Pleural Space Infection Research Articles

Tunneled Pleural Catheters for the Treatment of Patients With Pleural Infection and a Nonexpandable Lung: A Single-Center Case Series

SESSION TITLE: Chest Infections SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Pleural infection represents a common diagnosis encountered in clinical practice. It is associated with substantial morbidity, mortality, and increased hospital costs. Optimal management of patients with pleural infection varies depending on individual factors and co-morbidities but usually includes antibiotics, tube thoracostomy, intrapleural fibrinolytic therapy, and thoracoscopy (medical or video-assisted). Patients with pleural infection with non-expandable lung, who are not candidates for decortications have limited treatment options. These include open window thoracostomy (i.e. Clagett window, Eloesser flap or chronic chest tube drainage). Unfortunately, these procedures are associated with significant morbidity as they often lead to chest deformity and chronic pain. Tunneled pleural catheters (TPC) might represent a feasible, minimally invasive alternative for such patients. METHODS: This was a retrospective study conducted at Beth Israel Deaconess Medical Center between 2011 and 2016. Consecutive patients with pleural infection and a non-expandable lung initially treated with antibiotics, tube thoracostomy and intrapleural fibrinolytic therapy who were not fit for surgery, were included. RESULTS: Five catheters were inserted in five patients. All patients were discharged from the hospital within 6 days of TPC placement (range: 1-6 days, mean: 4 days). Following discharge, TPC drainage was performed daily in three patients and once every other day in the remaining two cases. Two patients received one dose of intrapleural fibrinolytic therapy into the TPC due to catheter blockage. These catheters were removed after 57 and 62 days due to auto-pleurodesis and successful complete drainage, respectively. The remaining three patients had advanced malignancy and the TPC continued to drain for as long as they were followed. These cases were followed for 10, 33 and 109 days after TPC insertion. No further adverse events related to TPC were reported during these periods. CONCLUSIONS: TPCs are safe and effective when used for drainage of patients with infected pleural space and a non-expandable lung. They should be considered a treatment option to complement adequate antibiotic therapy, in non-surgical candidates. This technique may favor prompt hospital discharge and ambulatory management, particularly benefiting patients with limited life expectancy. CLINICAL IMPLICATIONS: TPCs provide an alternative option to drain patients with infected pleural space and non-expandable lung, who are not fit for surgery. DISCLOSURE: The following authors have nothing to disclose: Andres De Lima, Fayez Kheir, Sebastian Fernandez-Bussy, Mihir Parikh, Alex Chee, Adnan Majid No Product/Research Disclosure Information

Impact of Delayed Chest Closure on Surgical Site Infection After Lung Transplantation

Delayed chest closure is an increasingly used approach in the management of bleeding and hemodynamic instability after lung transplantation. We sought to evaluate the impact of delayed chest closure on surgical site infection. We performed a single-center retrospective cohort study and included adult patients who received a lung transplant at our center between January 1, 2010, and July 31, 2014. We defined surgical site infection as a thoracotomy incision wound or pleural space infection. Follow-up was complete through 6 months after transplantation. We used logistic regression models to examine the impact of delayed chest closure on surgical site infection and to identify other potential risk factors. During the study period, 67 of the 232 transplant procedures (29%) required delayed chest closure, and surgical site infection developed in 22 recipients (9%). Among the patients with surgical site infection, 18 experienced a wound infection, and 8 experienced a pleural space infection; 4 experienced concomitant wound and pleural space infection. Among the 67 who underwent delayed chest closure, 13 patients (19%) experienced a surgical site infection compared with 9 of the 165 patients (5%) who underwent primary closure (p= 0.001). In multivariate analysis, delayed chest closure was an independent risk factor for surgical site infection. Although delayed chest closure may have an important role in the immediate management of recipients of a lung transplant, it is an independent risk factor for surgical site infection, and this is associated with increased morbidity.

Diagnostic approach to pleural diseases: new tricks for an old trade.

The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.

Use of intrapleural tissue plasminogen activator and deoxyribonuclease in pleural space infections: an update on alternative regimens.

