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Taniguchi J, Matsui H, Nagai T, Otsuki A, Ito H, Sugimura H, Nakashima K. Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study. BMC Pulm Med 2023; 23:273. [PMID: 37479981 PMCID: PMC10362621 DOI: 10.1186/s12890-023-02559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection. METHODS In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery. RESULTS Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003). CONCLUSIONS Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection. TRIAL REGISTRATION The participants were retrospectively registered.
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Affiliation(s)
- Jumpei Taniguchi
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296- 8602, Chiba, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Clinical Research Support Office, Kameda Medical Center, Chiba, Japan
| | - Tatsuya Nagai
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296- 8602, Chiba, Japan
| | - Ayumu Otsuki
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296- 8602, Chiba, Japan
| | - Hiroyuki Ito
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296- 8602, Chiba, Japan
| | - Hiroshi Sugimura
- Department of Thoracic Surgery, Kameda Medical Center, Chiba, Japan
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa, 296- 8602, Chiba, Japan.
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Maleche MA, Sirera B, Masika KB, Keitany KK, Oduor C, Diero L. A case report of a 16-year-old male with extrapulmonary tuberculosis presenting as multiloculated mediastinal, pleural, and paravertebral fluid collections with chest pain, Eldoret, Kenya. Clin Case Rep 2023; 11:e7574. [PMID: 37351360 PMCID: PMC10282118 DOI: 10.1002/ccr3.7574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 06/24/2023] Open
Abstract
Key Clinical Message Extrapulmonary TB presenting as multiloculated pleural fluid collections is rare in persons less than 18 years of age, but it can occur. High index of suspicion is important in establishing early diagnosis and treatment to reduce morbidity and mortality. Abstract We present a case report of an immunocompetent African young man who presented with persistent chest pain and fever, and was diagnosed with extrapulmonary tuberculosis (EPTB) following chest CT scan, pleural biopsy histopathology examination, and Ziehl-Neelsen (ZN) staining, and pleural fluid Gene Xpert studies.
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Affiliation(s)
| | - Betty Sirera
- Department of MedicineMoi University College of Health SciencesEldoretKenya
| | | | | | - Chrispine Oduor
- Department of MedicineMoi University College of Health SciencesEldoretKenya
| | - Lameck Diero
- Department of MedicineMoi University College of Health SciencesEldoretKenya
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3
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Zuccatosta L, Piciucchi S, Martinello S, Sultani F, Oldani S, de Grauw AJ, Maitan S, Corso MR, Poletti V, Ravaglia C. Is there any role for medical thoracoscopy in the treatment of empyema in children? THE CLINICAL RESPIRATORY JOURNAL 2023; 17:105-108. [PMID: 36594222 PMCID: PMC9892693 DOI: 10.1111/crj.13578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 12/20/2022] [Indexed: 01/04/2023]
Abstract
It is still controversial whether surgical or nonsurgical treatment approaches are most appropriate for empyema in children, and there are no data regarding the role of medical thoracoscopy in this population. The aim of this study was to describe our experience with medical thoracosocpy in children with multiloculated and organizing pneumonia. We retrospectively reviewed children admitted to our hospital with a diagnosis of empyema from 2011 to 2021 and treated with medical thoracoscopy. A total of six patients with empyema were treated by medical thoracoscopy; empyema was multiloculated in five cases and organized in one case; all children in the study recovered completely with full lung expansion after chest X-rays, and no disease sequelae were reported after clinical follow-up. Our small case series suggests that in selected cases, medical thoracoscopy could safely and effectively treat pleural empyema in children, with less invasiveness and reduced psychological consequences.
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Affiliation(s)
- Lina Zuccatosta
- Pulmonology and Bronchology UnitMarche Polytechnic University HospitalAnconaItaly
| | - Sara Piciucchi
- Radiology UnitG.B. Morgagni Hospital/University of BolognaForlìItaly
| | | | - Fabio Sultani
- Pulmonology UnitG.B. Morgagni Hospital/University of BolognaForlìItaly
| | - Stefano Oldani
- Pulmonology UnitG.B. Morgagni Hospital/University of BolognaForlìItaly
| | | | - Stefano Maitan
- Intensive Care UnitG.B. Morgagni Hospital/University of BolognaForlìItaly
| | | | - Venerino Poletti
- Pulmonology UnitG.B. Morgagni Hospital/University of BolognaForlìItaly,Dipartimento di Scienze Mediche e Chirurgiche (DIMES)Alma Mater Studiorum University of BolognaBolognaItaly
| | - Claudia Ravaglia
- Pulmonology UnitG.B. Morgagni Hospital/University of BolognaForlìItaly
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Gallyamov EA, Surkov AI, Nikulin AV, Diduev GI, Malofei AM, Romanikhin AI. XENOPERICARD COMBINED WITH NPWT (NEGATIVE PRESSURE WOUND THERAPY) IN THE TREATMENT OF ADVANCED PLEURAL EMPYEMA WITH BRONCHOPLEURAL FISTULA (CLINICAL FOLLOW-UP). SURGICAL PRACTICE 2022. [DOI: 10.38181/2223-2427-2022-2-75-83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The development of bronchopleural fistula (BPS) against the background of advanced pleural empyema, as a result of severe pneumonia, is a formidable complication. The most significant obstacle in the surgical treatment of this group of patients is: a pronounced comorbid background, low functional indicators of patients, high requirements for surgical technique when performing reconstructive plastic interventions in BPS. Multiple surgical methods for treating bronchopleural fistulas are suggested. The first of these were to suture the defect. However, access through the infected pleural cavity leads to suture eruption and recurrence of the fistula, despite the fact that some authors have proposed combining these operations with various variants of myoplasty, thoracoplasty, removal of the fibrous capsule of empyema. Unsatisfactory functional and cosmetic outcomes during these surgical interventions led to the development of endoscopic, minimally invasive surgical interventions. Modern technologies allow temporary endoscopic bronchiococclusion, which stops the release of air from the defect. However, at the same time, she "turns off " part of the lung tissue from the gas exchange. Prolonged bronchial occlusion leads to the development of pneumonia with an outcome in the destruction of lung tissue. Our team of authors treatment of bronchopleural fistula with xenopericardium in combination with negative pressure therapy. This area seems to us very promising, and in this work we would like to share our first experience.
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Affiliation(s)
- E. A. Gallyamov
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
| | - A. I. Surkov
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
| | - A. V. Nikulin
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
| | - G. I. Diduev
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
| | - A. M. Malofei
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
| | - A. I. Romanikhin
- GBUZ "City Clinical Hospital No. 23 named after I.V. Davydovsky Department of Health of the city of Moscow"
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Saxena K, Maturu VN. A Comparative Study of the Safety and Efficacy of Intrapleural Fibrinolysis With Streptokinase and Urokinase in the Management of Loculated Pleural Effusions. Cureus 2022; 14:e26271. [PMID: 35898352 PMCID: PMC9308892 DOI: 10.7759/cureus.26271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/05/2022] Open
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Zettinig D, D’Antonoli TA, Wilder-Smith A, Bremerich J, Roth JA, Sexauer R. Diagnostic Accuracy of Imaging Findings in Pleural Empyema: Systematic Review and Meta-Analysis. J Imaging 2021; 8:jimaging8010003. [PMID: 35049844 PMCID: PMC8778997 DOI: 10.3390/jimaging8010003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/17/2021] [Accepted: 12/23/2021] [Indexed: 12/26/2022] Open
Abstract
Computed tomography (CT) diagnosis of empyema is challenging because current literature features multiple overlapping pleural findings. We aimed to identify informative findings for structured reporting. The screening according to inclusion criteria (P: Pleural empyema, I: CT C: culture/gram-stain/pathology/pus, O: Diagnostic accuracy measures), data extraction, and risk of bias assessment of studies published between 01-1980 and 10-2021 on Pubmed, Embase, and Web of Science (WOS) were performed independently by two reviewers. CT findings with pooled diagnostic odds ratios (DOR) with 95% confidence intervals, not including 1, were considered as informative. Summary estimates of diagnostic accuracy for CT findings were calculated by using a bivariate random-effects model and heterogeneity sources were evaluated. Ten studies with a total of 252 patients with and 846 without empyema were included. From 119 overlapping descriptors, five informative CT findings were identified: Pleural enhancement, thickening, loculation, fat thickening, and fat stranding with an AUC of 0.80 (hierarchical summary receiver operating characteristic, HSROC). Potential sources of heterogeneity were different thresholds, empyema prevalence, and study year.
