Thoracocentesis indications. Thoracocentesis: indications, preparation and conduct, consequences

Thoracocentesis is main procedure for doctors intensive care and urgent medical care, in reanimation. Before the procedure, ultrasonography may be performed to determine the presence and size of pleural effusions, as well as their localization.

This study is used in real time to facilitate anesthesia, and then the needle is placed.

Thoracocentesis is indicated for the symptomatic treatment of large pleural effusions or for the treatment of empyema. Also, the procedure is necessary for pleural effusions of any size that require diagnostic analysis.

• Transudate effusions are due to a decrease in plasma and result from a decreased plasma oncotic pressure and an increase in hydrostatic pressure. Heart failure is the most common cause, followed by cirrhosis of the liver and nephrotic syndrome.
• exudate effusions result from local destructive or surgical processes that cause increased capillary permeability and subsequent exudate of intravascular components to potential sites of disease. Causes are varied and include pneumonia, dry pleurisy, cancer, pulmonary embolism and numerous infectious etiologies.

There are no absolute contraindications for thoracentesis.

Relative contraindications include the following:

• Uncorrected bleeding diathesis.
• cellulite walls chest at the puncture site.
• Patient disagreement.

Attention

Before performing a thoracocentesis, it is important to pay attention to the patient's consent and his hopes for the procedure, as well as possible risks and complications.

Consent for thoracocentesis must be obtained from the patient or family member. You need to make sure they have an understanding about the procedure so they can make an informed decision.

The patient should be warned about the following risks from thoracocentesis:

Before the thoracocentesis procedure, it is necessary to analyze which of the above risks can be avoided or prevented (for example, the position of the patient in which he remains as still as possible during the procedure).

Thoracentesis Kit: Basic Materials List

There are several special medical devices specifically designed to perform the thoracocentesis procedure.

Assortment of GRENA thoracocentesis kits (Great Britain)

Thoracocentesis: technique for performing the main procedure and drainage of the pleural cavity

• Preparation for the procedure includes appropriate anesthesia and proper positioning of the patient's body.
• In addition to local anesthesia, it may also be considered general anesthesia lorazepam, which will help to cope with any manifestations of pain.

In thoracocentesis, pain medication is a critical component, as complications may develop in its absence. Local anesthesia is achieved with lidocaine.

Important

Leather, subcutaneous tissue, rib, intercostal muscle and parietal pleura should be well saturated with local anesthetic. It is especially important to anesthetize the deep part of the intercostal muscle and the parietal pleura, because the puncture of these tissues is accompanied by the most acute pain.

Pleural fluid is often obtained through anesthetic penetration into deeper structures to help guide needle placement.

The most favorable position of patients for thoracocentesis is sitting, leaning forward, the head lies on the hands or on a pillow, which is located on a special table. This position of the patient facilitates access to the axillary space. Patients who are unable to be in this position, take the horizontal on the back.

The towel roll is placed under the contralateral shoulder (where the procedure will be performed) so that the thoracocentesis drains the pleural density successfully and allows access to the next axillary space.

Technique for performing thoracocentesis

• Ultrasonography. After the patient has been seated, ultrasonography is performed to confirm the pleural effusion, assess its size and location. Next, determine the most optimal puncture site. For ultrasonography, either a curvilinear transducer (2-5 MHz) or a high-frequency linear transducer (7.5-1 MHz) is used. Aperture must be explicitly defined. It is important to choose an intercostal interval in which the diaphragm will not rise on exhalation.
• open way. This type of ultrasonography is used to determine the depth of the lung and the amount of fluid between the chest wall and the inner pleura. A free-floating lung may be marked as a wave.

Ultrasonography- a useful study for thoracocentesis, which helps to determine the optimal puncture site, improves the localization of local anesthetics and, most importantly, minimize the complications of the procedure.

The optimal puncture site can be determined by looking for the largest pocket of fluid superficial to the lung, determining airway diaphragm. Traditionally, this area is located between the 7th and 9th ribs.