Pleural infection remains a common problem with significant associated morbidity and mortality. The current treatment paradigm for pleural infection appears to be shifting as more recent data have suggested that the use of intrapleural fibrinolytic therapy (IPFT) may be adequate for treatment, potentially avoiding the need for surgical intervention in a significant number of patients. The previous Multicenter Intrapleural Sepsis Trial demonstrated improved outcomes when utilizing combined IPFT, however, more recently alterations in this dosing regimen have been explored. Successful retrospective studies have examined the role of extended dosing (more than six sequential doses), concurrent dosing (instilling both medications together as opposed to separate medication dwell times), and daily dosing of intrapleural medications. Although the use of IPFT is likely shifting the management of pleural infection to less surgical intervention, the optimal dosing strategy of intrapleural therapy remains undefined. Within the last few years more data on variations of IPFT have emerged. This data remains of lower quality because of its retrospective nature and future prospective evaluation is required to further define the optimal dosing regimen for IPFT in complicated pleural space infections.

Latissimus Dorsi Muscle Harvest

Muscle flaps have multiple applications in thoracic surgery. Among the available flaps, the latissimus dorsi muscle flap is of special interest because of its unique characteristics, such as its large volume, making it suitable for filling pleural spaces, its constant pattern of vascular supply, and its wide arch of rotation, enabling transposition to different regional sites in the chest, back, and neck, thus eliminating the need for vascular microanastomosis in virtually all applications within the chest. Also, after division of the dominant vascular pedicle, the latissimus dorsi can be prepared as an inverted flap and used for reconstruction of the diaphragm. The latissimus dorsi muscle flap is useful for myoplasty of infected pleural spaces and bronchial fistulas, as well as for reconstruction of large soft tissue defects. The latissimus dorsi can be used either as a simple muscle flap or as a musculocutaneous flap. It is well suited to be used locally but also as a free flap with microvascular anastomosis in remote areas of the body. This paper presents the technique of harvesting the latissimus dorsi muscle flap and provides clues for its effective application in different clinical scenarios.

Tunneled Indwelling Pleural Catheters for Refractory Pleural Effusions after Solid Organ Transplant. A Case-Control Study.

The use of tunneled indwelling pleural catheters for management of refractory pleural effusions continues to increase. Pleural space infections are among the most common and serious complication of the procedure. The risk may be higher in patients receiving immunosuppressive medications. The aim of this study was to assess the risk of infections complicating placement of a tunneled indwelling pleural catheter in patients who have received a solid organ transplant. Electronic medical records were retrospectively reviewed to identify patients with prior solid organ transplant who subsequently underwent placement of a tunneled intrapleural catheter. We selected a matched sample of comparison patients without solid organ transplant who underwent the same procedure during the study period. Detailed chart abstraction was performed to compare baseline clinical information with procedure outcomes in both groups. Nineteen study patients underwent kidney, liver, lung, or heart transplant. Another 55 patients were included in the nontransplant comparison group. Transplant patients were taking a mean of 2.4 (range, 1-4) immunosuppressive medications. In transplant patients, the intrapleural catheter remained in place for a median of 95 days (interquartile range, 58-256 d). Two of the 19 transplant patients (16.9% 90-day Kaplan-Meier estimate) and 4 of the 55 control patients (11.0% weighted 90-day Kaplan-Meier estimate) developed a major infectious complication (not significant). There were no deaths attributed to intrapleural catheter placement in either group. In a series of 19 patients with solid organ transplantation taking daily immunosuppressive medications who underwent placement of a tunneled intrapleural catheter, we report an 11% rate of major infectious complications over the lifetime of the catheter in the transplant group with no significant difference in 90-day estimated risk of complication between transplant and nontransplant comparison group.

The American Association for the Surgery of Trauma grading scale for 16 emergency general surgery conditions: Disease-specific criteria characterizing anatomic severity grading.