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Affiliation(s)
- Desiree Zettinig
- Division of Research and Analytical Services, Department of Informatics, University Hospital Basel, 4031 Basel, Switzerland; (D.Z.); (T.A.D.); (A.W.-S.); (J.A.R.)
- Institute of Radiology, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Tugba Akinci D’Antonoli
- Division of Research and Analytical Services, Department of Informatics, University Hospital Basel, 4031 Basel, Switzerland; (D.Z.); (T.A.D.); (A.W.-S.); (J.A.R.)
- Department of Radiology, University Children’s Hospital Basel, 4056 Basel, Switzerland
| | - Adrian Wilder-Smith
- Division of Research and Analytical Services, Department of Informatics, University Hospital Basel, 4031 Basel, Switzerland; (D.Z.); (T.A.D.); (A.W.-S.); (J.A.R.)
| | - Jens Bremerich
- Department of Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland;
| | - Jan A. Roth
- Division of Research and Analytical Services, Department of Informatics, University Hospital Basel, 4031 Basel, Switzerland; (D.Z.); (T.A.D.); (A.W.-S.); (J.A.R.)
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, 4056 Basel, Switzerland
| | - Raphael Sexauer
- Division of Research and Analytical Services, Department of Informatics, University Hospital Basel, 4031 Basel, Switzerland; (D.Z.); (T.A.D.); (A.W.-S.); (J.A.R.)
- Department of Radiology and Nuclear Medicine, University Hospital Basel, 4031 Basel, Switzerland;
- Correspondence: ; Tel.: +41-6132-86-584
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Bedawi EO, Guinde J, Rahman NM, Astoul P. Advances in pleural infection and malignancy. Eur Respir Rev 2021; 30:200002. [PMID: 33650525 PMCID: PMC9488125 DOI: 10.1183/16000617.0002-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/12/2020] [Indexed: 02/03/2023] Open
Abstract
Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Julien Guinde
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Najiib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Philippe Astoul
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
- Aix-Marseille University, Marseille, France
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8
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Ranganatha R, Tousheed SZ, MuraliMohan BV, Zuhaib M, Manivannan D, Harish BR, Manjunath PH, Hibare KR, Kumar H, Sagar C, Annapandian VM. Role of medical thoracoscopy in the treatment of complicated parapneumonic effusions. Lung India 2021; 38:149-153. [PMID: 33687009 PMCID: PMC8098890 DOI: 10.4103/lungindia.lungindia_543_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: The role of medical thoracoscopy in the treatment of pleural infections is increasingly being recognized. This study was done to assess the role of medical thoracoscopy in the management of carefully selected subset of patients with complicated parapneumonic effusions (PPEs). Materials and Methods: We analyzed retrospective data of 164 thoracoscopic procedures performed at our center on patients with complicated PPE in the past 10 years. Patients were subjected to medical thoracoscopy based on ultrasonographic stratification and a computed tomography (CT) thorax. Medical thoracoscopy was performed after an intercostal block under conscious sedation with midazolam (2 mg) and fentanyl (50 mcg) and local anesthesia with lignocaine 2% (10–15 ml), through a single port 10 mm diameter thoracoscope. Results: A total of 164 patients (119 males and 45 females) underwent medical thoracoscopy during the study period. The mean age was 47.4 ± 15.9 (median, 50; range, 16–86). The final diagnosis by thoracoscopy was bacterial empyema in 93 patients and tuberculosis in 71 patients. Medical thoracoscopy was successful without subsequent intervention in 160 (97.5%) patients, two patients underwent a second procedure, in the form of decortication, and two patients died due to sepsis. There were no major procedure-related complications that required intervention. Conclusion: Early adhesiolysis and drainage of fluid using medical thoracoscopy should be considered in patients with multiloculated complicated PPE after careful radiological (ultrasonography and CT) stratification, as a more cost-effective and safe method of management.
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Affiliation(s)
- Ramanjaneya Ranganatha
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - Syed Zulkharnain Tousheed
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | | | - Muhammed Zuhaib
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - Deepika Manivannan
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - B R Harish
- Department of Anesthesia, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | | | - Kedar R Hibare
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - Hemanth Kumar
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
| | - Chandrasekar Sagar
- Department of Pulmonology and Internal Medicine, Mazumdar Shaw Medical Center, Narayana Health City, Bengaluru, Karnataka, India
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9
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Altmann ES, Crossingham I, Wilson S, Davies HR. Intra-pleural fibrinolytic therapy versus placebo, or a different fibrinolytic agent, in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2019; 2019:CD002312. [PMID: 31684683 PMCID: PMC6819355 DOI: 10.1002/14651858.cd002312.pub4] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pleural infection, including parapneumonic effusions and thoracic empyema, may complicate lower respiratory tract infections. Standard treatment of these collections in adults involves antibiotic therapy, effective drainage of infected fluid and surgical intervention if conservative management fails. Intrapleural fibrinolytic agents such as streptokinase and alteplase have been hypothesised to improve fluid drainage in complicated parapneumonic effusions and empyema and therefore improve treatment outcomes and prevent the need for thoracic surgical intervention. Intrapleural fibrinolytic agents have been used in combination with DNase, but this is beyond the scope of this review. OBJECTIVES To assess the benefits and harms of adding intrapleural fibrinolytic therapy to standard conservative therapy (intercostal catheter drainage and antibiotic therapy) in the treatment of complicated parapneumonic effusions and empyema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and Embase, ClinicalTrials.gov and the World Health Organization (WHO) trials portal. We contacted trial authors for further information and requested details regarding the possibility of unpublished trials. The most recent search was conducted on 28 August 2019. SELECTION CRITERIA Parallel-group randomised controlled trials (RCTs) in adult patients with post-pneumonic empyema or complicated parapneumonic effusions (excluding tuberculous effusions) who had not had prior surgical intervention or trauma comparing an intrapleural fibrinolytic agent (streptokinase, alteplase or urokinase) versus placebo or a comparison of two fibrinolytic agents. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. We contacted study authors for further information. We used odds ratios (OR) for dichotomous data and reported 95% confidence intervals (CIs). We used Cochrane's standard methodological procedures of meta-analysis. We applied the GRADE approach to summarise results and to assess the overall certainty of evidence. MAIN RESULTS We included in this review a total of 12 RCTs. Ten studies assessed fibrinolytic agents versus placebo (993 participants); one study compared streptokinase with urokinase (50 participants); and one compared alteplase versus urokinase (99 participants). The primary outcomes were death, requirement for surgical intervention, overall treatment failure and serious adverse effects. All studies were in the inpatient setting. Outcomes were measured at varying time points from hospital discharge to three months. Seven trials were at low or unclear risk of bias and two at high risk of bias due to inadequate randomisation and inappropriate study design respectively. We found no evidence of difference in overall mortality with fibrinolytic versus placebo (OR 1.16, 95% CI 0.71 to 1.91; 8 studies, 867 participants; I² = 0%; moderate certainty of evidence). We found evidence of a reduction in surgical intervention with fibrinolysis in the same studies (OR 0.37, 95% CI 0.21 to 0.68; 8 studies, 897 participants; I² = 51%; low certainty of evidence); and overall treatment failure (OR 0.16, 95% CI 0.05 to 0.58; 7 studies, 769 participants; I² = 88%; very low certainty of evidence, with evidence of significant heterogeneity). We found no clear evidence of an increase in adverse effects with intrapleural fibrinolysis, although this cannot be excluded (OR 1.28, 95% CI 0.36 to 4.57; low certainty of evidence). In a sensitivity analysis, the reduction in referrals for surgery and overall treatment failure with fibrinolysis disappeared when the analysis was confined to studies at low or unclear risk of bias. In a moderate-risk population (baseline 14% risk of death, 20% risk of surgery, 27% risk of treatment failure), intra-pleural fibrinolysis leads to 19 more deaths (36 fewer to 59 more), 115 fewer surgical interventions (150 fewer to 55 fewer) and 214 fewer overall treatment failures (252 fewer to 93 fewer) per 1000 people. A single study of streptokinase versus urokinase found no clear difference between the treatments for requirement for surgery (OR 1.00, 95% CI 0.13 to 7.72; 50 participants; low-certainty evidence). A single study of alteplase versus urokinase showed no clear difference in requirement for surgery (OR alteplase versus urokinase 0.46, 95% CI 0.04 to 5.24) but an increased rate of adverse effects, primarily bleeding, with alteplase (OR 5.61, 95% CI 1.16 to 27.11; 99 participants; low-certainty evidence). This translated into 154 (6 to 499 more) serious adverse events with alteplase compared with urokinase per 1000 people treated. AUTHORS' CONCLUSIONS In patients with complicated infective pleural effusion or empyema, intrapleural fibrinolytic therapy was associated with a reduction in the requirement for surgical intervention and overall treatment failure but with no evidence of change in mortality. Discordance between the negative largest trial of this therapy and other studies is of concern, however, as is an absence of significant effect when analysing low risk of bias trials only. The reasons for this difference are uncertain but may include publication bias. Intrapleural fibrinolytics may increase the rate of serious adverse events, but the evidence is insufficient to confirm or exclude this possibility.
