The “crime” of surgery for pleural infection is still happening across the world despite advances in management that have rendered surgery unnecessary delegates have heard.

Speaking at a session on the  advances and controversies in pleural medicine Gary Lee from Sir Charles Gairdner Hospital in Perth said Hippocrates was the first person to show a lot of interest in pleural infection.

Because he didn’t have ultrasound at that time (400 BC)  he used to shake patients by the shoulders to listen for the sound of fluid in the pleural space.

“I’ve tried that a couple of times and it never worked,” Lee said to a chuckling audience.

In the last 10 years we’ve seen more research and more advances in treating pleural infection than we have ever seen, Lee told delegates.

The main  principles of managing pleural infection has always been to try and manage infection and sepsis with antibiotics and evacuate the pleural infective collection by draining the pus usually through chest tubes, he said.

“If you are going to remember just one message from my talk it is that surgery is being performed unnecessarily every day around the world to clear residual pleural collections when the patient is already clinically improved and those radiological opacities will go away anyway,” Lee said.

“I urge you to remember to look upon pleural infection like pneumonia or lung infection the residual challenges will settle with time provided the infection is fully controlled”.

“The important point is to treat the patient and not the x-ray,” he said.

Lee’s top tips for managing pleural infection:

Antibiotics and chest tube drainage remain the key — you may need more than one chest drain and it should always be imaging guided.

If infection (fever and inflammatory markers) are not settled despite optimal antibiotics and drainage consider intrapleural tPA + DNase.

Surgery is rarely needed for pleural infection —  only if contraindications to tPA /DNase (especially broncho-pleural fistulas) or failure to respond (<5% of patients).