, and a thoracotomy or thoracoscopy will likely be neces- A contrast-enhanced CT scan is often obtained prior to cathe-
sary. Purulent fluid dictates catheter insertion. Nonpurulent fluid ter removal to assess drainage adequacy and to detect any
should be sent for immediate Gram’s stain to identify microor- residual collections.
ganisms. Organism presence warrants catheter drainage. Several options exist if clinical and radiographic assessment
Catheter insertion can be accomplished by placing a determines that drainage is inadequate. Occasionally, the
guidewire with a floppy distal segment (Bentsen or LLT, indwelling catheter requires repositioning to enhance drainage.
Cook, Bloomington, IN) through the needle’s lumen and coil- Conversion to a catheter with a larger diameter may promote
ing the wire into the collection. The needle is then removed, adequate drainage of thick pus or bloody material. Intrapleural
and sequential vascular dilators in increments of 2 French administration of fibnnolytic medication may aid in septated col-
are placed over the wire until the drainage catheter diameter lections or collections with multiple locules. Both streptokinase
is reached. The drainage catheter is placed over the [16, 17) and urokinase [17-19] have been used successfully to
guidewire and into the dependent part of the collection. Col- avoid open procedures in patients in whom simple closed thora-
lections with a large window of safety (i.e., broad area of con- costomy catheter drainage has failed. Several investigators
tact with the chest wall) are easily drained by trocar have reported the use of 80,000-100,000 IU of urokinase
placement of the drainage catheter in tandem with the diag- mixed in 100 ml of sterile water or saline administered through
nostic needle. Once the catheter has been placed to the the indwelling catheter and left in the pleural space for 2-12 hr
appropriate depth, the inner sharp-tipped trocar is removed before replacing the catheter to suction [16-19] (Fig. 3). Suc-
 584 KLEIN ET AL. AJA:164, March 1995
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A B C

Fig. 3-Urokinase infusion for multiloculated parapneumonic effusion In 2-year-old female with streptococcal pneumonia and large parapneumonic
effusion on CT.
A, Frontal chest radiograph shows opacificatlon of left hemithorax with contralateral mediastinal shift.
B, Radiograph obtained after sonographically guided catheter placementthat yieided only 10 ml of fluid shows small air/fluid level In left upperthorax (arrow).
C, Frontal radiograph after five daily Infusions of urokinase shows significant improvement with residual left lower lobe opacification and lateral pleu-
ral thickening.

