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Hemothorax (1)
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Thoracic Irrigation & CLR Use: Hemothorax Management

Retained hemothorax is common with standard chest drainage; frequently requires secondary interventions (e.g., lytics, VATS); and is associated with greater hospital length of stay and increased hospital costs.

Prakash 2020. In this 17-center study, 29% of patients with traumatic hemothorax developed retained hemothorax with standard management, 67% of these requiring secondary intervention. On average, patients with ret. HTX had 7 days longer hospital LOS (p = 0.002); 3 days longer ICU LOS (p = 0.001); 1 more ventilator day (p = 0.044); 3X more pneumonia (p < 0.001); and worse functional outcomes.

Zambetti 2022. Patients requiring VATS for retained hemothorax had similarly long hospital LOS (14 days) and ICU LOS (4 days) as found by Prakash 2020.

Wong 2022. Average increase in hospital costs associated with retained hemothorax management: lytics only $9,200, VATS only $10,700, open thoracotomy only $18,300. Costs higher if multiple interventions required.

Thoracic irrigation with CLR is associated with decreased odds of retained hemothorax requiring secondary intervention; fewer chest tube days; and zero safety events.   

Carver (TBD). For CLR irrigated patients, the odds of requiring a secondary intervention for retained hemothorax (e.g., VATS) was 80% lower than non-irrigated patients (Odds Ratio 0.20, p<0.001). CLR irrigated patients required 2 fewer chest tube days. Over 100 patients irrigated with CLR with zero safety events (e.g., no increased bleeding, no increased empyema).

Thoracic irrigation for hemothorax management is guideline-supported and associated with a decreased rate of retained hemothorax requiring secondary intervention, shorter hospital length of stay, and lower hospital charges.  

Lyons 2024. In this systematic review and meta-analysis, the group that received thoracic irrigation for traumatic hemothorax, had a lower failure rate (defined as incompletely drained or retained HTX requiring a second intervention such as lytics or VATS) – 10.7% vs. 18.2% in the non-irrigated group (p < 0.001); shorter hospital length of stay: (10.4 vs. 13.5 days, p < 0.001); shorter ICU length of stay (2.7 vs. 6.4 days, p < 0.001); lower rate of infectious complications (9.7% vs. 15.6%, p = 0.012); and a lower mean cost of the hospital stay ($223,729 vs. $312,481, p < 0.001).

Al Tannir 2024. Medical College of Wisconsin’s 5-year experience with thoracic irrigation: Lower retained HTX (10% vs 21%, p < 0.001); lower rate of VATS (6% vs 19%, p < 0.001); shorter chest tube duration (4 vs. 6 days, p < 0.001); shorter hospital LOS (8 vs. 10 days, p = 0.04).
Carver 2024. 11-center, prospective observational study. 493 hemithoraces. 44% decrease in the odds of requiring a secondary intervention (e.g., second chest tube, operative management) for retained hemothorax in the irrigation group (p = 0.005).​
Crankshaw 2022. Thoracic irrigation associated with 4 fewer hospital days than standard therapy (p = 0.04). When irrigated with >1000cc, patients stayed in hospital for 8 fewer days (p=0.002). Hospital charges an average of $88,000 lower in irrigated patients (p=0.02). No difference in thoracic infections.​
Kugler 2017. Thoracic irrigation associated with 84% lower odds of requiring a of secondary intervention for retained hemothorax: 5.6% vs. 21.8% for standard therapy patients (p<0.001). No difference in thoracic infections. ​
Kugler 2016. Thoracic irrigation associated with 75% reduction in secondary intervention for retained hemothorax in this pilot study: 5% vs. 20% for standard therapy patients. ​

Orlando Regional Medical Center’s Hemothorax Management Algorithm. Early and repeated (as needed) CLR-enabled thoracic irrigation is incorporated into ORMC’s standard hemothorax management.​

Western Trauma Association. Thoracic irrigation is incorporated in the WTA’s hemothorax management algorithm.​

McLauchlan 2024. 9-patient series of thoracic irrigation via 14F pigtail.