Diagnostic analysis of pleural fluid

The pleural fluid is labeled and sent for diagnostic analysis. If the effusion is small and contains a large number of blood, the liquid is placed in a blood tube with an anticoagulant so that this mixture does not thicken.

The following laboratory tests should show the following points:

• pH level;
• gram color;
• cell count and differential;
• glucose levels, protein levels and lactic acid dehydrogenase (LDH);
• cytology;
• creatinine level;
• amylase level if esophageal perforation or pancreatitis is suspected;
• triglyceride levels.

Pleural fluid of the exudative type can be distinguished from transudative pleural fluid in the following cases:

1. Liquid/serum LDH ratio ≥ 0.6
2. Liquid/serum protein ratio ≥ 0.5
3. Fluid LDH level within the upper two-thirds of normal serum LDH level

There are no complications during thoracocentesis, but their development is possible after the procedure.

The main complications after the procedure of thoracocentesis and drainage:

• Pneumothorax (11%)
• Hemothorax (0.8%)
• Rupture of the liver or spleen (0.8%)
• Diaphragmatic wound
• empyema
• Tumor

Minor complications include the following:

• Pain (22%)
• Dry (13%)
• Cough (11%)
• Subcutaneous hematoma (2%)
• Subcutaneous seroma (0.8%)
• Fainting

Indications for thoracocentesis

An incision-puncture of the chest wall for the introduction of a drainage tube - thoracocentesis, in an outpatient setting is indicated for spontaneous and tension pneumothorax, when the puncture of the pleural cavity is insufficient to resolve threatening state. Such situations sometimes occur with penetrating wounds of the chest, severe closed injuries associated with tension pneumothorax, hemopneumothorax. Drainage of the pleural cavity is also shown with massive accumulation of exudate; in the hospital - with pleural empyema, persistent spontaneous pneumothorax, chest injuries, hemothorax, after operations on the organs of the chest cavity.

Thoracocentesis technique

Thoracocentesis and insertion of a drainage tube are most easily accomplished using a trocar. In the second intercostal space along the midclavicular line (to remove excess air) or in the eighth along the midaxillary line (to remove exudate), infiltration anesthesia is performed with a 0.5% novocaine solution to the parietal pleura. A scalpel is used to make an incision in the skin and superficial fascia slightly larger than the trocar diameter. A drainage tube is selected for it, which should pass freely through the trocar tube. More often, siliconized tubes from disposable blood transfusion systems are used for this purpose.

Through the skin wound, a trocar with a stylet is introduced into the pleural cavity along the upper edge of the rib. It is necessary to apply a certain force to the trocar, simultaneously making small rotational movements with it. Penetration into the pleural cavity is determined by the feeling of "failure" after overcoming the parietal pleura. Remove the stylet and check the position of the trocar tube. If its end is in the free pleural cavity, then air enters through it in time with breathing or pleural exudate is released. A prepared drainage tube is inserted through the trocar tube, in which several lateral holes are made (Fig. 69). The metal tube of the trocar is removed, and the drainage tube is fixed to the skin with a silk ligature, circling the thread 2 times around the tube and tightly tightening the knot to prevent drainage from falling out during patient movements and during transportation.

Rice. 69. Thoracocentesis. Insertion of a drainage tube using a trocar. a - introduction of the trocar into the pleural cavity; b - removal of the stylet, the hole in the trocar tube is temporarily covered with a finger; c - introduction of a drainage tube into the pleural cavity, the end of which is pinched with a clamp; d, e - removal of the trocar tube.

If a trocar is not available, or if a drain larger than the trocar tube needs to be inserted, use the technique shown in Fig. 70. After an incision-puncture of the skin and fascia in soft tissues intercostal spaces (along the upper edge of the rib) introduce with some effort the reduced branches of the Billroth clamp, push apart the soft tissues, the parietal pleura and penetrate into the pleural cavity. The clamp is turned upward, parallel to the inner surface of the chest wall, and the jaws are pushed apart, expanding the wound of the chest wall. The drainage tube is seized with the removed clamp and together they are introduced into the pleural cavity along the previously prepared wound channel. The clamp with divorced branches is removed from the pleural cavity, at the same time holding and pushing deep into the drainage tube so that it does not move along with the clamp. Check the position of the tube by sucking air or pleural fluid through it with a syringe. If necessary, advance it deeper and then fix it with a silk ligature to the skin.

