Ultrasound‐assisted insertion of a small‐diameter thoracic catheter for acute dorsal empyema

Abstract

Key Clinical Message

Ultrasound‐assisted small catheter placement may be considered in cases where computed tomography guidance is unavailable, and ultrasound can identify pleural effusions clearly, even in cases where empyema is localized solely on the dorsal side.

Abstract

Thoracic catheter insertion for empyema can be challenging when the pleural effusion is localized dorsally and computed tomography guidance is unavailable. We report the case of a 40‐year‐old man with acute dorsal bacterial empyema who underwent successful ultrasound‐assisted catheter placement in an orthopneic position.

1. INTRODUCTION

The initial treatment for acute pleural empyema includes antimicrobial therapy and pleural drainage, usually performed in the supine position. ¹ However, when the empyema is localized dorsally, computed tomography (CT)‐guided drain placement is performed by an interventional radiologist (IVR) or surgeon because the difficulty of chest tube insertion is high in such cases. ²

The clinical problem is that immediate drainage for empyema may be necessary even in hospitals without a surgeon or IVR practitioner.

Herein, we describe a case of dorsal empyema in which ultrasound‐assisted small‐diameter catheter insertion was performed with the patient in an orthopneic position.

2. CASE PRESENTATION

A 40‐year‐old man with untreated diabetes mellitus presented with 2 weeks of persistent fever and right back pain in January 2023. Blood tests showed elevated C‐reactive protein (12.9 mg/dL) and HbA1c (11.4%) levels, indicating poor diabetic control. Chest CT revealed a right dorsal encapsulated pleural effusion (Figure 1). The pleural effusion was simple and encapsulated, not accompanied by septation on ultrasound. Thoracentesis showed pale red pleural effusion with a pH of 6.99 and a glucose level of 117 mg/dL. Culture of the pleural effusion revealed Prevotella intermedia and Fusobacterium nucleatum, confirming the diagnosis of an acute bacterial empyema.

FIGURE 1.

Chest imaging findings on admission. (A) The chest radiograph reveals decreased permeability in the right lung field and an elevated right diaphragm. (B–E) Chest computed tomography reveals a lung abscess in the right upper lobe (green arrowhead) and large dorsal encapsulated pleural effusions (red arrowheads) that also extend into interlober spaces. Images (B) and (D) show the lung window, and images (C) and (E) show the plain mediastinal window.

The patient was hospitalized, and intravenous treatment with sulbactam/ampicillin was initiated. We attempted a thoracic drainage procedure with the patient in the supine position; however, this was unsuccessful because pleural effusion was not identified on ultrasound imaging. Our institution had neither an interventional radiologist nor a thoracic surgeon, and the COVID‐19 pandemic prevented immediate referral to a nearby advanced‐care hospital. Therefore, the patient was placed in an orthopneic position, and a 12‐Fr aspiration catheter (Argyle™ Fukuroi Trocar Aspiration Kit, Cardinal Health, Dublin, OH, USA) was inserted in the right eighth intercostal space at the back under ultrasound assistance. Continuous aspiration was initiated under a negative pressure of 7 cmH₂O. Drainage was successful, and the catheter could be removed after 20 days. The empyema resolved after approximately 6 weeks of antimicrobial therapy (Figure 2).

FIGURE 2.

(A) A 12‐Fr catheter inserted dorsally in the orthopneic position. (B, C) Chest computed tomography performed after 15 days of pleural drainage reveals the successful insertion of the thoracic catheter and decreased pleural effusions. (D) Chest radiograph showing remarkable improvement in right empyema after 6 weeks of treatment.

3. DISCUSSION AND CONCLUSION

The present case suggests two clinical implications. First, it is possible to insert a catheter for dorsal empyema at the back and in an orthopneic position under ultrasound assistance instead of CT guidance. If the empyema is localized dorsally, the catheter is generally inserted in the prone position under CT guidance because of the difficulty identifying pleural effusions with ultrasound in the supine position. ² In contrast, thoracentesis is commonly performed in the orthopneic position, which is the easiest position to observe and puncture a pleural effusion. Therefore, we used ultrasound, were able to identify pleural effusions, and successfully inserted the catheter in the orthopneic position without the need for CT guidance.

Second, although there is no consensus on the appropriate drain size for empyema, ¹ using a small‐diameter catheter for the initial treatment of empyema is acceptable. The lateral thoracic intercostal space can be widened by elevating the upper extremities; however, the dorsal intercostal space is narrow and difficult to widen by posture. Furthermore, dorsal thoracentesis requires more caution because, at sites close to the spine, the intercostal artery is exposed within the intercostal space. ³ Therefore, a 12‐Fr catheter was inserted to ensure successful drainage.

In conclusion, pleural drainage of acute empyema localized to the dorsal aspect is challenging. Ultrasound‐assisted small catheter placement may be considered in cases where CT guidance is unavailable, and ultrasound can identify pleural effusions clearly.

AUTHOR CONTRIBUTIONS

Yudai Hasegawa: Writing – original draft. Akihito Okazaki: Writing – review and editing. Kazuhiko Iwasaki: Writing – review and editing.

FUNDING INFORMATION

This research was not supported by any specific grant from any funding agency in the public, commercial, or nonprofit sectors. Therefore, no funding body was involved in the design of the study, the collection, analysis, and interpretation of the data, the writing of the manuscript, or the decision to submit the manuscript for publication.

CONSENT

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

Hasegawa Y, Okazaki A, Iwasaki K. Ultrasound‐assisted insertion of a small‐diameter thoracic catheter for acute dorsal empyema. Clin Case Rep. 2024;12:e8576. doi: 10.1002/ccr3.8576

DATA AVAILABILITY STATEMENT

No datasets were generated or analyzed during this case report.