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Affiliation(s)
- Emile S Altmann
- John Hunter HospitalDepartment of General MedicineNew Lambton HeightsNew South WalesAustralia
| | | | - Stephen Wilson
- East Lancashire Hospitals NHS TrustBlackburnLancashireUK
| | - Huw R Davies
- Southern Adelaide Local Health Network (SALHN)Respiratory and Sleep ServicesBedford ParkSouth AustraliaAustralia5041
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10
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Beckert L, Brockway B, Simpson G, Southcott AM, Lee YCG, Rahman N, Light RW, Shoemaker S, Gillies J, Komissarov AA, Florova G, Ochran T, Bradley W, Ndetan H, Singh KP, Sarva K, Idell S. Phase 1 trial of intrapleural LTI-01; single chain urokinase in complicated parapneumonic effusions or empyema. JCI Insight 2019; 5:127470. [PMID: 30998508 DOI: 10.1172/jci.insight.127470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Current dosing of intrapleural fibrinolytic therapy (IPFT) in adults with complicated parapneumonic effusion (CPE) / empyema is empiric, as dose-escalation trials have not previously been conducted. We hypothesized that LTI-01 (scuPA), which is relatively resistant to PA inhibitor-1 (PAI-1), would be well-tolerated. METHODS This was an open-label, dose-escalation trial of LTI-01 IPFT at 50,000-800,000 IU daily for up to 3 days in adults with loculated CPE/empyema and failed pleural drainage. The primary objective was to evaluate safety and tolerability, and secondary objectives included assessments of processing and bioactivity of scuPA in blood and pleural fluid (PF), and early efficacy. RESULTS LTI-01 was well tolerated with no bleeding, treatment-emergent adverse events or surgical referrals (n=14 subjects). uPA antigen increased in PFs at 3 hours after LTI-01 (p<0.01) but not in plasma. PF saturated active PAI-1, generated PAI-1-resistant bioactive complexes, increased PA and fibrinolytic activities and D-dimers. There was no systemic fibrinogenolysis, nor increments in plasma D-dimer. Decreased pleural opacities occurred in all but one subject. Both subjects receiving 800,000 IU required two doses to relieve pleural sepsis, with two other subjects similarly responding at lower doses. CONCLUSION LTI-01 IPFT was well-tolerated at these doses with no safety concerns. Bioactivity of LTI-01 IPFT was confirmed, limited to PFs where its processing simulated that previously reported in preclinical studies. Preliminary efficacy signals including reduction of pleural opacity were observed.
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Affiliation(s)
| | - Ben Brockway
- University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | | | - Y C Gary Lee
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
| | - Richard W Light
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John Gillies
- Clinical Network Services (CNS), Auckland, New Zealand
| | | | | | | | | | - Harrison Ndetan
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
| | - Karan P Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
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11
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Affiliation(s)
- William Bremer
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
| | - Charles E Ray
- Department of Radiology, University of Illinois College of Medicine, Chicago, Illinois
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12
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Abstract
The widely accepted and still increasing use of video-assisted thoracic surgery (VATS) in pleuro-pulmonary pathology imposes the need to deal with two major pitfalls: the first is to avoid its unselective use, while the second relates to inappropriate rejection of VATS on the basis of "insufficient radicality". Unlike a quite established role of VATS in lung cancer patients, in patients with pleural empyema, the role of VATS is less clearly defined. The current evidence about VATS in patients with pleural empyema could be summarised as follows: VATS is accepted as a useful treatment option for fibrinopurulent empyema, but the treatment failure rate increases with the increasing proportion of stage III empyema, necessitating further surgical options like thoracotomy and decortication. As both pulmonologists and surgeons deal with diagnosis and treatment of pleural empyema, this article is an attempt to highlight the existing evidence in a more user-friendly way in order to help practising physicians to optimise the use of VATS in these patients. In other words, in the absence of randomised studies comparing VATS and thoracotomy, the key question to be answered is: are there any pre-operative findings that can be used to select patients for initial VATS versus proceeding directly to a thoracotomy?
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Affiliation(s)
- Dragan Subotic
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
| | - Didier Lardinois
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
| | - Aljaz Hojski
- Clinic for Thoracic Surgery, University Hospital Basel, Basel, Switzerland
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Elsayed HH, Mostafa A, Fathy E, Diab HS, Nofal IM, AbdelHamid OA, El-Bawab HY, ElNori AA. Thoracoscopic management of early stages of empyema: is this the golden standard? J Vis Surg 2018; 4:114. [PMID: 29963403 DOI: 10.21037/jovs.2018.05.18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/08/2018] [Indexed: 11/06/2022]
Abstract
Background Empyema is a well-known disease that significantly increases the morbidity and mortality associated with pneumonia. There are a number of treatment modalities available but recently video assisted thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly in early stages. The aim of this study is to assess the safety and effectiveness of using initial VATS for all surgically fit patients with early stages of empyema. Methods Sixty-six patients with early stage empyema were prospectively studied between December 2013 and March 2016. Patients were divided into two groups: group A (28 patients) were managed conservatively without surgery for stage I (exudative) phase empyema by the chest physicians; and group B (38 patients) were managed by the thoracic surgeons by VATS for stage I (exudative) and stage II (fibrino-purulent) empyema. Comparison was made between both groups. Results There was no statistically significant difference between the groups from the point of view of age, sex or pre-intervention comorbidities (P>0.05). Average hospital stay in group A was 22 days (7-131 days), it was 4.1 days (2-14 days) in group B (P=0.004; 95% CI: 10.3-25.5) with a resultant lower cost. Three patients (10.7%) in group A suffered from major morbidity during treatment while none in group B suffered a major postoperative morbidity (P=0.039). There were 2 mortalities (7.1%) in group A and no deaths in group B (P=0.094). During a mean follow up period of 8 months [6-14] in group A 14.3% of the patients underwent open decortication, whereas in group B, 5.3% of the patients underwent the same procedure (P=0.047). Conclusions Thoracoscopic management of early stages of empyema should be the golden standard of management in surgically fit patients; particularly in the fibro-exudative phase of empyema. It is an effective and safe technique that reduces hospital stay, cost, complications and avoids the need for a decortication via a thoracotomy in most cases.
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Affiliation(s)
- Hany Hasan Elsayed
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Ahmed Mostafa
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Essam Fathy
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
| | - Haytham S Diab
- Pulmonology Department, Ain Shams University Hospital, Cairo, Egypt
| | | | | | | | - Ahmed A ElNori
- Thoracic Surgery Department, Ain Shams University Hospital, Cairo, Egypt
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14
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Abstract
Pleural cavity infection continuously seriously threatens human health with continuous medical progress. From the perspective of pathophysiology, it can be divided into three stages: exudative stage, fibrin exudation and pus formation stage, and organization stage. Due to the pathogenic bacteria difference of pleural cavity infection and pulmonary infection, it is very important for disease treatment to analyze the bacteria and biochemical characteristics of the infectious pleural effusion. Most prognoses of patients have been relatively good, while for some patients, the complicated parapneumonic effusion or empyema could be evolved. Antibiotic treatment and sufficient drainage are the foundation for this treatment. No evidence can support the routine use of a fibrin agent. However, it has been reported that the plasminogen activator and deoxyribonuclease can be recommended to be applied in the pleural cavity. In case of failure on conservative medical treatment, operative treatment can be applied such as thoracoscopy and pleural decortication. According to the clinical characteristics of these patients, it is a key to research prognosis, as well as early evaluation and stratification, in the future.