Figure 70 Insertion of a pleural drain with a clamp. a - incision-puncture of the skin and subcutaneous fat; b - blunt expansion of the soft tissues of the intercostal space with a Billroth clamp; in - the imposition of a clamp on the end of the drainage tube; d - introduction of drainage into the pleural cavity through the prepared wound channel; e - fixing the drainage tube to the skin with a ligature.

The finger of a rubber glove with a cut top is put on the free end of the drainage tube and fixed with a circular ligature and placed in a jar with antiseptic solution(furatsilin), covering only the end of the tube. This simple device prevents the suction of air from the atmosphere into the pleural cavity during inspiration. A kind of valve system is created that allows fluid and air to only exit the pleural cavity to the outside, but prevents it from flowing out of the jar. When transporting a patient, the end of the drainage is placed in a bottle, which is tied to a stretcher or to the belt of the patient, who is in a vertical (sitting) position during transportation. Even if the tube (with a dissected finger from a glove at the end) falls out of the vial, the valve mechanism of drainage will continue to operate: if negative pressure occurs in the pleural cavity, the walls of the finger from the glove collapse and air access to the peripheral end of the drainage is blocked. In specialized hospitals, the drainage tube is connected to the suction (active aspiration system), which allows you to keep the lung in a straightened state.

Minor surgery. IN AND. Maslov, 1988.

Thoracostomy (in other words, fenestration of the chest wall) is performed to quickly remove intoxication by simultaneously emptying the abscess formed during pyopneumothorax, and creating access for its sanitation through a wide thoracotomy wound. Thoracocentesis- puncture of the chest wall in order to establish a diagnosis, to obtain the contents of the chest cavity, as well as to remove accumulated exudate or transudate for the purpose of treatment.

Thoracocentesis

Indications:

• Establishment of the etiology of pleural effusion;
• Removal of pleural effusion for therapeutic purposes;
• For the administration of drugs;
• Emergency removal of air in tension pneumothorax.

Contraindications:

• Obliteration of the pleural cavity;
• Coagulopathy - INR more than 2, thrombocytopenia less than 50×109/l;
• Varicose pleural veins in portal hypertension.

Thoracocentesis technique

A chest x-ray should be taken prior to the procedure. In case of pneumothorax, to remove air from the pleural cavity, the puncture should be performed in the 2nd intercostal space along the midclavicular line (with the patient sitting) or in the 5-6th intercostal space along the midaxillary line (with the patient lying on healthy side with a hand behind the head).

Attention. For pneumothorax, perform pleural puncture only in the most urgent cases (for example, tension pneumothorax). In the vast majority of cases, pneumothorax requires pleural catheterization.

With hydro- and puncture can be performed in the 6-7 intercostal space along the posterior axillary or scapular line (landmark - the lower edge of the scapula). A puncture is done to the patient in a sitting position - a person sits on the edge of the bed, putting his hands behind his head or putting them on the bedside table. The nurse insures him by holding his shoulders. If the patient cannot be seated, then the puncture site is chosen closer to the midaxillary line in the 5th-6th intercostal space.

1. Treat the puncture site with an antiseptic solution;

2. Draw 10 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture with an intramuscular needle (G22), perform layer-by-layer anesthesia of the skin, subcutaneous tissue, muscles, periosteum of the rib and parietal pleura. Gently advance the needle just above the upper edge of the underlying rib into the pleural cavity, with the syringe in the plunger-to-pull position. After the appearance of pleural contents in the syringe, remove the needle;

3. Take a needle from the kit for pleural puncture or another of suitable caliber (G14-18) and length (8-10 cm) and connect it to a 10 ml syringe;

