Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas

Minimally invasive treatment of complex collections: safety and efficacy of recombinant tissue plasminogen activator as an adjuvant to percutaneous drainage

Objective

To analyze the efficacy of recombinant tissue plasminogen activator (r-TPA) injection in the evolution of percutaneous drainage of thick collections.

Materials and Methods

This was a single-center study involving the retrospective analysis of hospitalized patients undergoing percutaneous drainage of thick (superficial or intracavitary) fluid collections, followed by injection of a fibrinolytic agent (r-TPA) into the affected space.

Results

A total of 53 percutaneous drainage procedures, with r-TPA injection, were performed in 51 patients. Abdominal and pelvic collections were the most common, being seen in 38 (73%) of the procedures; in 35 (66%), the etiology of the collection was attributed to postoperative complications. A total of 61 catheters were used in order to drain the 53 collections. Of those 61 catheters, 52 (85%) were large (12-16 Fr) and 9 (15%) were small (4-10 Fr). The mean r-TPA dose was 5.7 mg/collection per day, and the mean time from r-TPA injection to drain removal was 7.7 days. Percutaneous drainage in combination with r-TPA injection was successful in 96% of the cases. None of the patients showed coagulation changes during the study period.

Conclusion

The use of once-daily, low-dose r-TPA for up to three consecutive days, as an adjunct to percutaneous drainage of thick collections, with or without loculation, appears to be an effective technique.

Surgical versus non-surgical management for pleural empyema

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.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study

Today, in spite of the developments in imaging methods and antibiotherapy, childhood pleural empyema is a prominent cause of morbidity and mortality. In recent years, it has been shown that there has been an increase in the frequency of pleural empyema in children, and antibiotic resistance in microorganisms causing pleural empyema has made treatment difficult. Despite the many studies investigating thoracoscopic debridement and fibrinolytic treatment separately in the management of this disease, there is are not enough studies comparing these two treatments. The aim of this study was to prospectively compare the efficacy of two different treatment methods in stage II and III empyema cases and to present a perspective for treatment options.WE EXCLUDED FROM THE STUDY CASES WITH: i) thoracoscopic intervention and fibrinolytic agent were contraindicated; ii) immunosuppression or additional infection focus; iii) concomitant diseases, those with bronchopleural fistula diagnosed radiologically, and Stage I cases. This gave a total of 54 cases: 23 (42.6%) in stage II, and 31 (57.4%) cases in stage III. These patients were randomized into two groups of 27 cases each for debridement or fibrinolytic agent application by video-assisted thoracoscopic decortication (VATS). The continuity of symptoms after the operation, duration of thoracic tube in situ, and the length of hospital stay in the VATS group were of significantly shorter duration than in the streptokinase applications (P=0.0001). In 19 of 27 cases (70.37%) in which fibrinolytic treatment was applied and in 21 cases of 27 (77.77%) in which VATS was applied, the lung was fully expanded and the procedure was considered successful. There was no significant difference with respect to success rates between the two groups (P=0.533). The complication rate in our cases was 12.96% and no mortality was observed. Similar success rates in thoracoscopic drainage and enzymatic debridement, and the low cost of enzymatic drainage both served to highlight intrapleural streptokinase treatment as a reliable method in reducing the need for surgery in complicated empyema.

Regulation of intrapleural fibrinolysis by urokinase-alpha-macroglobulin complexes in tetracycline-induced pleural injury in rabbits

The proenzyme single-chain urokinase plasminogen activator (scuPA) more effectively resolved intrapleural loculations in rabbits with tetracycline (TCN)-induced loculation than a range of clinical doses of two-chain uPA (Abbokinase) and demonstrated a trend toward greater efficacy than single-chain tPA (Activase) (Idell S et al., Exp Lung Res 33: 419, 2007.). scuPA more slowly generates durable intrapleural fibrinolytic activity than Abbokinase or Activase, but the interactions of these agents with inhibitors in pleural fluids (PFs) have been poorly understood. PFs from rabbits with TCN-induced pleural injury treated with intrapleural scuPA, its inactive Ser195Ala mutant, Abbokinase, Activase, or vehicle, were analyzed to define the mechanism by which scuPA induces durable fibrinolysis. uPA activity was elevated in PFs of animals treated with scuPA, correlated with the ability to clear pleural loculations, and resisted (70-80%) inhibition by PAI-1. Alpha-macroglobulin (alphaM) but not urokinase receptor complexes immunoprecipitated from PFs of scuPA-treated rabbits retained uPA activity that resists PAI-1 and activates plasminogen. Conversely, little plasminogen activating or enzymatic activity resistant to PAI-1 was detectable in PFs of rabbits treated with Abbokinase or Activase. Consistent with these findings, PAI-1 interacts with scuPA much slower than with Activase or Abbokinase in vitro. An equilibrium between active and inactive scuPA (k(on) = 4.3 h(-1)) limits the rate of its inactivation by PAI-1, favoring formation of complexes with alphaM. These observations define a newly recognized mechanism that promotes durable intrapleural fibrinolysis via formation of alphaM/uPA complexes. These complexes promote uPA-mediated plasminogen activation in scuPA-treated rabbits with TCN-induced pleural injury.