Abstract The American Association for the Surgery of Trauma (AAST) Committee on Patient Assessment has previously published a uniform system for describing anatomic severity for Emergency General Surgery (EGS) diseases and applied these to 16 specific EGS disease processes: appendicitis, breast infections, acute cholecystitis, acute diverticulitis of the colon, esophageal perforation, hernias (internal or abdominal wall), infectious colitis, intestinal obstruction, intestinal arterial ischemia of the bowel, acute pancreatitis, pelvic inflammatory disease, perforated peptic ulcer disease, perirectal abscess, pleural space infection, skin and soft tissue infections, and surgical site infections. Standardized definitions of categorizing these diseases will be essential for risk adjustment and comparing patient outcomes among different centers. We now report on the final construct for the data dictionaries including clinical, imaging, operative, and pathologic criteria to correspond with each grade of each EGS disease. The data dictionaries are based on review of the literature, examination of existing grading systems, and discussion with expert consensus. Level V - Expert opinion STUDY TYPE: Current Opinion or Special Report.

Isolated empyema necessitans in a renal transplant recipient: A case report

Empyema necessitans is a rare sequel of untreated pleural space infection and is most commonly secondary to tuberculosis. Isolated tuberculous empyema necessitans in a renal transplant recipient is extremely rare. It is an important differential diagnosis of a chest mass in renal transplant recipient. Early identification and treatment prevents progression and morbidity. We hereby report a 62-year-old male renal transplant recipient who presented with classical features of tubercular empyema necessitans and was managed with antitubercular therapy and tube thoracostomy drainage.

Practical management of pleural empyema

Empyema is defined as pus in the thoracic cavity due to pleural space infection and has a multifactorial underlying cause, although the majority of cases are post-bacterial pneumonia. Despite treatment with antibiotics, patients with empyema have a considerable morbidity and mortality due at least in part to inappropriate management of the effusion. Timely diagnosis of pleural space infection and rapid initiation of effective pleural drainage represent fundamental principles for managing patients with empyema. Ultrasound is particularly useful to identify early fibrin membranes and septations in the pleural cavity conditioning treatment strategy. Empyema and large or loculated effusion with a pH < 7.20 need to be drained. Thoracoscopy has largely been used in pleural effusion due to lung infection. Whereas the efficacy of video-assisted thoracic surgery (VATS) in empyema management has been evaluated in several retrospective studies showing favourable results, less is known about the role of medical thoracoscopy (MT) in pleural infection. MT, appears to be safe and successful in multiloculated empyema treatment. It is also lower in cost and in frail patients is better tolerated than VATS which requires tracheal intubation.

Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections.

The use of intrapleural therapy with tissue plasminogen activator and DNase improves outcomes in patients with complicated pleural space infections. However, little data exists for the use of combination intrapleural therapy after the initial dosing period of six doses. We sought to describe the safety profile and outcomes of intrapleural therapy beyond this standard dosing. A retrospective review of patients receiving intrapleural therapy with tissue plasminogen activator and DNase was performed at two institutions. We identified 101 patients from January 2013 to August 2015 receiving intrapleural therapy for complicated pleural space infection. The extended use of intrapleural tissue plasminogen activator and DNase therapy beyond six doses was utilized in 20% (20/101) of patients. The mean number of doses in those undergoing extended dosing was 9.8 (range of 7–16). Within the population studied there appears to be no statistically significant increased risk of complications, need for surgical referral, or outcome differences when comparing those receiving standard or extended dosing intrapleural therapy. Future prospective study of intrapleural therapy as an alternative option for patients who fail initial pleural drainage and are unable to tolerate/accept a surgical intervention appears a potential area of study.

Tunneled Indwelling Pleural Catheters (TIPC) for Refractory Pleural Effusions in Patients With Solid Organ Transplant