4. At the selected point, maintaining the vacuum in the syringe (the “piston towards you” position), the chest wall and parietal pleura are pierced with a slow and smooth movement. The puncture of the chest wall is done, focusing on the upper edge of the underlying rib in order to avoid injury to the intercostal vessels;

5. If air or pleural contents begin to enter the syringe, the advance of the needle is immediately stopped;

6. Collect pleural contents into the syringe for laboratory testing. With hemothorax, a Revelua-Gregoire test is performed - if the blood obtained from the pleural cavity forms clots, then this indicates ongoing bleeding from the pleural cavity;

7. Depending on the situation, a conductor is passed through the needle and the pleural cavity is catheterized according to Seldinger (preferred option). Or attach a disposable blood transfusion system to the needle. Connect the distal end of the system to the suction low pressure(vacuum 20-30 cm water column), or, if the contents of the pleural cavity is fluid, simply lower its end below the level of the puncture.

Use a special catheter for pleural catheterizations. If the catheter you need is not available and you are using a central vein catheter to catheterize the pleural cavity. Choose for these purposes a catheter of the maximum diameter available to you. Make a small (1/3 of the catheter diameter) lateral hole 3-4 cm from the distal end with a scalpel blade - this will dramatically increase the efficiency of its work. Do not use peripheral venous catheters for drainage of the pleural cavity - they are too thin-walled and easily bent.

8. The signal to remove the needle (or catheter) is the appearance of pain as a result of its contact with the visceral pleura, the cessation of the release of fluid, air;

9. If the fluid is poorly evacuated, by changing the position of the patient's body, achieve an increase in the outflow rate. Or connect a low-pressure suction to the catheter for several hours via an extension cord. It is clear that when a needle was used instead of a catheter in a patient, such manipulations cannot be carried out;

10. After the end of the procedure, the skin puncture site is treated with an antiseptic solution and covered with a sterile gauze sticker.

11. Take a follow-up chest x-ray.

Thoracostomy

Indications

• Pleural effusion in a significant amount, which could not be evacuated by pleural puncture;
• Purulent pleurisy.

Execution Method

Training

1. Specify the localization of pneumothorax or pleural effusion using chest x-ray;

2. The patient should be in a prone or reclining position, the arm on the side of the lesion is thrown behind the head. The triangle is highlighted in the figure, where the introduction of drainage is most safe (6-4 intercostal space along the anterior axillary or mid axillary line);

3. Provide venous access and oxygenation through a nasal catheter. Consider the advisability of premedication (, narcotic analgesics);

4. Set up standard monitoring: ECG, SpO2, non-invasive blood pressure;

5. Determine the fifth intercostal space along the midaxillary line (located at the level of the nipple in men and the base of the mammary gland in women). With a marker, or otherwise, mark this point;

6. Widely treat the puncture site with an antiseptic and limit the skin with sterile wipes;

7. Draw 20 ml of 1% lidocaine solution into the syringe. At the point chosen for puncture with an intramuscular needle, perform layer-by-layer anesthesia of the skin, subcutaneous tissue, muscles and parietal pleura, focusing on the upper edge of the underlying rib;

8. Use a scalpel to make a 1-1.5 cm incision in the intercostal space just above the upper edge of the underlying rib. Drainage is prepared in advance. The end of the drainage, intended for insertion into the pleural cavity, is cut obliquely. Stepping back 2-3 cm from it, 2-3 side holes are made. 8-12 cm above the upper lateral opening, which depends on the thickness of the chest and is determined by pleural puncture, a ligature is tightly tied around the drainage. The other end of the drain is clamped with a clamp.

9. Further introduction of the drainage tube into the pleural cavity can be carried out through a trocar or in an open way using a clamp. And if smaller diameter drainages are used - according to Seldinger.

A trocar with an inserted stylet is inserted into the pleural cavity through the incision with rotational movements, focusing on the appearance of a feeling of failure. Then the stylet is removed and a drainage tube is inserted through the trocar sleeve into the pleural cavity. After removing the sleeve, the tube is carefully pulled out of the pleural cavity until a control ligature appears.