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Affiliation(s)
- Wei Yang
- Department of Respiratory Medicine, Medical School of Chinese PLA, Beijing 100853, China
| | - Bo Zhang
- Department of Respiratory Medicine, Medical School of Chinese PLA, Beijing 100853, China
| | - Ze-Ming Zhang
- Department of Respiratory Medicine, Pudong New Area Zhoupu Hospital, Shanghai 201318, China
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15
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Lai C, Mohammad N, Hassan TM, Abdul Hamid MF. Low-dose intrapleural alteplase (without deoxyribonuclease) in complicated parapneumonic effusion: case series and literature reviews. BMJ Case Rep 2017; 2017:bcr-2017-221239. [PMID: 28893806 DOI: 10.1136/bcr-2017-221239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
This case series reviews two cases of elderly patients who presented with fever, cough and shortness of breath. Clinical examinations and initial chest radiographs confirmed unilateral pleural effusion. Thoracenteses were consistent with exudative pleural effusion. We commenced intravenous antibiotics treating for parapneumonic effusions. The first case showed persistent effusion despite drainage, and the second case had a little aspirate from pleural tapping. Subsequent ultrasound of the thorax showed multiloculated effusions. We made the decisions for intrapleural fibrinolytic therapy using low-dose alteplase 2.5 mg each time, in view of the elderly patient as sacrosanct for risk of bleeding. Furthermore, DNase was not used, as it is not yet available in our setting. Both of our patients had good clinical and radiological outcomes, without the need for surgical interventions.
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Affiliation(s)
- Carol Lai
- Department of Medical, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Nurashikin Mohammad
- Department of Internal Medicine, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Tidi Maharani Hassan
- Department of Medical, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
| | - Mohamed Faisal Abdul Hamid
- Department of Medical, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia.,Department of Medical, Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Kuala Lumpur, Malaysia
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16
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Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part II: Catheter Care and Management of Common Systemic Post-procedural Complications. Cardiovasc Intervent Radiol 2017; 40:1304-1320. [PMID: 28584946 DOI: 10.1007/s00270-017-1709-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 05/23/2017] [Indexed: 01/14/2023]
Abstract
Interventional radiology (IR) has evolved into a full-fledged clinical specialty with attendant comprehensive patient care responsibilities. Providing excellent and thorough clinical care is as essential to the practice of IR as achieving technical success in procedures. Basic clinical skills that every interventional radiologist should learn include routine management of percutaneously inserted drainage and vascular catheters and rapid effective management of common systemic post-procedural complications. A structured approach to post-procedural care, including routine follow-up and early identification and management of complications, facilitates efficient and thorough management with an emphasis on quality and patient safety. The aim of this second part, in conjunction with part 1, is to complete the comprehensive review of post-procedural care in patients undergoing interventional radiology procedures. We discuss common problems encountered after insertion of drainage and vascular catheters and describe effective methods of troubleshooting these problems. Commonly encountered systemic complications in IR are described, and ways for immediate identification and management of these complications are provided.
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17
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Heimes J, Copeland H, Lulla A, Duldulao M, Bahjri K, Zaheer S, Wallen JM. The use of thrombolytics in the management of complex pleural fluid collections. J Thorac Dis 2017; 9:1310-1316. [PMID: 28616283 DOI: 10.21037/jtd.2017.04.56] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. METHODS We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). RESULTS One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. CONCLUSIONS Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.
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Affiliation(s)
- Jessica Heimes
- Department of Thoracic and Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hannah Copeland
- Cardiothoracic Surgery Richmond, McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Aditya Lulla
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marjulin Duldulao
- Weill Cornell Medical Center, New York Presbyterian Hospital, New York, USA
| | - Khaled Bahjri
- School of Public Health, Loma Linda University, Loma Linda, California, USA
| | - Salman Zaheer
- Department of Thoracic and Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Jason M Wallen
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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18
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Abstract
BACKGROUND Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment. OBJECTIVES To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016). SELECTION CRITERIA Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals. AUTHORS' CONCLUSIONS Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.
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Affiliation(s)
| | - Tze Yang Chin
- The Prince Charles HospitalRode RoadChermsideQueenslandAustralia4032
- The University of QueenslandSchool of Medicine288 Herston RoadBrisbaneQLDAustralia4006
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineBrisbaneQueenslandAustralia4029
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19
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Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery. World J Surg 2016; 40:1121-8. [PMID: 26711639 DOI: 10.1007/s00268-015-3378-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery. OBJECTIVE To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery. METHODS From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days. RESULTS The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions. CONCLUSIONS Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.
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20
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Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA, Hecker A. Stage-directed therapy of pleural empyema. Langenbecks Arch Surg 2016; 402:15-26. [DOI: 10.1007/s00423-016-1498-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/10/2016] [Indexed: 11/29/2022]
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21
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Abstract
The efficacy of fibrinolytic therapy in two loculated abscesses is being reported. First case had a postoperative mediastinal abscess in left paraspinal location and the second case had two bilateral tubercular psoas abscesses. Both cases were managed with pig tail catheter drainage of abcesses and fibrinolytic therapy with instillation of urokinase followed by aspiration. Both cases had significant drainage, clinical and radiological resolution. There were no adverse effects in either case.
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Affiliation(s)
- M S Barthwal
- Department of Pulmonary Medicine, Military Hospital, (Cardiothoracic Centre), AFMC, Pune, India
| | - Rahul Tyagi
- Department of Pulmonary Medicine, INHS Asvini Hospital, Mumbai, Maharashtra, India
| | - Kislay Kishore
- Department of Pulmonary Medicine, Command Hospital, Lucknow, Uttar Pradesh, India
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22
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Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections. Can Respir J 2016; 2016:9796768. [PMID: 27445574 PMCID: PMC4944060 DOI: 10.1155/2016/9796768] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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23
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Birkenkamp K, O'Horo JC, Kashyap R, Kloesel B, Lahr BD, Daniels CE, Nichols FC, Baddour LM. Empyema management: A cohort study evaluating antimicrobial therapy. J Infect 2016; 72:537-43. [PMID: 26987740 DOI: 10.1016/j.jinf.2016.02.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Empyemas require aggressive antimicrobial and surgical management. However, the specifics of antimicrobial therapy have not been studied in clinical trials. The present study examines management and outcomes among a cohort of patients with empyema cared for in a tertiary-care referral hospital over a decade. METHODS We retrospectively identified patients hospitalized with empyema from January 2000 through December 2010 at one institution. Patient demographics, laboratory findings, treatments, and patient outcomes were abstracted using a standard form. Data were summarized with standard descriptive statistics. RESULTS A total of 91 patients were identified. The predominant organisms were viridans group streptococci, which were isolated in 64% of cases with cultures. The median length of hospitalization was 9 days. Length of antimicrobial therapy from time of source control was variable, with a median (interquartile range) duration of 27 (15-31) days. Of note, longer courses of parenteral, but not oral, therapy were associated with fewer cases of clinical failure. CONCLUSIONS This descriptive analysis demonstrated a higher rate of viridans group streptococci than expected. Three weeks of therapy was generally adequate and prevented clinical failure, but further study is needed with a much larger cohort to better define the optimal drug regimen, route, and duration of antimicrobial therapy for empyema.