SESSION TITLE: Interventional Pulmonary SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 25, 2015 at 04:30 PM - 05:30 PM PURPOSE: The use of tunneled indwelling pleural catheters (TIPC) for symptomatic management of refractory pleural effusions continues to rise. Pleural space infections occur in 5% of patients with TIPC for malignant pleural effusions, and this risk is likely higher in patients receiving immunosuppressive therapy which is often considered a relative contraindication to TIPC placement. The use of TIPCs for refractory pleural effusions in solid organ transplant recipients, a population typically maintained on high levels of immunosuppression, has not been reported. METHODS: Electronic records were retrospectively reviewed to identify all patients at our institution with solid organ transplant who subsequently underwent TIPC placement between 1/1/2005 and 12/31/2014. In each patient meeting inclusion criteria, a detailed chart abstraction was performed to identify indication for catheter placement, duration of TIPC, immunosuppressive medication regimen, and TIPC related complications including infection or death. RESULTS: A total of 19 patients were identified, with the following solid organ transplants: kidney (n=12), liver (n=4), heart (n=4), and lung (n=1) with some patients having several organ transplants. TIPC was placed for malignant pleural effusion in 26% (5/19) with the remainder placed for non-malignant indications such as congestive heart failure or hepatic hydrothorax. Patients were taking a mean of 2.4 different immunosuppressive agents at the time of their TIPC placement, and the two most commonly used agents were tacrolimus (n=13) and mycophenolate (n=13). The TIPC remained in place for a median of 95 days (interquartile range 58-241 days). The most common reasons for removal were patient death (n=9) and autopleurodesis (n=8). Two out of the 19 patients developed pleural space infection; both requiring hospitalization. In both cases, the patients were successfully treated with IV and oral antibiotics and did not require thoracic surgical intervention or removal of the TIPC. There were no deaths due to TIPC complication. CONCLUSIONS: In this series of patients with solid organ transplantation who underwent TIPC implantation, we report an 11% rate of major infectious complication with no fatal complications. CLINICAL IMPLICATIONS: Placement of TIPC may be an option for patients with prior solid organ transplant who develop refractory pleural effusions. The benefit to the patient must be weighed against the risk of infection. DISCLOSURE: The following authors have nothing to disclose: Joseph Skalski, Fabien Maldonado No Product/Research Disclosure Information

Prolonged Intrapleural Fibrinolytic Therapy in Complicated Pleural Space Infections: Identification of Risk Factors and Complications of Use

Prolonged Intrapleural Fibrinolytic Therapy in Complicated Pleural Space Infections: Identification of Risk Factors and Complications of Use

(629) - Distractions During Lung Transplantation Surgery - Do Interruptions Matter?

Interruptions and non-operative distractions during surgery may lead to surgical errors and are associated with poorer outcomes within many surgical specialities. Lung transplantation’s multi-disciplinary nature and its inherent complexity makes it more vulnerable to theatre distractions. We aimed to investigate the frequency and severity of distracting events during lung transplantation and its impact on post-operative complications. A prospective study was undertaken by direct observation of distractions and interruption events during lung transplantations. Theatre team was ‘blinded’to the study. Events were identified and assessed using the Imperial College Error Capture tool(ICECAP). ICU & hospital stay, pleural space infections, bleeding and anastomotic complications were correlated with the number and severity of distracting events. 287 hours was observed across 41 lung transplants (36 bilateral & 5 single lung transplants) from August 2011 to August 2014. We recorded 2059 interrupting or distracting events. Surgeons were consciously aware of 19.2% of recorded events. 61% were due to procedure-independent pressures, 15% were due to equipment problems, 12% were due to communication issues (misunderstandings or inability to hear each other) and the remainder were associated with technical problems or patient-safety concerns. 83% of procedure-independent pressures were non-operative distractions. Common causes of non-operative distractions were ringing telephones and patient-unrelated discussions. 9% were caused by staff absences at a critical moment of surgery. The number and severity of distracting events were positively correlated with post-operative bleeding (p<0.01), anastomotic complications(p<0.03) and prolonged ICU stay (p=0.002) but not with pleural space infection(p=0.2) or hospital stay (p=0.08). Surgeons were often unaware of the large number of distractions and interruptions whilst operating. Situational awareness must be raised to provide a safer operating environment. Greater numbers of distractions and interruptions were associated with more anastomotic complications, re-operations for bleeding and longer ICU stay. NOTSS or FOCUS frameworks may be implemented to reduce theatre distractions and interruptions to improve patient outcomes.

