Key Points

• Most pleural infections are successfully treated with closed chest tube drainage or by surgical decortication.
• Patients who have localized infection not adequately treated by insertion of a chest tube and who are too infirm for a more extensive surgical decortication are best treated with an open drainage procedure.
• Open drainage allows for durable treatment of localized infection with minimal morbidity.
• Tissue transposition techniques may be used to close the open drainage cavity once the infection is controlled.

Open drainage of established pleural space infections has been described since the time of Hippocrates. It is only in the past 100 years, with the advent of radiographic imaging and antibiotic therapy, that open drainage has become an infrequent tool in the thoracic surgeon’s armamentarium. Most pleural infections are successfully treated with closed suction drainage. In the presence of entrapped lung or multiloculated collection in a patient who is physiologically capable of tolerating an extended thoracotomy, decortication and removal of pleural peel is indicated. However, a small fraction of patients present with chronic empyema and are unable to tolerate extensive thoracotomy. These patients are the optimal candidates for open drainage.

Historically, use of open drainage led to unacceptably high mortality rates. It was not until World War I that open drainage early in the course of an empyema was abandoned due to recognition of the hemodynamic consequences of the resulting pneumothorax.

The indications for open drainage are as follows:

• Open drainage is typically reserved for high-risk patients who may not tolerate more aggressive interventions.
• The empyema must be localized and the underlying lung not likely to re-expand with tube thoracostomy or decortication. This may be the result of parenchymal destruction or chronic fibrosis of the underlying lung.
• Surrounding lung tissue must be well adhered to the surrounding chest wall to prevent complications of open pneumothorax.
• Postpneumonectomy empyema with or without bronchopleural fistula is particularly amenable to open drainage. Definitive closure of the chest may be performed later, once the infection is controlled and the fistulas have healed.