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Affiliation(s)
- Kate Birkenkamp
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - John C O'Horo
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA.
| | - Rahul Kashyap
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Ben Kloesel
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Craig E Daniels
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis C Nichols
- Division of General Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic, Rochester, MN, USA; Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Florova G, Azghani A, Karandashova S, Schaefer C, Koenig K, Stewart-Evans K, Declerck PJ, Idell S, Komissarov AA. Targeting of plasminogen activator inhibitor 1 improves fibrinolytic therapy for tetracycline-induced pleural injury in rabbits. Am J Respir Cell Mol Biol 2016; 52:429-37. [PMID: 25140386 DOI: 10.1165/rcmb.2014-0168oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Endogenous active plasminogen activator inhibitor 1 (PAI-1) was targeted in vivo with monoclonal antibodies (mAbs) that redirect its reaction with proteinases to the substrate branch. mAbs were used as an adjunct to prourokinase (single-chain [sc] urokinase [uPA]) intrapleural fibrinolytic therapy (IPFT) of tetracycline-induced pleural injury in rabbits. Outcomes of scuPA IPFT (0.25 or 0.0625 mg/kg) with 0.5 mg/kg of mouse IgG or mAbs (MA-33H1F7 and MA-8H9D4) were assessed at 24 hours. Pleural fluid (PF) was collected at 0, 10, 20, and 40 minutes and 24 hours after IPFT and analyzed for plasminogen activating (PA), uPA, fibrinolytic activities, levels of total plasmin/plasminogen, α-macroglobulin (αM), mAbs/IgG antigens, free active uPA, and αM/uPA complexes. Anti-PAI-1 mAbs, but not mouse IgG, delivered with an eightfold reduction in the minimal effective dose of scuPA (from 0.5 to 0.0625 mg/kg), improved the outcome of IPFT (P < 0.05). mAbs and IgG were detectable in PFs at 24 hours. Compared with identical doses of scuPA alone or with IgG, treatment with scuPA and anti-PAI-1 mAbs generated higher PF uPA amidolytic and PA activities, faster formation of αM/uPA complexes, and slower uPA inactivation. However, PAI-1 targeting did not significantly affect intrapleural fibrinolytic activity or levels of total plasmin/plasminogen and αM antigens. Targeting PAI-1 did not induce bleeding, and rendered otherwise ineffective doses of scuPA able to improve outcomes in tetracycline-induced pleural injury. PAI-1-neutralizing mAbs improved IPFT by increasing the durability of intrapleural PA activity. These results suggest a novel, well-tolerated IPFT strategy that is tractable for clinical development.
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Affiliation(s)
- Galina Florova
- 1 Texas Lung Injury Institute of the University of Texas Health Science Center at Tyler, Tyler, Texas
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25
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Tomlinson JE, Byrne E, Pusterla N, Magdesian KG, Hilton HG, McGorum B, Davis E, Schoster A, Arroyo L, Dunkel B, Carslake H, Boston RC, Johnson AL. The Use of Recombinant Tissue Plasminogen Activator (rTPA) in The Treatment of Fibrinous Pleuropneumonia in Horses: 25 Cases (2007-2012). J Vet Intern Med 2015; 29:1403-9. [PMID: 26256909 PMCID: PMC4858032 DOI: 10.1111/jvim.13594] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 05/06/2015] [Accepted: 07/08/2015] [Indexed: 11/29/2022] Open
Abstract
Background Information about treatment protocols, adverse effects and outcomes with intrapleural recombinant tissue plasminogen activator (rTPA) use in horses with fibrinous pleuropneumonia is limited. Hypothesis/Objectives Describe factors that contribute to clinical response and survival of horses treated with rTPA intrapleurally. Animals Horses with bacterial pneumonia and fibrinous pleural effusion diagnosed by ultrasonography, that were treated with rTPA intrapleurally. Methods Retrospective multicenter case series from 2007–2012. Signalment, history, clinical and laboratory evaluation, treatment, and outcome obtained from medical records. Regression analysis used to identify associations between treatments and outcomes. Results Thirty three hemithoraces were treated in 25 horses, with 55 separate treatments. Recombinant tissue plasminogen activator (375–20,000 μg/hemithorax) was administered 1–4 times. Sonographically visible reduction in fibrin mat thickness, loculations, fluid depth, or some combination of these was seen in 32/49 (65%) treatments. Response to at least 1 treatment was seen in 17/20 (85%) horses with sonographic follow‐up evaluation after every treatment. Earlier onset of rTPA treatment associated with increased survival odds. No association was found between cumulative rTPA dose or number of rTPA doses and survival, development of complications, duration of hospitalization or total charges. Clinical evidence of hypocoagulability or bleeding was not observed. Eighteen horses (72%) survived to discharge. Conclusions and clinical importance Treatment with rTPA appeared safe and resulted in variable changes in fibrin quantity and organization within the pleural space. Recombinant tissue plasminogen activator could be a useful adjunct to standard treatment of fibrinous pleuropneumonia, but optimal case selection and dosing regimen remain to be elucidated.
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Affiliation(s)
- J E Tomlinson
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
| | - E Byrne
- Alamo Pintado Equine Medical Center, Los Olivos, CA
| | - N Pusterla
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA
| | - K Gary Magdesian
- Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California, Davis, CA
| | - H G Hilton
- Departments of Structural Biology and Microbiology & Immunology, Stanford University School of Medicine, Stanford, CA
| | - B McGorum
- Royal (Dick) School of Veterinary Studies and Roslin Institute, University of Edinburgh, Easter Bush, Midlothian, UK
| | - E Davis
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, KS
| | - A Schoster
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - L Arroyo
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, Canada
| | - B Dunkel
- Department of Clinical Science and Services, The Royal Veterinary College, North Mymms, Herts, UK
| | - H Carslake
- Philip Leverhulme Equine Hospital, University of Liverpool, Wirral, UK
| | - R C Boston
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
| | - A L Johnson
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA
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Komissarov AA, Florova G, Azghani AO, Buchanan A, Bradley WM, Schaefer C, Koenig K, Idell S. The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits. Am J Physiol Lung Cell Mol Physiol 2015; 309:L562-72. [PMID: 26163512 DOI: 10.1152/ajplung.00136.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/02/2015] [Indexed: 11/22/2022] Open
Abstract
The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n = 10) and scuPA (0.5 mg/kg; n = 12) was monitored by serial ultrasonography alone (n = 12) or alongside CT scanning (n = 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0-240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, α-macroglobulin/fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (kobs = 0.016 and 0.042 min(-1)). Significant amounts of bioactive uPA/α-macroglobulin (but not tPA; P < 0.05) complexes accumulated at 0-40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS ≤ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r(2) = 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4-8 h. CT scanning was associated with less effective (GLIS > 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4-8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes.
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Affiliation(s)
- Andrey A Komissarov
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas;
| | - Galina Florova
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Ali O Azghani
- The Department of Biology at the University of Texas at Tyler, Tyler, Texas
| | - Ann Buchanan
- UTHSCT Vivarium, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - William M Bradley
- The Department of Radiation Oncology, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Chris Schaefer
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Kathleen Koenig
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Steven Idell
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
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Ferreiro L, San José ME, Valdés L. Management of Parapneumonic Pleural Effusion in Adults. Arch Bronconeumol 2015; 51:637-46. [PMID: 25820035 DOI: 10.1016/j.arbres.2015.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Not all infectious effusions are parapneumonic and, in such cases, the organisms found in the pleural space are not the same as those observed in lung parenchyma infections. The diagnostic difficulty lies in knowing whether an infectious effusion will evolve into a complicated effusion/empyema, as the diagnostic methods used for this purpose provide poor results. The mainstays of treatment are to establish an early diagnosis and to commence an antibiotic regimen and chest drain as soon as possible. This should preferably be carried out with fine tubes, due to certain morphological, bacteriological and biochemical characteristics of the pleural fluid. Fluid analysis, particularly pH, is the most reliable method for assessing evolution. In a subgroup of patients, fibrinolytics may help to improve recovery, and their combination with DNase has been found to obtain better results. If medical treatment fails and surgery is required, video-assisted thoracoscopic surgery (VATS) is, at least, comparable to decortication by thoracotomy, so should only undertaken if previous techniques have failed. Further clinical trials are needed to analyze factors that could affect the results obtained, in order to define new evidence-based diagnostic and therapeutic strategies that provide more effective, standardized management of this disease.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - María Esther San José
- Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
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28
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Takahashi K, Porcel JM, Lee P, Leung CC. Year in review 2014: Lung cancer, pleural diseases, respiratory infections and tuberculosis, bronchoscopic intervention and imaging. Respirology 2015; 20:674-83. [DOI: 10.1111/resp.12502] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 02/01/2015] [Indexed: 12/29/2022]
Affiliation(s)
- Kazuhisa Takahashi
- Department of Respiratory Medicine; Graduate School of Medicine; Juntendo University; Tokyo Japan
| | - José M Porcel
- Pleural Medicine Unit; Department of Internal Medicine; Biomedical Research Institute of Lleida; Arnau de Vilanova University Hospital; Lleida Spain
| | - Pyng Lee
- Department of Medicine; National University Hospital; Singapore
| | - Chi Chiu Leung
- Tuberculosis and Chest Service; Department of Health; Hong Kong China
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29
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Dabó H, Meira L, Neves I, Marinho A, Gomes I. Combined intrapleural therapy in infectious pleural effusion. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:105-106. [PMID: 25926377 DOI: 10.1016/j.rppnen.2014.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/06/2014] [Accepted: 12/10/2014] [Indexed: 06/04/2023] Open
Affiliation(s)
- H Dabó
- Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal.
| | - L Meira
- Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal
| | - I Neves
- Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal
| | - A Marinho
- Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal
| | - I Gomes
- Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal
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Abstract
Multidisciplinary management of thoracic infection, including experts in thoracic surgery, pulmonology, infectious disease, and radiology, is ideal for optimal outcomes. Initial assessment of parapneumonic effusion and empyema requires computed tomographic evaluation and consideration for fluid sampling or drainage. Goals for the treatment of parapneumonic effusion and empyema include drainage of the pleural space and complete lung reexpansion. Pulmonary abscess is often successfully treated with antibiotics and observation. Surgical intervention for the treatment of fungal or tuberculous lung disease should be undertaken by experienced surgeons following multidisciplinary assessment. Sternoclavicular joint infection often requires joint resection.