cess rates in these small series of selected patients were 77- patients need a repeat therapeutic thoracentesis at 1 month
92%. Despite these maneuvers, the decision to proceed to tho- [23]. These latter patients require drainage and obliteration of
racoscopy or open surgical drainage should be made when the pleural space, which is usually accomplished by thora-
more conservative measures fail and there is clinical and radio- costomy tube drainage, followed by intrapleural administra-
graphic evidence of persistent pleural infection and sepsis. tion of sclerosing agents. Image-guided catheter placement
Successful treatment of infected pleural collections is defined has largely replaced surgical thoracostomy tube as the initial
by the completeness of pleural fluid evacuation that resolves procedure of choice for management of free-flowing malig-
pulmonary symptoms and sepsis and that avoids more invasive nant effusions.
procedures. Retrospective studies of radiologically guided pleu- Malignant pleural effusions can be managed with several
ral drainage procedures have shown success rates of 72-88% surgical alternatives. The reemergence of thoracoscopy in
[6, 13, 15], which compares favorably with success rates of 66- the last decade has seen this technique used both as a diag-
83% reported in the surgical literature [1 6, 20] for thoracostomy nostic tool in evaluation of pleural disease and as a means of
tube drainage. Even in patients who require an additional open administering talc poudrage as a definitive sclerosing agent.
surgical procedure for control of pleural infection, a radiologi- Pleural decortication is an effective treatment for malignant
cally placed drainage catheter is a reasonable first step in effusion [24] but is associated with an unacceptably high
staged management of these collections [21] (Fig. 1), particu- morbidity and mortality. Pleuroperitoneal shunting has also
larly when surgery is technically difficult or carries significant been used successfully in selected patients with malignant
morbidity and mortality. Careful patient selection is required, pleural effusions [25].
however, to ensure a successful outcome. Because most malignant effusions are free flowing, they are
Complications of image-guided pleural drainage are most easily accessed for catheter drainage by sonographic
uncommon but include bleeding due to intercostal vessel examination with placement of the drainage catheter in the
injury [1 5] and pneumothorax. dependent portion of the pleural space [26, 27) (Fig. 4). For large
collections and in patients who cannot sit upright for the proce-
dure, fluoroscopy may be used for catheter placement [28]. In
Malignant Effusions general, a small-bore catheter (8-12-French) suffices for serous
Malignant disease accounts for nearly half of all exudative collections. A direct trocar technique is safe in most patients with
pleural effusions in patients undergoing thoracentesis [22]. moderate or large collections, while a Seldinger technique is
Approximately 75% of these malignant effusions are due to reserved for smaller collections. A fluid quantity not exceeding
lung and breast carcinoma and lymphoma [23]. Malignant 1 .5 I is withdrawn initiallyto avoid reexpansion pulmonary edema.
cells on cytologic examination of pleural fluid or presence of Complete pleural fluid evacuation with reexpansion of the
tumor implants on pleural biopsy is necessary for diagnosis. underlying lung and apposition of visceral and parietal pleural
Whereas some effusions resolve with treatment of the surfaces is necessary for successful pleurodesis. Adequate
underlying malignancy (e.g., small-cell carcinoma or lym- fluid drainage is determined by radiographic resolution of the
phoma), most require external drainage. Although therapeutic effusion and daily catheter output of less than 100 ml, usually
large-volume thoracentesis is appropriate in selected patients accomplished within 5 days of drainage catheter placement
with a short life expectancy (i.e., several weeks), 97% of [27, 28]. A thick pleural peel, endobronchial obstruction, or
 AJA:164, March 1995 IMAGE-GUIDED THORACIC FLUID DRAINAGE 585

Fig. 4.-Sonographically guided drainage of

malignant pleural effusion In 64-year-old man
with bronchogenic carcinoma.
A, Sagfttal sonogram shows guidewlre (arrows)
within subpulmonlc effusion (E) coursing toward
diaphragm (D). L = lung.
B, Sagittal sonogram shows drainage cathe-
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ter containing injected air (arrowheads) has

been advanced over guldewire Into effusion.