The pathogenesis of pleural space loculation and fibrosis

PURPOSE OF REVIEW

Organization of parapneumonic effusions may complicate pneumonia, and, annually, thousands of patients require procedures to treat intrapleural loculation and fibrosis. Surgical procedures are often used for the treatment, as fibrinolytic therapy is now not a routine and is undergoing reassessment. Investigation of mechanisms that underlie intrapleural loculation and fibrosis is therefore timely, as are studies on new strategies to medically address these problems with improved efficacy and safety.

RECENT FINDINGS

Contributions made over the past year include basic and translational studies unified by their broad focus on mechanisms by which the pleural compartment undergoes repair. Intrapleural single-chain urokinase was reported to effectively reverse intrapleural loculation when compared with commercially available agents in rabbits with tetracycline-induced pleurodesis. The ability of exogenous sclerosants to produce intrapleural loculation and fibrosis was compared. Overexpression of transforming growth factor beta in the pleural mesothelium promoted subpleural fibrosis, implicating the mesothelial cell in the pathogenesis of this lesion. A new model of pleurodesis in mice was reported, which could facilitate the use of transgenic animals to study the pathogenesis of pleural injury.

SUMMARY

New findings consolidate and extend the view that common mechanisms by which intrapleural organization occurs can be exploited to either generate pleurodesis or effectively reverse intrapleural loculation and fibrosis.

Surgical and other invasive approaches to recurrent pleural effusion with malignant etiology

With an increasing number of cancer survivors, the annual incidence of malignant pleural effusions has been rising in recent decades worldwide. Many patients with various forms of cancer develop malignant pleural effusions at some point in their life. Patients most commonly present with progressive dyspnea. These effusions are refractory and are associated with impaired quality of life for these patients. The main goals of management are evacuation of the pleural fluid and prevention of its re-accumulation. The therapy plan should consider the general health of the patients, their performance status, the presence of trapped lung, and the primary malignancy. However, there is no universally established, standard approach. Surgical options include thoracentesis, chest tube drainage, thoracoscopy followed by chemical and mechanical pleurodesis, Pleur-X catheter drainage, and pleurectomy. Chemical pleurodesis is the most common modality of therapy for patients with recurrent pleural effusion. For example, Talc is the most successful pleurodesis agent with similar equal to that of poudrage or slurry. Pleur-X catheter can reduce hospital stay and adds value to the treatment of patients with trapped lung, who are not appropriate candidates for pleurodesis. Furthermore, a mechanical pleurodesis has been shown to be effective particularly in pleural effusions with lower pH. This article reviews the surgical and other invasive options as well as their technical aspects in the management of recurrent malignant pleural effusions.

Cerebral Gas Embolism Caused by Pleural Fibrinolytic Treatment

Background and Purpose— Intrapleural fibrinolytic therapy is a technique used to treat empyemas and parapneumonic effusions. Cerebral air embolism is an unusual potentially severe complication of this technique.

Summary of Case— A patient with parapneumonic pleural effusion underwent pleural lavage with streptokinase when he suddenly demonstrated focal neurological signs and seizures. The CT revealed multiple air-isodense spots in right hemisphere of the brain, suggesting cerebral air embolism. As a result of early diagnosis and emergency hyperbaric oxygenation, the patient recovered without delayed sequelae.

Conclusions— Air embolism is a potentially severe complication which can occur during fibrinolytic pleural lavage, and clinicians should be aware of this risk. In this context, the onset of acute focal neurological signs or seizures should suggest the possibility of air embolism and lead to the transfer of the patient close to a hyperbaric facility within a few hours.

Gastropleural fistula as a complication of empyema thoracis

Gastropleural fistula is an uncommon entity, especially in children. Here we report a 7-year-old child who developed gastropleural fistula as a complication of empyema thoracis. The child was also diagnosed to have chronic granulomatous disease.