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Affiliation(s)
- Daniel Raymond
- Thoracic & Cardiovascular Surgery, Cleveland Clinic Foundation, 9500 Euclid Avenue, J4-1, Cleveland, OH 44195, USA.
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31
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Kim SK, Kang CU, Song SH, Cho DG, Cho KD, Kim CH. Factors predictive of the failure of medical treatment in patients with pleural infection. Korean J Intern Med 2014; 29:603-12. [PMID: 25228836 PMCID: PMC4164724 DOI: 10.3904/kjim.2014.29.5.603] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 11/18/2013] [Accepted: 02/20/2014] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND/AIMS The clinical outcomes of some patients with pleural infection may be favorable with medical treatment alone, but in others, the disease progresses and requires additional surgical treatment. However, little is known about the factors affecting this difference. The aim of this study was to investigate the factors predictive of failure of medical treatment in patients with pleural infection. METHODS A cohort of 127 consecutive patients who were admitted to the hospital with pleural infection was studied. Clinical manifestations and laboratory findings in patients in whom medical treatment succeeded or failed were reviewed. RESULTS In univariate analysis, the significant factors associated with medical treatment outcome were age, smoking history, duration of chief complaint, serum albumin level, and pleural fluid glucose and lactate dehydrogenase levels (p < 0.05). Multivariate logistic regression analysis identified age and duration of chief complaint as independent predictive factors for failure of medical treatment, with odds ratios of 0.871 (p = 0.013) and 0.797 (p = 0.026), respectively. Receiver operating characteristic curve analysis determined cutoff values of 50.5 years for age and 4.5 days for duration of chief complaint. CONCLUSIONS We demonstrated that a younger age < 50.5 years and shorter duration of chief complaint < 4.5 days were independent predictive factors for the failure of medical treatment in patients with pleural infection. This suggests their role as evaluative criteria in setting indications for the optimal treatment in patients with pleural infection. A larger, prospective study is required to confirm these findings.
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Affiliation(s)
- Sung-Kyoung Kim
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Chul Ung Kang
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - So Hyang Song
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Kyu Do Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Chi Hong Kim
- Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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32
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Breen DP, Daneshvar C. Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema. Respirology 2014; 19:970-8. [PMID: 25039299 DOI: 10.1111/resp.12339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 04/07/2014] [Accepted: 05/06/2014] [Indexed: 02/01/2023]
Abstract
Pleural infection is a major problem that affects 80,000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.
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Affiliation(s)
- David P Breen
- Respiratory Department, Galway University Hospitals, Galway, Ireland
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33
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Colice GL, Idell S. Counterpoint: should fibrinolytics be routinely administered intrapleurally for management of a complicated parapneumonic effusion? No. Chest 2014; 145:17-20. [PMID: 24394817 DOI: 10.1378/chest.13-2356] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Gene L Colice
- George Washington University School of Medicine & Health Sciences, Washington Hospital Center, Washington, DC; Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington, DC.
| | - Steven Idell
- School of Medical Biological Sciences, The University of Texas Health Science Center at Tyler, Tyler, TX
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34
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Nie W, Liu Y, Ye J, Shi L, Shao F, Ying K, Zhang R. Efficacy of intrapleural instillation of fibrinolytics for treating pleural empyema and parapneumonic effusion: a meta-analysis of randomized control trials. CLINICAL RESPIRATORY JOURNAL 2014; 8:281-91. [PMID: 24428897 DOI: 10.1111/crj.12068] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 09/26/2013] [Accepted: 10/24/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Wencheng Nie
- Department of Cardiology, The First Affiliated Hospital of Zhejiang University; School of Medicine; Hangzhou China
| | - Yanru Liu
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Jian Ye
- Department of Respiratory Medicine; The First People's Hospital of Hangzhou; Hangzhou China
| | - Liuhong Shi
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Fangchun Shao
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Kejing Ying
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Ruifeng Zhang
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
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35
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Abstract
This article discusses thoracic emergencies, including the anatomy, pathophysiology, clinical presentation, examination, diagnosis, technique, management, and treatment of acute upper airway obstruction, massive hemoptysis, spontaneous pneumothorax, and pulmonary empyema.
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Affiliation(s)
- Stephanie G Worrell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, CA 90033, USA
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36
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Komissarov AA, Florova G, Azghani A, Karandashova S, Kurdowska AK, Idell S. Active α-macroglobulin is a reservoir for urokinase after fibrinolytic therapy in rabbits with tetracycline-induced pleural injury and in human pleural fluids. Am J Physiol Lung Cell Mol Physiol 2013; 305:L682-92. [PMID: 23997178 DOI: 10.1152/ajplung.00102.2013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Intrapleural processing of prourokinase (scuPA) in tetracycline (TCN)-induced pleural injury in rabbits was evaluated to better understand the mechanisms governing successful scuPA-based intrapleural fibrinolytic therapy (IPFT), capable of clearing pleural adhesions in this model. Pleural fluid (PF) was withdrawn 0-80 min and 24 h after IPFT with scuPA (0-0.5 mg/kg), and activities of free urokinase (uPA), plasminogen activator inhibitor-1 (PAI-1), and uPA complexed with α-macroglobulin (αM) were assessed. Similar analyses were performed using PFs from patients with empyema, parapneumonic, and malignant pleural effusions. The peak of uPA activity (5-40 min) reciprocally correlated with the dose of intrapleural scuPA. Endogenous active PAI-1 (10-20 nM) decreased the rate of intrapleural scuPA activation. The slow step of intrapleural inactivation of free uPA (t1/2(β) = 40 ± 10 min) was dose independent and 6.7-fold slower than in blood. Up to 260 ± 70 nM of αM/uPA formed in vivo [second order association rate (kass) = 580 ± 60 M(-1)·s(-1)]. αM/uPA and products of its degradation contributed to durable intrapleural plasminogen activation up to 24 h after IPFT. Active PAI-1, active α2M, and α2M/uPA found in empyema, pneumonia, and malignant PFs demonstrate the capacity to support similar mechanisms in humans. Intrapleural scuPA processing differs from that in the bloodstream and includes 1) dose-dependent control of scuPA activation by endogenous active PAI-1; 2) two-step inactivation of free uPA with simultaneous formation of αM/uPA; and 3) slow intrapleural degradation of αM/uPA releasing active free uPA. This mechanism offers potential clinically relevant advantages that may enhance the bioavailability of intrapleural scuPA and may mitigate the risk of bleeding complications.
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Affiliation(s)
- Andrey A Komissarov
- The Univ. of Texas Health Science Center at Tyler, 11937 US Highway 271, Lab C-6, Tyler, TX 75708. or
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37
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Empyema in a woman with cystic fibrosis: a cautionary tale. Case Rep Pulmonol 2013; 2013:159508. [PMID: 23533902 PMCID: PMC3603167 DOI: 10.1155/2013/159508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/11/2013] [Indexed: 11/27/2022] Open
Abstract
Cystic fibrosis (CF) is a disease which predisposes individuals to recurrent infective exacerbations of suppurative lung disease; however, empyema is a rare complication in these patients. Empyemas secondary to Staphylococcus aureus and Burkholderia cepacia have been described in patients with CF. We report the case of pleural empyema with mixed S. aureus and Pseudomonas aeruginosa infection in a 34-year-old woman with CF, which was managed with ultrasound-guided pigtail catheter insertion, fibrinolysis, and antibiotic therapy. Physicians should be aware of this unusual complication in CF patients, especially those receiving an immunosuppressive therapy.