“Specialized devices, such as the CLR Irrigator… can allow for more ergonomic lavage as well as the ability to rapidly cycle between irrigation and suction… [and] may agitate and more effectively dilute the traumatic HTX, theoretically inhibiting coagulation. Cycling irrigation may also help to clear mild obstructions formed during suction…”

Episode 732, 2024. Hot Topics in Trauma: Western Trauma Association 2024. ​

“I’ll be honest with you, when we started the whole process [of thoracic irrigation] there was a lot of resistance. But [now]… we like it, we love it…” (Univ Med Center, New Orleans, re: CLR use)​

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Thoracic Irrigation & CLR Use: Complicated Pleural Effusion Management

 Retained pleural collection is common with standard chest drainage and systemic antibiotics; frequently requires secondary interventions (e.g., lytics, VATS). 

Corcoran 2020. In this 29-center, international prospective study, 33.5% of patients with pleural infection failed to have an adequate response to standard chest tube drainage and systemic antibiotics. Failure was defined as “the presence of a significant residual pleural collection alongside clinical or biochemical features of uncontrolled infection, such as ongoing fevers or persistently elevated inflammatory markers” as “measured at 3– 5 days post study inclusion.” Failure was not significantly different in groups with different baseline RAPID risk categorization.

Hooper 2015. PIT Trial. In this randomized controlled pilot study involving 35 patients, saline irrigation (3x/day for 3 days) added to standard management was compared to standard management alone. Irrigated patients had a significantly greater reduction in pleural collection volume on CT (32.3% vs. 15.3%, p<0.04) and significantly fewer irrigated patients were referred for surgery (OR 7.1, p=0.03)

Bansal 2019. In this study of 82 patients with complicated pleural effusions, 200cc normal saline irrigations 3x/day for 3 days performed similarly to use of intrapleural streptokinase (250,000 units/day in 50 ml normal saline for 3 days) with regard to both residual fluid noted on ultrasonography and hospital length of stay.
Guinde 2021. Saline lavage was used for empyema management in 30 patients, 11 with an active cancer, with improvement in effusion size on chest x-ray and in inflammatory markers. A low percentage (13.3%) of patients required an additional pleural procedure. No surgical referrals required.
Mennander 2005. An active pleural irrigation protocol (2000cc 3x/day for 2-4 days) was instituted for empyema patients post-thoracotomy if persistent opaque discharge noted. No reoperations required in the irrigated group vs. 14% re-operation in non-irrigated patients. No deaths in the irrigated group vs. 12% in the non-irrigated group.
Ikebe 2025. Saline irrigation successfully employed for patient with empyema with fistula formation in the context of massive pulmonary embolism and recent cardiac arrest.
Porcel 2016. This study compared 23 patients with complicated parapneumonic effusion or empyema who received saline flushing in addition to serine protease urokinase to 39 patients who only received fibrinolytic therapy. The administration of saline flushes reduced fibrinolytic therapy (a single dose of urokinase being sufficient in 44% vs 15%, p=.019); chest tube duration (2 vs 5 days, p < .01); and length of hospital stay (6 vs 8 days, p=.011) as compared with urokinase alone.
Kheir 2020. In this prospective multicenter RCT, 32 patients underwent either early medical thoracostomy including 1-liter saline irrigation or intrapleural fibrinolytic therapy. The median LOS after an intervention was 4 days in the lytic arm and 2 days in the medical thoracoscopy incl. irrigation arm (P = 0.026). The total hospital LOS was 6 days in the lytic arm and 3.5 days in thoracoscopy arm (P = 0.12).
Uribe 2025. In four patients with complicated pleural infections and contraindications to intrapleural fibrinolytic therapy, CLR irrigation was well-tolerated and yielded significant clinical and radiographic improvement. No major adverse events occurred, and no patient required a further pleural intervention.
Belt 2025. A case of successful pleural evacuation with one sitting of CLR irrigation in a patient with a loculated and potentially infected malignant effusion.

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Disclaimer: The studies depicted above should not be interpreted as an endorsement of CLR device use for a specific clinical indication, use case, or clinical protocol, or as a claim of a specific clinical outcome. Use of CLR devices must always be guided by clinical judgement per the indications for use.
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