[Parapneumonic effusion and empyema]

The infectious effusion, one of the most frequent causes of pleural effusions in the clinical practice, is a sign of complication of the pneumonic disease. The early recognition of the parapneumonic effusion is crucial to determine the best treatment form and reduce the risk of morbidity and mortality. The evolution in the diagnostic methods and the contribution of several studies published in the literature allowed to establish evidence-based guidelines that are used to guide the treatment of the parapneumonic pleural effusion and empyema.

Malignant pleural effusion, current and evolving approaches for its diagnosis and management

Malignant pleural effusion is a common and debilitating complication of advanced malignant diseases. This problem seems to affect particularly those with lung and breast cancer, contributing to the poor quality of life. Approximately half of all patients with metastatic cancer develop a malignant pleural effusion at some point, which is likely to cause significant symptoms such as dyspnea and cough. Evacuation of the pleural fluid and prevention of its re-accumulation are the main goals of management. Optimal treatment is controversial and there is no universally standard approach. Intervention options range from observation in the case of asymptomatic effusions through simple thoracentesis to more invasive methods such as chemical and mechanical pleurodesis, pleur-X catheter drainage, pleuroperitoneal shunting, and pleurectomy. The best results are reported with thoracoscopy and talc insufflation, with an acceptable morbidity. Development of novel methods to control malignant pleural effusion should be a high priority in palliative care of cancer patients. This article reviews the current, as well as, novel approaches that show some promise for the future. The aim is to identify the proper approach for each individual patient.

Once-daily vs. twice-daily intrapleural urokinase treatment of complicated parapneumonic effusion in paediatric patients: A randomised, prospective study

To evaluate the effective dose frequency (once daily vs. twice daily) of intrapleural urokinase treatment in children who required tube thoracostomy for drainage of a complicated parapneumonic effusion, we designed a randomised prospective study in a tertiary medical centre in Taiwan. From June 2002 to January 2005, 30 paediatric patients with complicated parapneumonic effusion who had received chest tube drainage were randomised 1 : 1 to the once-daily (urokinase 5000-6000 IU/kg/dose) or twice-daily (urokinase 2500-3000 IU/kg/dose) treatment. We compared clinical manifestations and outcomes in both groups. There were no differences in pleural effusion characteristics between the groups. Six patients had Streptococcus pneumoniae, one had Staphylococcus aureus, one had Group A Streptococcus, and 22 had unknown pathogens. There were no significant differences between the once- vs. twice-daily group in the amount of drained pleural fluid (564.9 +/- 422.1 ml vs. 560.5 +/- 198.6 ml, respectively), fever duration after chest tube insertion (4.3 +/- 3.2 days vs. 5.3 +/- 2.7 days), or total admission days (14.3 +/- 3.9 days vs. 14.6 +/- 3.0 days) (p > 0.05 for all). Only two patients (one in each group) required the surgery. Thus, we found that both once- and twice-daily administration of urokinase were similarly efficacious, and resulted in good clinical outcomes. Both obviated the need for surgery in most (93%) cases of pneumonia with complicated parapneumonic effusion in this series. A larger, multicentre study is necessary to verify our findings.

Intrapleural activation, processing, efficacy, and duration of protection of single-chain urokinase in evolving tetracycline-induced pleural injury in rabbits

Intrapleural fibrinolysins have been used to treat pleural loculations. However, the efficacy of clinically available agents has recently been questioned, providing a rationale for investigation of new interventions. Single-chain urokinase plasminogen activator resists inhibition by serpins, and repeated, daily intrapleural administration of this agent prevents intrapleural loculation more effectively than complexes of this proenzyme with its receptor (Idell S, Mazar A, Cines D, Kuo A, Parry G, Gawlak S, Juarez J, Koenig K, Azghani A, Hadden W, McLarty J, Miller E. Am J Respir Crit Care Med 166: 920-926, 2002). Understanding of the protective mechanism and intrapleural processing remains unclear. We speculated that single-chain urokinase could induce sustained local fibrinolysis and protection by selective administration either before, during, or following loculation after pleural injury induced by tetracycline in rabbits. Enzymography, immunoassays, histology, immunohistochemistry, morphology, and morphometry were used to test the efficacy, duration of protective effect, and processing of single-chain urokinase. Intrapleural single chain urokinase prevented loculation at 72 h after injury (P < 0.01) if given either before or during adhesion formation and was converted to two-chain high-molecular-weight urokinase, which remained active for at least 24 h within pleural fluids. The effect was dose dependent, and established loculations at 72 h after tetracycline-induced injury were reversed at 96 h by single-dose treatment. Single-chain urokinase bound and saturated intrapleural plasminogen activator inhibitory (PAI)-1-like activity and urokinase-related immunoreactivity of the mesothelium was comparable in treatment or vehicle-control groups. Adhesions recurred by 2 wk after treatment with recurrence of excess local PAI activity. Single-chain urokinase induces sustained local fibrinolysis and reversibly prevents pleural loculation for up to 48 h after intrapleural administration after tetracycline-induced injury.