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38
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Bhatnagar R, Maskell NA. Treatment of complicated pleural effusions in 2013. Clin Chest Med 2013; 34:47-62. [PMID: 23411056 DOI: 10.1016/j.ccm.2012.11.004] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The incidence of pleural infection seems to be increasing worldwide. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. This article summarizes the current evidence and opinions on the epidemiology, etiology, and management of complicated pleural effusions caused by infection, including empyema. Although many parallels may be drawn between children and adults in such cases, most trials, guidelines, and series regard pediatric patient groups and those more than 18 years of age as separate entities. This review focuses mainly on the treatment of adult disease.
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Affiliation(s)
- Rahul Bhatnagar
- Respiratory Research Unit, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol BS10 5NB, UK
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39
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Chung CL, Hsiao SH, Hsiao G, Sheu JR, Chen WL, Chang SC. Clinical importance of angiogenic cytokines, fibrinolytic activity and effusion size in parapneumonic effusions. PLoS One 2013; 8:e53169. [PMID: 23308155 PMCID: PMC3538784 DOI: 10.1371/journal.pone.0053169] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 11/26/2012] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the relationship among angiogenic cytokines, fibrinolytic activity and effusion size in parapneumonic effusion (PPE) and their clinical importance. METHODS From January 2008 through December 2010, 26 uncomplicated (UPPE) and 38 complicated (CPPE) PPE were studied. Based on chest ultrasonography, there were non-loculated in 30, uni-loculated in 12, and multi-loculated effusions in 22 patients. The effusion size radiological scores, and effusion vascular endothelial growth factor (VEGF), interleukin (IL)-8, plasminogen activator inhibitor type-1 (PAI-1) and tissue type plasminogen activator (tPA) were measured on admission. Treatment outcome and pleural fibrosis, defined as radiological residual pleural thickening (RPT), were assessed at 6-month follow-up. RESULTS The effusion size and effusion VEGF, IL-8 and PAI-1/tPA ratio were significantly higher in CPPE than in UPPE, and significantly higher in multi-loculated PPE than in non-locualted and uni-loculated PPE, respectively. VEGF (cutoff value 1975 pg/ml) and IL-8 (cutoff value 1937 pg/ml) seemed best to discriminate between UPPE and CPPE. VEGF, IL-8 and effusion size correlated positively with PAI-1/tPA ratio in both UPPE and CPPE. Moreover, the level of VEGF, but not IL-8, correlated positively with effusion size in all patients (r = 0.79, p<0.001) and in UPPE (r = 0.64, p<0.001) and CPPE (r = 0.71, p<0.001) groups. The patients with higher VEGF or greater effusion were prone to have medical treatment failure (n = 10; VEGF, odds ratio 1.01, p = 0.02; effusion size, odds ratio 1.26, p = 0.01). Additionally, ten patients with RPT had larger effusion size and higher levels of VEGF and PAI-1/tPA ratio than did those without. CONCLUSIONS In PPE, VEGF and IL-8 levels are valuable to identify CPPE, and higher VEGF level or larger effusion is associated with decreased fibrinolytic activity, development of pleural loculation and fibrosis, and higher risk of medical treatment failure.
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Affiliation(s)
- Chi-Li Chung
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shih-Hsin Hsiao
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - George Hsiao
- Graduate Institute of Medical Sciences and Department of Pharmacology, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Joen-Rong Sheu
- Graduate Institute of Medical Sciences and Department of Pharmacology, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wei-Lin Chen
- Graduate Institute of Medical Sciences and Department of Pharmacology, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Shi-Chuan Chang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
- * E-mail:
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40
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Dusemund F, Weber M, Nagel W, Schneider T, Brutsche M, Schoch O. Characteristics of Medically and Surgically Treated Empyema Patients: A Retrospective Cohort Study. Respiration 2013; 86:288-94. [DOI: 10.1159/000353424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 05/28/2013] [Indexed: 11/19/2022] Open
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41
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Schweigert M, Solymosi N, Dubecz A, Beron M, Thumfart L, Oefner-Velano D, Stein HJ. Surgical management of pleural empyema in the very elderly. Ann R Coll Surg Engl 2012; 94:331-5. [PMID: 22943228 PMCID: PMC3954374 DOI: 10.1308/003588412x13171221592212] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Parapneumonic pleural empyema is a critical illness. Age is an acknowledged risk factor for both pneumonia and pleural empyema. Furthermore, elderly patients often have severe co-morbidity. In the case of pleural empyema, their clinical condition is likely to deteriorate fast, resulting in life threatening septic disease. To prevent this disastrous situation we adapted early surgical debridement as the primary treatment option even in very elderly patients. This study shows the outcome of surgically managed patients with pleural empyema who are 80 years or older. METHODS The outcomes of 222 consecutive patients who received surgical therapy for parapneumonic pleural empyema at a German tertiary referral hospital between 2006 and 2010 were reviewed in a retrospective case study. Patients older than 80 years were identified. RESULTS There were 159 male and 63 female patients. The mean age was 60.5 years and the overall in-hospital mortality rate was 7%. Of the 222 patients, 37 were 80 years or older (range: 80–95 years). The frequencies of predominantly cardiac co-morbidity and high ASA (American Society of Anesthesiologists) grades were significantly higher for very elderly patients (p<0.001). A minimally invasive approach was feasible in 34 cases (92%). Of the 37 patients aged over 80, 36 recovered while one died from severe sepsis (in-hospital mortality 3%). There was no significant difference in mortality between the very elderly and the younger sufferers (p=0.476). CONCLUSIONS Early surgical treatment of parapneumonic pleural empyema shows excellent results even in very elderly patients. Despite considerable co-morbidity and often delayed diagnosis, minimally invasive surgery was feasible in 34 patients (92%). The in-hospital mortality of very elderly patients was low. It can therefore be concluded that advanced age is no contraindication for early surgical therapy.
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42
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Abstract
Most cases of hemothorax are related to blunt or penetrating chest trauma. Criteria for surgical intervention for initial hemothorax are well defined. Appropriate management of retained hemothorax following initial trauma management is critical, and the best approach remains controversial. Spontaneous hemothorax is much less common and results from a variety of pathologic processes. This article reviews the etiology, diagnosis, and treatment of traumatic and spontaneous hemothorax in modern practice.
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43
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Desai H, Agrawal A. Pulmonary emergencies: pneumonia, acute respiratory distress syndrome, lung abscess, and empyema. Med Clin North Am 2012; 96:1127-48. [PMID: 23102481 DOI: 10.1016/j.mcna.2012.08.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This article describes the clinical presentation of pneumonia, acute respiratory distress syndrome, lung abscess, and empyema: life-threatening infections of the pulmonary system. The etiology and risk factors for each of these conditions are described, diagnostic approaches are discussed, and evidence-based management options are reviewed.
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Affiliation(s)
- Himanshu Desai
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA-23507, USA.
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44
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Rodríguez Suárez P, Freixinet Gilart J, Hernández Pérez JM, Hussein Serhal M, López Artalejo A. Treatment of complicated parapneumonic pleural effusion and pleural parapneumonic empyema. Med Sci Monit 2012; 18:CR443-9. [PMID: 22739734 PMCID: PMC3560768 DOI: 10.12659/msm.883212] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We performed this observational prospective study to evaluate the results of the application of a diagnostic and therapeutic algorithm for complicated parapneumonic pleural effusion (CPPE) and pleural parapneumonic empyema (PPE). MATERIAL/METHODS From 2001 to 2007, 210 patients with CPPE and PPE were confirmed through thoracocentesis and treated with pleural drainage tubes (PD), fibrinolytic treatment or surgical intervention (videothoracoscopy and posterolateral thoracotomy). Patients were divided into 3 groups: I (PD); II (PD and fibrinolytic treatment); IIIa (surgery after PD and fibrinolysis), and IIIb (direct surgery). The statistical study was done by variance analysis (ANOVA), χ2 and Fisher exact test. RESULTS The presence of alcohol or drug consumption, smoking and chronic obstructive pulmonary disease (COPD) were strongly associated with a great necessity for surgical treatment. The IIIa group was associated with increased drainage time, length of stay and complications. No mortality was observed. The selective use of PD and intrapleural fibrinolysis makes surgery unnecessary in more than 75% of cases. CONCLUSIONS The selective use of PD and fibrinolysis avoids surgery in more than 75% of cases. However, patients who require surgery have more complications, longer hospital stay, and more days on PD and they are more likely to require admittance to the Intensive Care Unit.