Open method: through the incision of the skin and subcutaneous tissue, a drainage tube is inserted into the pleural cavity with rotational movements, clamped with the tip of a clamp with sharp branches. After feeling a sense of failure, the clamp is slightly opened, and the drain is pushed to the required depth with the other hand. Then the clamp is carefully removed, holding the tube at the required level.

A U-shaped suture is placed around the tube to seal the pleural cavity. The seam is tied with a bow on the balls. The tube is fixed to the skin with 1-2 sutures, paying attention to the tightness of the sutures around the tube. Seldinger catheterization uses special kits and catheters for drainage of the pleural cavity.

Attention. Do not use tubes from disposable intravenous systems as drains. They are thin-walled, easily pinched.

10. In the case of a small pneumothorax, or in the presence of a liquid effusion, a 10-12 size French catheter (1Fr = 0.33 mm) is quite sufficient. With hemothorax - the size of the drainage tube should be at least 24 Fr (preferably 28-30 Fr). Thoracostomy using a trocar catheter, or a Seldinger catheter, is quite effective in pneumothorax, pleurisy, but not in the case of hemothorax. In case of hemothorax, immediately install a large diameter drainage tube (28-30 Fr).

11. Place a gauze bandage between the skin and the drainage tube and secure the drainage tube to the chest with adhesive tape.

12. Through an extension cord, connect the drain tube to a special (cavitary) low pressure suction. Vacuum - 20 cm of water. Art. (not higher - 30 cm water column).

Attention. Never connect the drain to a conventional surgical suction. This is deadly for the patient.

Another option is Bulau drainage. A safety valve is fixed at the outer end of the drainage tube - a finger from a rubber glove with a cut 1.5-2 cm long. Or an industrial valve. The valve must be immersed to a depth of 3-4 cm in a vial with a sterile solution (sodium chloride 0.9%). The tube is fixed so that the valve does not float and is always in solution. The valve prevents air and the contents of the jar from entering the drain tube. Do not occlude the pleural drain even for short period up to the moment of its removal, if the patient is undergoing mechanical ventilation.

13. Once the drain is in place, take a follow-up chest x-ray.

Removal of pleural drainage

With pneumothorax, the drainage is removed if air has not been discharged through the tube during the day. In other cases, the question of the time of removal of the tube is decided individually. Usually, the drainage is removed when the volume of discharge from the pleural cavity becomes less than 100-200 ml / day.

Deletion sequence

1. Remove the bandage and adhesive tape, cut off the seam that secures the tube;

2. Apply pressure to the skin next to the tube and remove the drain while exhaling;

3. Tie a U-shaped seam, apply a gauze bandage;

4. Take a follow-up chest x-ray to rule out pneumothorax.

Indications. Pleural effusion unclear etiology, detected radiographically, is the most common indication for pleural puncture; it is especially necessary if an exudative effusion is suspected. Patients with transudates usually do not undergo thoracocentesis, except in cases of suspicious effusion, when it is necessary to make sure that there are no other reasons for its appearance, except for an increase in hydrostatic pressure or a decrease in oncotic pressure. Thoracocentesis is indicated for infections of unknown origin or failure antimicrobial therapy. It is rarely needed for simple parapneumonic effusions if the patient is improving. Analysis of the pleural effusion is important in diagnosing and staging a suspected or known malignancy, and in unusual reasons the appearance of fluid in the pleural cavity (for example, hemothorax, chylothorax, or empyema), since in these cases, as a rule, additional invasive treatment. Sometimes it is necessary to investigate the effusion that occurs when systemic diseases(for example, with collagenoses).

Therapeutic indications. Thoracocentesis is used to eliminate respiratory failure caused by massive pleural effusion, as well as for the introduction of antitumor or sclerosing agents into the pleural cavity (after removal of the effusion). Most physicians prefer last case use thoracostomy tubes.