underlying interstitial lung disease, all of which prevent ade- CT scans are obtained in all patients with suspected lung
quate reexpansion of the lung and obliteration of the pleural abscess to further characterize findings detected on conven-
space, may preclude successful pleurodesis. Once the effusion tional radiographs and to evaluate for obstructing endobronchial
has been evacuated and the lung has reexpanded, chemical lesions. Distinction of lung abscess from loculated empyema is
pleurodesis is performed by intrapleural administration of a scle- somewhat important, as the latter always requires external
rosing agent. Because injectable tetracycline is no longer com- drainage. On CT, a lung abscess appears as a rounded intra-
mercially available for this purpose [29], alternative agents- pulmonary mass that contacts the chest wall at acute angles
including doxycycline, minocycline, bleomycin, Cotynebacte- and contains central necrosis or cavitation. The enhancing wall
rium paivum, and talc-may be used [30, 31]. Talc, adminis- of an abscess on CT is typically thick with an irregular inner
tered as a suspension through a chest tube or insufflated into margin. In contrast, an empyema is oval and creates obtuse
the pleural space dunng thoracoscopy, has a success rate of angles as itfollows the contour ofthe chest wall. The “wall” of an
93-95% and is the agent of choice when available [32, 33]. empyema represents the visceral and parietal pleural limiting
Transcatheter chemical pleurodesis is performed at the membranes [37]. These inflamed pleural layers are seen on CT
bedside with the sclerosing agent admixed with lidocaine. as enhancing thin curvilinear lines separated by infected pleural
Following injection of the sclerosing agent, the catheter is fluid, termed the “split pleura” sign [38].
clamped and the patient is slowly rotated to ensure adequate Until the early 1940s, surgical pneumonotomy and drain-
distribution of the agent over the entire pleural space, age were the accepted treatments for lung abscess [39].
although this latter maneuver is probably unnecessary in Subsequent advances in anesthesia and surgical techniques
most patients [34]. The catheter is then reconnected to suc- led to the advent of lung resection as the preferred therapy,
tion and usually removed the following day. until availability of effective antibiotics rendered open drain-
Success of image-guided drainage and sclerosis of malig- age unnecessary in most patients [40]. Current first-line ther-
nant effusions is usually defined as absence of symptomatic apy for lung abscess is antibiotic therapy directed atthe likely
reaccumulation of fluid 1 month after sclerosis. Reported causative organisms, usually anaerobes or mixed aerobic
success rates of small-bore catheter treatment range from and anaerobic bacteria [41].
62-92% [26, 28, 35], which are comparable to those Conservative medical therapy proves effective in 80-90%
reported with large-bore tubes [36]. of patients with lung abscess [42, 43]. Patients who display
Procedure complications include infection and self-limited no radiographic evidence of improvement or who show signs
pneumothorax [26, 35]. Reexpansion pulmonary edema has of persistent sepsis or develop complications such as
been associated with rapid evacuation of large pleural collections hemoptysis or bronchopleural fistula and empyema require
[35] and is avoided by gradual fluid drainage over the first 24 hr. external drainage or resection for definitive treatment. Exter-
nal drainage is the preferred method of treatment for pleural-
based abscesses, particularly in patients with a high risk of
Lung Abscess
surgical mortality. Both surgical [42, 43] and image-guided
Primary lung abscess usually results from aspiration of [44, 45] percutaneous drainage have been successfully used
anaerobic oropharyngeal bacteria into gravity-dependent por- for treatment of lung abscess.
tions of the lung, most often the posterior segments ofthe upper CT scans are obtained in all patients as an aid to diagnosis to
lobes and the superior segments of the lower lobes. It is seen assess presence of pleural involvement by the infectious process
most commonly in alcoholics and other persons with altered and to plan a safe transthoracic route for drainage catheter place-
consciousness, patients with gastroesophageal dysmotility, and ment. Catheter placement is usually performed using CT (Fig. 5)
those with poor dental hygiene [36]. Most abscesses are dis- orfluoroscopy for guidance, although sonography can be used in
covered when fever and pulmonary symptoms lead to a chest selected patients. The patient with the abscess must be placed in
radiograph that reveals a solid or cavitary lung mass. a gravity-dependent position whenever possible to avoid soiling
 586 KLEIN ET AL. AJR:164, March 1995
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Fig. 5.-Percutaneous lung abscess drainage under CT guidance.

A, Posteroanterior chest radiograph in 64-year-old alcoholic with purulent sputum shows anterior segment right upper lobe mass.
B, Contrast-enhanced CT scan demonstrates mass with Irregular wall containing gas and necrotic material.
C, CT following trocar placement of 14-French vanSonnenberg chest drain and saline lavage of cavity. Malodorous fluid diagnostic of anaerobic lung
abscess was withdrawn through catheter, which was removed 48 hr later.