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Affiliation(s)
- Pedro Rodríguez Suárez
- Department of Thoracic Surgery, University Hospital of Gran Canaria Dr. Negrín, Canary Islands, Spain.
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Rosenstengel A. Pleural infection-current diagnosis and management. J Thorac Dis 2012; 4:186-93. [PMID: 22833824 DOI: 10.3978/j.issn.2072-1439.2012.01.12] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 01/26/2012] [Indexed: 11/14/2022]
Abstract
Pleural infection is a common and increasing clinical problem in thoracic medicine, resulting in significant morbidity and mortality. In recent years there has been a marked increase in interests and publications relating to evolving interventions and management options for pleural infection and empyema. Recently published research data as well as guidelines have suggested better approaches of radiological assessment, updated management algorithms for pleural infection, intrapleural adjunct therapies and re-examined the roles of biomarkers, pleural drainage techniques, and the role of surgery. This review highlights some of the recent advances and recommendations relevant to clinical care of pleural infection.
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Affiliation(s)
- Andrew Rosenstengel
- Clinical Pleural Fellow, Respiratory Dept, Sir Charles Gairdner Hospital, Perth WA 6009, Australia
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Abstract
Empyema remains a major source of morbidity and health care expenditure in the thoracic surgery community. Early intervention in pleural space infections is key to prevention of chronic empyemas and the need for surgical intervention. The advent of video-assisted thoracoscopic surgery has made it possible to treat stage I and stage II empyemas with significantly less morbidity. Although management of chronic empyema remains a significant challenge, surgical intervention is usually successful in cleaning up the pleural space.
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Affiliation(s)
- Matthew D Taylor
- Department of Surgery, University of Virginia, Box 800300, Charlottesville, VA 22908-0679, USA
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Management of infectious processes of the pleural space: a review. Pulm Med 2012; 2012:816502. [PMID: 22536502 PMCID: PMC3317076 DOI: 10.1155/2012/816502] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Revised: 12/12/2011] [Accepted: 12/17/2011] [Indexed: 11/18/2022] Open
Abstract
Pleural effusions can present in 40% of patients with pneumonia. Presence of an effusion can complicate the diagnosis as well as the management of infection in lungs and pleural space. There has been an increase in the morbidity and mortality associated with parapneumonic effusions and empyema. This calls for employment of advanced treatment modalities and development of a standardized protocol to manage pleural sepsis early. There has been an increased understanding about the indications and appropriate usage of procedural options at clinicians' disposal.
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Chai FY, Kuan YC. Massive hemothorax following administration of intrapleural streptokinase. Ann Thorac Med 2011; 6:149-51. [PMID: 21760848 PMCID: PMC3131759 DOI: 10.4103/1817-1737.82451] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 03/30/2011] [Indexed: 11/25/2022] Open
Abstract
The administration of intrapleural streptokinase (IPSK) is widely practiced in the management of loculated empyema thoracis. To our knowledge, there have been only 4 cases of hemorrhagic complications attributed to the administration of IPSK reported in the literature. In this article, we report a case of a 17-year-old girl who received IPSK and developed shock, anemia, coagulopathy and massive hemothorax. Our discussion focuses on the hemorrhagic complication of chest tube insertion and the role of IPSK in blood clot lysis and inhibition of local hemostasis.
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Affiliation(s)
- Feng Yih Chai
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan, Kuala Lampur, Malaysia
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Shah SS, Hall M, Newland JG, Brogan TV, Farris RWD, Williams DJ, Larsen G, Fine BR, Levin JE, Wagener JS, Conway PH, Myers AL. Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood. J Hosp Med 2011; 6:256-63. [PMID: 21374798 PMCID: PMC3112472 DOI: 10.1002/jhm.872] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 10/04/2010] [Accepted: 10/18/2010] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine the comparative effectiveness of common pleural drainage procedures for treatment of pneumonia complicated by parapneumonic effusion (ie, complicated pneumonia). DESIGN Multicenter retrospective cohort study. SETTING Forty children's hospitals contributing data to the Pediatric Health Information System. PARTICIPANTS Children with complicated pneumonia requiring pleural drainage. MAIN EXPOSURES Initial drainage procedures were categorized as chest tube without fibrinolysis, chest tube with fibrinolysis, video-assisted thoracoscopic surgery (VATS), and thoracotomy. MAIN OUTCOME MEASURES Length of stay (LOS), additional drainage procedures, readmission within 14 days of discharge, and hospital costs. RESULTS Initial procedures among 3500 patients included chest tube without fibrinolysis (n = 1762), chest tube with fibrinolysis (n = 623), VATS (n = 408), and thoracotomy (n = 797). Median age was 4.1 years. Overall, 716 (20.5%) patients received an additional drainage procedure (range, 6.8-44.8% across individual hospitals). The median LOS was 10 days (range, 7-14 days across individual hospitals). The median readmission rate was 3.8% (range, 0.8%-33.3%). In multivariable analysis, differences in LOS by initial procedure type were not significant. Patients undergoing initial chest tube placement with or without fibrinolysis were more likely to require additional drainage procedures. However, initial chest tube without fibrinolysis was the least costly strategy. CONCLUSION There is variability in the treatment and outcomes of children with complicated pneumonia. Outcomes were similar in patients undergoing initial chest tube placement with or without fibrinolysis. Those undergoing VATS received fewer additional drainage procedures but had no differences in LOS compared with other strategies.
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Affiliation(s)
- Samir S Shah
- Division of Infectious Diseases, The Children's Hospital of Philadelphia and the Departments of Pediatrics and Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Augustin P, Desmard M, Mordant P, Lasocki S, Maury JM, Heming N, Montravers P. Clinical review: intrapericardial fibrinolysis in management of purulent pericarditis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:220. [PMID: 21575282 PMCID: PMC3219308 DOI: 10.1186/cc10022] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Purulent pericarditis (PP) is a potentially life-threatening disease. Reported mortality rates are between 20 and 30%. Constrictive pericarditis occurs over the course of PP in at least 3.5% of cases. The frequency of persistent PP (chronic or recurrent purulent pericardial effusion occurring despite drainage and adequate antibiotherapy) is unknown because this entity was not previously classified as a complication of PP. No consensus exists on the optimal management of PP. Nevertheless, the cornerstone of PP management is complete eradication of the focus of infection. In retrospective studies, compared to simple drainage, systematic pericardiectomy provided a prevention of constrictive pericarditis with better clinical outcome. Because of potential morbidity associated with pericardiectomy, intrapericardial fibrinolysis has been proposed as a less invasive method for prevention of persistent PP and constrictive pericarditis. Experimental data demonstrate that fibrin formation, which occurs during the first week of the disease, is an essential step in the evolution to constrictive pericarditis and persistent PP. We reviewed the literature using the MEDLINE database. We evaluated the clinical efficacy, outcome, and complications of pericardial fibrinolysis. Seventy-four cases of fibrinolysis in PP were analysed. Pericarditis of tuberculous origin were excluded. Among the 40 included cases, only two treated by late fibrinolysis encountered failure requiring pericardiectomy. No patient encountered clinical or echocardiographic features of constriction during follow-up. Only one serious complication was described. Despite the lack of definitive evidence, potential benefits of fibrinolysis as a less invasive alternative to surgery in the management of PP seem promising. Early consideration should be given to fibrinolysis in order to prevent both constrictive and persistent PP. Nevertheless, in case of failure of fibrinolysis, pericardiectomy remains the primary option for complete eradication of infection.
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Affiliation(s)
- Pascal Augustin
- Département d'Anesthésie et Réanimation Chirurgicale, Hôpital Bichat Claude Bernard, Assistance Publique - Hôpitaux de paris, Paris 7 University (Denis Diderot), 46 rue Henri-Huchard, 75877 Paris Cedex 18, France.
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