Lactobacillus Empyema in a Patient With Schizophrenia

Lactobacillus species are anaerobic gram-positive rods that are part of the normal human flora as well as commercially available probiotic formulations. Although their pathogenicity in the normal host has been the subject of debate, lactobacilli have been associated with serious infections in immunosuppressed patients and those with predisposing risk factors. We report a case of a patient with a history of schizophrenia who presented with an empyema, cultures of which identified Lactobacillus acidophilus and Lactobacillus rhamnosus as the causative organisms. To our knowledge, this is the first case of Lactobacillus parapneumonic pleural space infection reported from the Western Hemisphere.

Posterior Spinal Fiksasyon İçin Kullanılan Lomber Orta Hat İnsizyonundan Torasik Ampiyemin Spontan Drenajı

Empyema is defined as pus in the thoracic cavity due to a pleural space infection caused by bacterial infection following community or hospital- acquired pneumonia or, rarely, blunt or penetrating chest injuries or surgical procedures. Evidence-based guidelines indicated that surgical drainage is more likely to be effective in patients with empyema. The spontaneous drainage of pus through intercostal and paravertebral muscles to the outside is a rare event. In our case, thoracic empyema was drained spontaneously via a lumbar median skin incision for used posterior spinal fixation in an unusual way. Chest and spine injury are found together in the majority of trauma cases. To our knowledge, this case whose thoracic empyema was drained lumbar median skin incision will be first case in the current literature. The surgeons should consider thoracic empyema as a cause of postoperative wound infection or discharge after thoracolumbar fixation.

Application of a uniform anatomic grading system to measure disease severity in eight emergency general surgical illnesses.

Emergent general surgical diseases encompass a broad spectrum of anatomy and pathophysiology, creating challenges for outcomes assessment, research, and surgical training. The goal of this study was to measure anatomic disease severity for eight emergent general surgical diseases using the uniform grading system of the American Association for the Surgery of Trauma (AAST). The Committee on Patient Assessment and Outcomes of AAST applied the previously developed uniform grading system to eight emergent general surgical diseases using a consensus of experts. It was then reviewed and approved by the Board of Managers of AAST. Severity grades for eight commonly encountered emergent general surgical conditions were created: breast abscess, esophageal perforation, infectious colitis, pelvic inflammatory disease, perirectal abscess, pleural space infections, soft tissue infections, and surgical site infections. The range of grades from I through V, reflect progression from mild disease, limited to within the organ itself, to widespread severe disease. This article provides a uniform grading system for measuring anatomic severity of eight emergent general surgical diseases. Consistent adoption of these grades could improve standardization for quality assurance, outcomes research, and surgical training.

Anaerobes in nosocomial and community acquired pleural infections

Anaerobes are important causes of pleural space infections. The aim of the study is to evaluate the role of the anaerobic bacteria in pleural infections. The study involved 278 consecutive clinical samples sent to the Clinical Microbiology Laboratory of Tertiary Chest Hospital. Anaerobes were isolated in 39 community acquired and five nosocomial cases out of 278 anaerobic cultivations (15.8%). Total of 56 anaerobe strains were identified and 21 aerobes were accompanied to anaerobic isolates. Aerobe isolates were associated with anaerobic microorganisms in 19 cases (43.2%). Bacteroides species (21.4%) and Pseudomonas aeruginosa (33.3%) were the most common anaerobic and aerobic isolates.

Indwelling Pleural Catheter Insertion Following Inefficient Thoracoscopic Decortication in Postpneumonic Empyema: Beneficial or Contraindicated?

Video assisted thoracic surgery in advanced stage postpneumonic empyema aims for thorough debridement and washout of the pleural space followed by an attempt to release the entrapped lung (decortication). When the latter isn’t successful, and the patient is in a poor performance status, applying tube thoracostomy is the usual routine, to avoid conversion to thoracotomy and open decortication. Tube thoracostomy, however, is associated with complications necessitating further surgery, needs long term follow up and also entails quality of life distorting issues. To overcome these disadvantages, we instead inserted a PleurX&reg indwelling pleural catheter in four patients in the above situation. The method brought success (lung re-expansion and complete or partial pleurodesis) without the need for further surgery or quality of life problems in either patient. Although the use of the indwelling pleural catheter in infected pleural space is not recommended by manufacturers, we noted no complications.