the normal lung. A trocar technique of catheter insertion through blunt chest trauma or as an iatrogenic complication of thora-
the point of contact of the abscess with the pleural surface is centesis, central venous catheterization, or transbronchial or
safely performed because the abscess induces local pleural transthoracic lung biopsy. Spontaneous pneumothorax may
symphysis in this region. If the window to the abscess is narrow, be divided into a primary form, which has no identifiable
a Seldinger technique is a safer procedure. Traversing normal cause and is often related to apical intrapleural bleb rupture,
lung with the abscess drainage catheter should be avoided and a secondary form, which is associated with underlying
because of risk of hemorrhage and bronchopleural fistula forma- parenchymal lung disease. Symptoms of pneumothorax
lion with empyema [44]. Placement of a relatively large-bore include pleuritic chest pain, dyspnea, and cough.
catheter (1 2-French or greater outer diameter) is keyto establish- Patients with small, stable pneumothoraces are safely
ing adequate external drainage and maintaining catheter observed on bed rest with administration of supplemental
patency. Once positioned in the abscess cavity, fluid is aspirated oxygen. Indications for pneumothorax drainage include col-
manually, and the cavity is irrigated with saline. The drainage lections estimated to exceed 25% of the volume of one
catheter is placed to suction at -20 cm of water to help evacuate hemithorax, an enlarging pneumothorax indicating persistent
pus and collapse the cavity. The catheter should be irrigated with air leak, or any size pneumothorax that causes dyspnea or
sterile saline at least twice daily to maintain patency. When daily severe chest pain [47]. An additional indication for pneu-
assessment by clinical parameters (temperature, WBC count) mothorax drainage is to allow successful completion of a
and chest radiographs indicates resolution of the abscess, the transthoracic needle biopsy complicated by pneumothorax
catheter may be removed. A repeat CT scan is obtained when [48]. Patients with recurrent pneumothorax or persistent
there is lack of improvement, particularly if a complicating bron- bronchopleural fistula may require more than simple chest
chopleural fistula and empyema are concerns. tube drainage, including thoracostomy tube with chemical
Several investigators have reported their results with image- pleurodesis [48], thoracoscopic talc poudrage [49], and tho-
guided percutaneous drainage of lung abscess [44-46]. In the racotomy with bullectomy or stapling of apical blebs [50].
largest series published to date, vanSonnenberg et al. [44] Most patients who have fluoroscopically guided catheter
reported successful percutaneous lung abscess drainage in drainage of pneumothorax have sustained the pneumothorax
all 1 9 patients referred forthis procedure, with surgery avoided as a complication of transthoracic or transbronchial lung
in 16 patients (84%). Mean time to abscess resolution is biopsy or thoracentesis [47]. Some patients with spontane-
approximately 10-1 5 days, although marked improvement in ous pneumothorax without a large air leak are successfully
sepsis indicators (fever, leukocytosis) is seen within 48 hr of managed with small catheters attached to a flutter (Heimlich)
drainage [44, 45]. Potential percutaneous abscess drainage valve [51]. Occasionally, a patient is referred for CT-guided
complications are pneumothorax, bronchopleural fistula for- catheter drainage of a loculated pneumothorax.
mation with empyema, and hemorrhage. Each is more likely Pneumothorax drainage using small-gauge catheters in the
when normal lung is traversed by the drainage catheter [44]. radiology department is performed under fluoroscopy. CT may
be used for loculated collections and for large pneumothora-
ces that complicate CT-guided chest biopsy or drainage pro-
Pneumothorax
cedures. Several small-gauge catheters are commercially
Pneumothorax may be traumatic or spontaneous. Trau- available for percutaneous pneumothorax drainage. These
matic pneumothorax most often results from penetrating or include the Cook pneumothorax catheter (Cook, Bloomington,
 AJR:164, March 1995 IMAGE-GUIDED THORACIC FLUID DRAINAGE 587

