Abstract Background Empyema and complicated parapneumonic effusions are commonly managed with chest tube drainage, antibiotics, and intrapleural fibrinolytic therapy. While saline irrigation has been proposed as an adjunctive method to enhance pleural drainage, its role is not well established. Case Presentation A 61-year-old incarcerated transgender female with history of multiple sclerosis and gender identity disorder on estradiol presented with acute shortness of breath and hypoxia. On admission, she had tachypnea with a respiratory rate of 30 breaths per minute and required 40 L/min of oxygen at 100% FiO2 via high-flow nasal cannula. Laboratory results were notable for an elevated white blood cell (WBC) count of 17.8 × 109/L, acute kidney injury (creatinine 2.4 mg/dL), and lactic acidosis (6.7 mmol/L). CT chest demonstrated a large loculated right pleural effusion with compressive atelectasis and right lower lobe consolidation. Broad-spectrum antibiotics were initiated and thoracentesis revealed turbid pleural fluid with 91,000 WBC (75% neutrophils). Cultures grew Candida species and Streptococcus mitis/oralis. A chest tube was placed and intrapleural Tissue Plasminogen Activator and Dornase Alfa (tPA/DNase) therapy was started; micafungin was added for fungal coverage. Despite therapy, the patient developed septic shock requiring vasopressors and mechanical ventilation. Bronchoscopy revealed mucus plugging, which was cleared, but chest tube drainage ceased, raising concern for persistent loculations. A second chest tube was placed in a more posterior position. Immediately following placement, large fibrinous dark blue and orange material obstructed the tubing (Figure 1A, 1B). After this, 500 mL of sterile saline was instilled into the pleural cavity, which mobilized copious fibrinous and purulent material, allowing free drainage. Pathology of the debris revealed vegetable matter with acute inflammation suggestive of intestinal or aspirated material, and cultures grew Candida glabrata. Repeat CT imaging demonstrated hyper-dense material within the pleural space consistent with oral contrast from a lower esophageal perforation (Figure 1C, 1D). The patient’s hypoxia and shock rapidly improved after irrigation and drainage. She was extubated shortly after and subsequently underwent right-sided VATS with decortication and esophageal stent placement for a small posterior perforation. Conclusion This case illustrates the potential benefit of bedside pleural irrigation with sterile saline in enhancing drainage and improving outcomes in complicated empyema, particularly when fibrinous material impedes chest tube function. Further studies are warranted to evaluate its efficacy and to establish whether saline irrigation should be incorporated into standard empyema management protocols. This abstract is funded by: None
Bhagat et al. (Fri,) studied this question.