Technics. Thoracocentesis can be performed in different areas of the chest, depending on the indication (see terms Drainage of the pleural cavity, “Thoracotomy”). If it is necessary to perform thoracocentesis of the lateral wall of the chest, the patient is placed on the healthy half, under which a roller is placed so that the intercostal spaces move apart, if in the II-III intercostal space in front - on the back. When diagnosing respiratory failure, thoracocentesis should be performed with the patient half-sitting.

After processing the surgical field (within a radius of at least 10 cm), a 0.25-0.5% novocaine solution is used to produce local anesthesia skin along the projection of the intercostal space, and with a longer needle - anesthesia of the subcutaneous tissue, muscles. The advancement of the needle further should be accompanied by the continuous injection of novocaine solution. When the pleura is pierced, pain will appear. To clarify the location of the needle in the pleural cavity, pull the syringe plunger towards you - the entry of air or other contents into the syringe indicates that the needle has entered the pleural cavity. After that, the needle is slightly removed from the pleural cavity (for anesthesia of the parietal pleura) and 20-40 ml of novocaine solution is injected. Then the needle connected to the syringe is slowly and perpendicular to the chest cavity advanced into the pleural cavity, continuously bringing the syringe plunger towards itself.

The flow of fluid or air from the pleural cavity into the syringe makes it possible to characterize the depth of the free pleural cavity, to which it is safe to insert a trocar or clamp without fear of hurting internal organs. Having calculated the depth of the free pleural cavity by this method, the SKIN is cut and the soft tissues are moved apart and a trocar or clamp is inserted into the pleural cavity, depending on the purpose of the thoracocentesis. If, after this manipulation, drainage is introduced into the pleural cavity, the latter is fixed with a U-shaped suture, the ends of the thread are tied with a bow. This is done so that after removal of the drainage, it is possible to tighten the knot and close the wound without violating the tightness of the pleural cavity. If drainage is not introduced, the wound is sutured with 1-2 sutures, after which an aseptic dressing is applied.

Pyothorax in animals or thoracic empyema - inflammation of the pleura, characterized by the accumulation of purulent effusion in the chest cavity.

Pyothorax is the result of a bacterial or fungal infection of the pleural cavity. In most cases, pyothorax is characterized by moderate or significant number pleural exudate.

In animals with pyothorax, many pathogens can be sown, but there is a high frequency of diseases in which a single anaerobic pathogen is identified. Most commonly cultivated Bacteroides and Fusobacterium, as well as Pasteurella multocida. Also often found streptococci, staphylococci, different kinds Corynebacterium, Clostridium, Enterobacteriacae, Mycoplasma and even some types of fungi.

Causes purulent inflammation the pleural cavity may be:

• penetrating wounds of the chest cavity,
• bacterial pneumonia,
• penetration of foreign bodies,
• esophageal perforation,
• spread of infections from the neck or lumbar and mediastinum,
• hematogenous and lymphogenous dissemination of bacteria,
• perforation of the chest wall,
• osteomyelitis,
• inhalation of awns of cereals and their subsequent migration into the bronchi and pleural space.

Reliable breed or gender predisposition to the development of pyothorax in small domestic animals has not been identified. There is an opinion that young intact cats involved in skirmishes and receiving chest wounds have an increased risk of pyothorax, however, recent studies have shown that most common cause feline pyothorax - invasion through the light microflora of the oropharynx. Adult dogs may be predisposed to developing pyothorax large breeds(especially hunting), due to more frequent inhalation of plant foreign material (plant awns) and getting penetrating wounds of the chest. Cats with multiple housing may also be predisposed to pyothorax.

The course of the disease depends on the form and severity of the process. Secondary pleurisy can take months and years (tuberculosis). Purulent and putrefactive pleurisy often ends in the death of the animal during the first decade of the disease.

Symptoms

Pyothorax often has an insidious course, and the appearance of clinical signs may not be expressed for a long time. Clinical features are due to restrictive processes and include:

• inspiratory dyspnea,
• rapid shallow breathing,
• dyspnea (violation of the frequency and depth of breathing, accompanied by a feeling of lack of air.),
• orthopnea (difficulty breathing while lying down).