IN) [52], the Sacks catheter (Electro-Catheter, Rahway, NJ) suction (i.e., Pleur-evac) or to a flutter valve.
[53], and the Arrow pneumothorax catheter (Arrow Interna- Patients with indwelling pneumothorax catheters can be
tional, Reading, PA). A compact, one-piece pneumothorax managed as inpatients or outpatients. A patient whose lung
drainage system available for pneumothorax treatment is the completely reexpands following transcatheter pleural air evac-
Tru-Close Thoracic Vent (UreSil, Skokie, IL) [54]. This unit is uation and who shows no evidence of an air leak is safely
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composed of a 12- or 13-French, 10-cm-long catheter con- managed as an outpatient with a Heimlich valve [55]. Such a
nected to a rectangular chamber that contains a self-sealing patient should return to the hospital in 1 or 2 days for a follow-
aspiration port, a red signal diaphragm indicating entry into up chest radiograph. lfthe lung remains reexpanded, the cath-
the pleural space, and a flutter valve. The device also has self- eter is removed. Debilitated patients, those with severe
adhesive side flaps that help affix it to the chest wall. obstructive lung disease, and patients with a persistent air
In most patients, an anterior approach through the second leak precluding complete lung expansion should be hospital-
intercostal space in the midclavicular line is used to direct the ized and placed on suction. These patients should be moni-
catheter into the pleural apex. In women, a lateral approach tored daily with upright chest radiographs and the water seal
via the third, fourth, or fifth intercostal space in the midaxil- chamber of the drainage system checked for air leaks [56].
lary line may be used to avoid traversing the breast. After Once the lung has completely reexpanded and there is no evi-
sterile preparation and draping of the chest wall, 1% dence of an air leak, the catheter is removed. Patients with
lidocaine is administered liberally down over the superior prolonged air leaks and incomplete reexpansion of the lung
margin of the rib until air is aspirated from the pleural space. may require thoracoscopic or open procedures.
After a small skin incision is made over the rib beneath the Success of image-guided drainage of postbiopsy pneu-
interspace to be traversed, the catheter/trocar combination is mothorax using catheters from 5.5- to 16-French in outer
gradually advanced through the chest wall in a cephalad diameter is 87-93% [47, 53, 54], with mean duration of pleural
direction to enter the pleural space over the superior aspect drainage approximately 3 days. The slightly lower success
of the rib. Once an intrapleural position is confirmed by aspi- rate and longer duration of treatment reported in the medical
rating air through the hollow trocar, the catheter/trocar com- [51] and surgical [55] literature for management of spontane-
bination is advanced an additional 1 cm to be certain the ous pneumothorax likely is related to higher incidence of per-
catheter tip is intrapleural. The trocar is then steadied, and sistent air leak in these patients. Pneumothorax drainage
the catheter is advanced over the lung apex under fluoro- failure may be due to catheter kinking or occlusion by blood or
scopic guidance (Fig. 6). To alleviate pain associated with fibrin [47, 51], inadvertent withdrawal from the pleural space
the catheter contacting the apical parietal pleura, 3 ml of [57], or presence of a large air leak [47]. Chest pain following
lidocaine is injected through the catheter once it has reached catheter placement is common [51] and probably results from
the pleural apex. The catheter is then taped or sutured to the catheter contact with the parietal pleura. Wound infection [55],
skin, and the pneumothorax is manually aspirated with a chest wall hematoma [58], and hemothorax may occur.
large syringe until resistance is encountered. Petroleum
gauze is packed around the catheter at the insertion site, and
an occlusive dressing is applied. The catheter is then Miscellaneous Intrathoracic Collections
attached via an adapter to an underwater seal device with Mediastinal abscesses not considered for surgical drain-
age can be drained percutaneously or by a transesophageal
approach successfully [59]. Sonography-guided pericardio-
centesis and transcatheter pericardial drainage have been
S

used in patients with infectious and malignant pericardial

effusions [60]. Recent reports have described successful
imaging-guided percutaneous treatment of aspergillomas
using amphotericin B and itraconazole [61].
Although the radiologist’s role in detecting intrathoracic air
and fluid collections is clear, his or her role in management of
these collections is less well defined. Radiologists performing
thoracic drainage procedures must be familiar with chest patho-
physiology and be willing to manage patients in consultation
with the primary physician. These factors and results of pro-
spective randomized trials comparing surgical and radiologic
drainage of intrathoracic collections will determine the role of
image-guided thoracic drainage in treating these disorders.

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