Management of purulent pleurisy: punctures and active aspiration
The initial stage of treatment for purulent accumulation in the pleural cavity is pleural puncture. It is performed daily, trying to remove the exudate as completely as possible. A reliable sign that the cavity is cleared is negative pressure in the syringe: when the plunger is pulled, the contents do not flow, and when released, the plunger is pulled back in. After removing the fluid, proteolytic enzymes and antibiotics are injected inside.
If a series of punctures proves ineffective, proceed to active continuous aspiration. The procedure includes:
- Skin incision with a scalpel.
- Puncture of the intercostal space with a wide trocar (stylet inside the cannula).
- Insertion of a drainage tube through the sleeve followed by removal of the trocar.
- Fixation of the drainage to the skin with a suture or adhesive tape.
There is also an alternative installation method, where the drainage is passed through an incision, clamping it with the jaws of a hemostatic clamp. A constant negative pressure (50–100 mm H₂O) is created in the installed system using a water-jet or electric vacuum suction pump. This ensures reliable removal of pus and apposition of the pleural layers.
To increase efficiency, the system is supplemented with a flushing function. In this case, a flushing drain (with a throttle clamp to control the supply of the solution) is placed in the upper part of the cavity, and an aspiration drain connected to an exudate collector, a water vacuum gauge, and a compressor is placed in the lower part.
Passive aspiration and thoracostomy
When it is impossible to arrange continuous active traction, passive suction according to Bülau is used. The essence of the method is to create a one-way outflow:
- A valve cut from surgical glove rubber is placed on the outer end of the drain.
- The tube is lowered into a jar filled with an antiseptic solution.
The valve works on the nipple principle. During exhalation, it lets pus and air out of the chest cavity. During inhalation, negative pressure occurs in the pleural cavity, causing the rubber valve to collapse, reliably blocking the back-suction of air or fluid.
In rare cases, when all options of closed drainage yield no result, thoracostomy (the open method) is resorted to. Wide access is necessary to physically remove dense masses that do not pass through a narrow drain: thick pus, massive fibrin clots, and sequestra of destroyed lung tissue.
Diagnosis and treatment of purulent pericarditis
When purulent inflammation develops in the pericardial sac, the patient is provided with strict bed rest in a semi-sitting position. Pericardial puncture plays a key role in making the diagnosis and saving the patient's life.
The manipulation is performed in a sitting position under local infiltration anesthesia. The injection is made on the left, in the angle between the base of the xiphoid process and the cartilage of the VII rib. The needle or thin trocar is advanced behind the sternum strictly upward, constantly pulling the plunger toward oneself until fluid is obtained. The instrument must be advanced extremely cautiously, as there is a high risk of myocardial damage.
As soon as pus appears in the syringe, the diagnostic procedure turns into a therapeutic one. The exudate is completely evacuated, and antibiotics in a procaine solution (e.g., 500,000 IU of kanamycin in 25–30 ml of 0.25% procaine) are injected into the pericardial cavity. Subsequently, the antibiotic is adjusted based on the results of bacteriological culture. Such therapeutic punctures are repeated at intervals of 3–5 days. If conservative measures and punctures do not lead to improvement, surgical intervention—pericardiostomy—is indicated.
To understand the mechanism of Bülau drainage, imagine a turnstile for exit: on exhalation, the flaps (rubber valve) open, releasing pus, and on inhalation, they snap shut from the inward pull, keeping air out.
Class and exam questions
How to understand that no pus remains in the pleural cavity during a puncture?
The procedure is completed when negative pressure is recorded in the syringe. When pulling the plunger, the contents do not enter, and if the plunger is released, it returns to its original position by itself.
Why is the needle directed behind the sternum upwards during a pericardial puncture?
Such a trajectory from the injection site (between the xiphoid process and the VII rib on the left) provides the shortest access to the lower part of the pericardial cavity where the exudate accumulates, and minimizes the risk of direct heart damage.
What to do if thick pus and fibrin do not drain through the drainage tube?
In cases where closed drainage methods cannot cope with thick pus and pulmonary sequestra, a transition to thoracostomy—an open surgical method of cavity cleansing—is indicated.
What else to study on this topic
- Stages and technique of local infiltration anesthesia during punctures
- Diagram of vacuum drainage with a flushing system (connection of the BK-1 compressor)
- Interpretation of the results of macro- and microscopic examination of exudate
- Indications for pericardiostomy and its execution technique
- Selection of proteolytic enzymes for administration into the pleural cavity
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Other topics from the section "CHAPTER 11. SURGICAL INFECTION (PURULENT-INFLAMMATORY DISEASES)"
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