Western Trauma Association Critical Decisions in Trauma

P leural infection associated with pneumonia is a potentially lethal disease afflicting more than 60,000 patients annually in the United States. The incidence continues to rise, and the mortality rate exceeds that of myocardial infarction. Five thousand years ago, the Egyptian physician Imhotep first described pleural space disease,4 and Hippocrates in 400 BC was credited for recognizing that prompt drainage of the infected pleural space is essential.5 When these infections become loculated, they are no longer amenable to tube thoracostomy and operative decortication is required. To understand the pathophysiology of a complicated parapneumonic effusion, it is instructive to review the anatomy of the pleural and cytologic players maintaining homeostasis in this unique space. The pleural cavity arises from the coelom that also forms the pericardium and peritoneum. The pleural cavity is lined by mesothelial cells surrounded by a layer of connective tissue, macula cribiformis, which is then encased in two layers of elastic tissue. Visceral mesothelium is intricately connected to the lung parenchyma, whereas the parietal layer is more loosely connected to the thoracic structures separated by a variable fatty layer. The parietal pleura has specialized areas known as stoma, and an extensive lymphatic network exists below which is the predominant route of fluid resorption. Under normal conditions, it is estimated that each pleural cavity generates 0.2 to 0.4 mL/kg per hour. The fluid originates predominantly from the parietal capillaries because of hydrostatic pressure, augmented by the negative pressure of the pleural space. Less fluid is produced by the visceral pleura because the hydrostatic pressure is attenuated by pulmonary venous drainage. However, the visceral surface will add more pleural fluid with increased pulmonary interstitial pressure. The capacity for pleural fluid absorption is thought to exceed 500 mL of fluid from each cavity with an intact lymphatic system. Thus, the net accumulation of pleural fluid is the result of a dynamic system of fluid production and absorption. Recent ultrasound studies of healthy individuals suggest that less than 4 mm of dependent pleural fluid should be considered normal. Complicated parapneumonic effusions, and ultimately empyemas, develop in three conceptual phases. The early phase is a sterile effusion caused by parenchymal inflammation that activates mesothelial cells and enhances capillary permeability, termed exudative (days 2Y5). This is thought to be driven by proinflammatory cytokines, including interleukin 8 and tumor necrosis factor->.8 Ultimately, the volume of fluid traversing into the pleural cavity exceeds the capacity to reabsorb the fluid and an effusion develops. The second phase is termed fibropurulent, which is initiated by bacterial infection (days 5Y10). At this point, the immune system is activated and the once hypocoagulable environment is changed dramatically. Bacterial and neutrophil activity acidify the fluid, consume glucose, increase protein content, and release lactate dehydrogenase (LDH) from cellular apoptosis and necrosis. The environment now becomes hypercoagulable because of the integrated responses of the innate immune and coagulation systems. These findings are directly relevant to the evolution of complicated effusions because the exuberant fibrin deposition is a concerted effort to control progressive infection. The final state of a complicated effusion is referred to as the organization phase (days 10Y21). Fibroblasts migrate into the pleural space and create a dense fibrotic lining of the visceral and parietal surfaces. This phase is thought to be driven by regenerative cytokines, for example, transforming growth factor-A and platelet-derived growth factor released primarily from activated mesothelial cells. The net result is a progressive rind that encases the lung, reducing ventilatory capacity and sequestering bacteria. The objective of this management algorithm for parapneumonic fluid collections (Fig. 1) is to outline cost-effective diagnostic and therapeutic interventions in the surgical intensive care unit (SICU) based on the pathologic state of the pleural cavity. These guidelines are derived from the published experience with adult populations, but conceptually, the same principles apply to the pediatric age group.17Y20

Critique of ‘Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study’

Background: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy. Methods: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 h of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications. Results: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH≤300 cc (odds ratio [OR], 3.7 [2.0–7.0]; p&lt;0.001). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6–13.7]; p=0.005), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2–9.0]; p=0.023), and volume of RH≤900 cc (OR, 3.9 [1.4–13.2]; p=0.03). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4–9.9]; p&lt;0.001), RH&gt;900 cc (OR, 3.2 [1.4–7.5]; p=0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; p=0.015). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively. Conclusion: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.