PYOTHORAX

FIRST, AN ANATOMY LESSON (BECAUSE MOST PEOPLE DON'T KNOW WHAT THE PLEURAL SPACE IS):

Pyothorax happens in an area of the chest called the "pleural space" and since this isn't a mainstream body part, we will explain exactly where that is. The thorax is another way of saying "chest cavity." We all know our chest cavities contain our heart and lungs and if we think about it a little, there are some other important organs as well: the esophagus transverses the entire chest cavity to get to the stomach, there are some very large blood vessels coming off the heart, the trachea (windpipe) connects to the lungs etc.). But all these important organs aren't just packed in there; they are organized.

A structure called the mediastinum separates the chest cavity into right and left (sort of the way your nasal septum divides your nasal cavity into right and left). Inside the mediastinum, the heart, large vessels, esophagus and any other central organs all rest so that they don't go flopping around whenever you roll over or turn in a circle. The lungs fill in the right and left sides of the chest cavity but keep in mind they are not attached to the chest wall directly. They mostly fill the space but not completely.

The space around the lungs is the pleural space.

The canine pleural cavity and its contents. The pleural space is shown in yellow.
(Photocredit: Veterinary Information Network)
 

The pleural space normally contains less than a teaspoon of fluid for lubrication. In disease, the pleural can fill with any of the following fluids:

• Air (“Pneumothorax”)
• Blood (“Hemothorax”)
• Lymph (“Chylothorax”)
• Clear fluid (“Hydrothorax”)
• Pus (“Pyothorax”)

THE STORY OF PYOTHORAX

Normally, the pleural space is very small as most of the chest cavity is taken up by the expanding lungs. A small amount of fluid is present for lubrication purposes. If fluid actually fills the pleural space, however, it becomes difficult for the lung to expand as there simply is not enough room in the chest for lots of fluid and normal lung volume. The patient cannot breathe and begins to use abdominal muscle to expand the chest. Breaths become labored, rapid, and shallow. Because the fluid is so inflammatory, there is usually a fever. The pet is listless, will not eat, and has effortful rapid breathing (the abdominal muscles are recruited to assist respiration).

HOW DOES PUS GET INTO THE PLEURAL SPACE?

inflammation and pus. This situation tends to be more complicated than the feline situation as it involves the presence of an actual foreign body that must be removed to resolve the pyothorax (see later). the infection. Regardless of whether there is a bite wound or a foreign body the results are the same. Extra fluid is produced and overwhelms the normal fluid drainage conduits so that fluid production and drainage are no longer in balance. Soon the entire pleural space is filled with pus. The patient has difficulty breathing and the toxic, inflammatory material in the fluid creates fever, listlessness, and death is expected without treatment.

Other causes of pyothorax include: rupture of the esophagus, bacterial pneumonia leading to rupture of a lung abscess, or lung parasites.

In the dog, the definitive cause of the pyothorax is found in only 4 - 14% of cases
while in cats the cause is found in 40 - 67% of cases. 

Diagnosis is confirmed when the chest is tapped with a needle and pus is obtained from inside the chest cavity. The pus is generally cultured to get a better handle on what organisms are present and thus which antibiotics are likely to be the most helpful.

TREATMENT

Pyothorax is one of those conditions where prognosis can be reasonably good (assuming the patient is not too far gone at the time of presentation) as long as aggressive treatment is pursued. If one tries to go with inexpensive alternatives to proper treatment, a poor outcome is likely. So what is needed to “do this disease right.”

• In-dwelling chest tubes are placed (usually one on each side of the chest). The management of these tubes generally demands 24 hour hospitalization.
• Fluid is flushed into the tubes and the pus is drained out several times daily.
• Intravenous antibiotic administration geared towards both anaerobic and aerobic growing bacterial is required (or antibiotics are selected based on culture of the pus).
• Ideally some kind of advanced imaging is performed to see if surgery is going to be required (presence of an abscessed lung lobe harboring an inhaled foxtail, a physical structure on the internal chest wall that harbors the infection such as a broken off twig etc.). If a foreign body or abscessed internal structure is present inside the chest, it will have to be removed which adds tremendous expense but may be the only way to resolve the pyothorax.

Less likely to be adequate would be:

• Periodically tapping the chest with a needle to withdraw the pus. This is will probably not provide enough drainage.
• Oral antibiotics without beginning with intravenous antibiotics in the initial stages.
• Leaving a chest tube unattended overnight. If the tube unclamps, the patient’s chest cavity becomes open to the outside atmosphere. When this occurs, the patient cannot breathe. In hospitals where they do not offer overnight care, the tube can be clamped and wrapped but an industrious animal can potentially chew through these safeguards and the owner should understand this risk if the patient is left alone overnight.
• Antibiotics alone without some kind of chest drainage will not be effective.

After the fluid has stopped re-forming and the patient has a good appetite, the tubes are withdrawn and the patient can go home. Antibiotics are given for many weeks to ensure that this very deep infection is cleared. Recurrence is possible if the infection is not completely cleared and is felt to be more likely if the anaerobic organisms: Actinomyces or Nocardia have been cultured. In a review of several pyothorax studies, recurrence rates ranged from 0% to 14% in cats and 11.6% in dogs. Positive outcome/recovery was achieved in 58%-100% of the patients depending on the study

The overall message is that pyothorax is a life-threatening condition and death can be expected without treatment. Proper treatment requires critical care, which may be expensive, but has a fair chance for success. Surviving patients will need several weeks of medication at home. Some patients will require surgery.
 

Page last updated: 4/14/2021