Additional clinical signs are intolerance physical activity, lethargy, anorexia and fever. Chronic or severe course infection leads to septic shock, dehydration, exhaustion and hypothermia.

Peculiarities clinical manifestations in dogs:

• depression, anorexia, fever;
• shortness of breath, shallow breathing, abdominal type;
• with dry pleurisy, pain in the intercostal spaces, friction noises coincide with excursions of the chest.
• with effusion pleurisy, splashing noises during auscultation, with percussion - horizontal dullness, regardless of the change in posture;
• body temperature rises by 1-1.5 ° C;

Features of clinical manifestations in cats:

• oppression, appetite is lowered;
• cyanosis of the mucous membranes;
• the temperature rises by 1-2°C;
• brown urine with a fetid odor, dry feces;
• shortness of breath, frequent breathing of the abdominal type;
• on palpation, the animal is worried, moaning;
• when the cat lies down, the chest is compressed, which interferes with breathing, so the cat is afraid to lie down;
• the slightest load leads to sharp deterioration states.

Diagnostics

Diagnosis is based on blood tests, chest x-ray, and thoracocentesis, followed by cytological and microbiological research received liquid.

At laboratory research revealed pronounced neutrophilic leukocytosis, degenerative shift to the left, anemia of chronic inflammation. Also, when examining blood and urine, signs of secondary infection of organs (hepatitis, pyelonephritis) can be detected.

On thoracocentesis, the effusion is opaque, white to amber to red in color, and the protein content is usually greater than 3.5 g/dl. At cytological examination a large number of degenerative neutrophils are detected. Macrophages and reactive mesothelial cells are present in the effusion in varying amounts, depending on the pathogen and chronicity of pyothorax. Culture of effusion is indicated in all animals with pyothorax, but positive results are not always achievable, especially when infected with anaerobic organisms.

At x-ray examination, due to the fact that the liquid has great ability absorb rays, a typical pattern is observed. It is characterized by a sharp division of the projection of the entire lung field into two parts, lower and upper. In the upper part, the shadows of the vertebrae and ribs stand out in contrast, and somewhat thickened root and lung patterns are also visible. Bottom part the chest is represented by a continuous, extensive, deeply intense and homogeneous darkening, upper bound which has a horizontal and sharply contoured edge. Against the background of this homogeneous dense shading, which is formed due to pleural effusion, in contrast to pneumonic shading, even the shadows of the ribs do not protrude. With extensive effusions, the cardiac silhouette is also not visible.

Treatment

The basis of the treatment of pyothorax - drainage.

After the diagnosis is made, a thoracostomy tube is inserted through which periodic lavage is performed ( 2-3 times a day) with warm saline with aspiration of the contents one hour after administration. The introduction of an antibiotic into the lavage solution does not present any advantages over their systemic administration. The duration of lavage with pyothorax can take up to 5-7 days.

Supportive care is often needed, including intravenous fluids and nutrition (through a nasal feeding tube or gastrostomy tube) to replace nutrient losses.

The final choice of antibiotic is based on the results of a culture study, and a combination of antibiotics is prescribed until the results are awaited. It should be remembered that the anaerobic microflora is not always determined by culture. The duration of antibiotic therapy for pyothorax is 4-6 weeks.

If the condition does not improve, further investigations should be done to look for underlying diseases (eg, feline viral leukemia, viral immunodeficiency, presence of a foreign body) or encapsulated abscesses in the lungs or pleura; they may develop as a result of insufficient timely or insufficient effective treatment. If there is an abscess, it must be opened after a thoracotomy.

In animals with pyothorax, in case of failure conservative treatment, an attempt is made to identify and surgically correct the source of infection ( foreign body, lung abscess, volvulus of the lobe of the lung). Surgical correction it can also be indicated for resection of tissues involved in the process and removal of debris.

The prognosis for pyothorax is favorable. In animals treated only with systemic antibiotics without lavage, the likelihood of recurrence of pyothorax is high. With the development of fibrinous pleurisy, the prognosis may not be favorable.