Activation and degradation of protein C by primary rabbit pleural mesothelial cells

The protein C (PC) anticoagulant pathway is the major mechanism that controls thrombin generation in vivo and may thereby influence pathophysiologic fibrin turnover associated with intrapleural inflammation. We hypothesized that pleural mesothelial cells could regulate local expression of PC in evolving pleurodesis where inflammation and thrombosis play an important role. To test this hypothesis, we determined the ability of rabbit pleural mesothelial cells (RPMC) to support the activation of PC as well as its binding, internalization, and degradation. Lung fibroblasts were also assessed to test the specificity of the responses. We found that both cell types could support thrombin-dependent activation of PC in vitro. Both cell types were capable of binding, internalizing, and degrading 125I-PC. Degradation of 125I-PC by these cells was prevented by the lysosomal inhibitor chloroquine but not the proteasomal inhibitor lactacystin, supporting involvement of a lysosomal mechanism of PC degradation. During evolving tetracycline (TCN)-induced pleural injury in rabbits, PC levels in pleural fluids were sustained, exhibited a trend toward progressive decline, and were temporally correlated with pleural adhesion formation in vivo. These observations indicate that sustained expression of PC during evolving pleurodesis induced by TCN is subject to regulation by resident pleural cells: both RPMC and lung fibroblasts. Both cell types support local generation of APC. Internalization and degradation of PC by RPMC and fibroblasts may regulate its intrapleural expression and influence remodeling of extravascular fibrin in the setting of evolving pleurodesis induced by TCN.

Intrapleural fibrinolytic therapy for pleural infection

Pneumonia with secondary pleural infection causes considerable morbidity and mortality. Intrapleural instillation of fibrinolytic agents to dissolve fibrinous adhesions is intended to improve pleural fluid drainage and prevent pleural loculations. In the last 20 years their application in the every day clinical practice has dragged much of attention and several studies have supported their use in the management of parapneumonic pleural effusions (PPE) and pleural empyema (PE). However, recent published data cast doubt on the effectiveness of intrapleural fibrinolytic agents in promoting drainage of infected pleural effusions. Pending future clinical trials, fibrinolytic therapy may be used selectively in patients who fail drainage with appropriately sized, image-guided chest tubes if reasons exist to delay or avoid definitive surgical drainage. The scope of this article is to systematically review evidence for the efficacy of intrapleural fibrinolytic therapy in the treatment of PPE and PE with emphasis on controlled trials and present some of the future perspectives.

[Clinical phase I trial of concurrent chemo-radiotherapy with S-1 for T2NO glottic carcinoma]

We conducted a phase I study to determine a recommended dose (RD) of S-1 for chemo-radiotherapy consisting of S-1+ radiotherapy for T 2 N 0 larynx cancer. The method of administration used to assess the RD was irradiation with 2 Gy/day for 5 days a week until a total dose of 60 Gy, and concomitant administration of S-1 once a day for 2 weeks beginning on the day therapy was started followed by 2 weeks off the drug and 2 weeks on the drug with the dose escalating from S-1 60 mg/body/day (level 1) to 80 mg/body/day (level 2), and then to 100 mg/body/day (level 3). 18 patients were enrolled. 4 patients developed an adverse event of grade 3 radiation dermatitis which became a dose-limiting toxicity (DLT) at level 3. We then concluded that 100 mg/body/day was the maximum tolerated dose (MTD) of S-1 and decided that the RD of S-1 was 80 mg/body/day.

[Diagnosis and management of pleural effusions in critically iII patients]

INTRODUCTION

Pleural effusions are common in ICU patients. Causes include massive fluid resuscitation in shock, pneumonia--either community acquired or nosocomial, cardiac insufficiency, hypoalbuminemia and hepatic impairment. Pleural effusions frequently complicate cardiac and abdominal surgery and haemothorax may complicate trauma.

STATE OF THE ART

The incidence of pleural effusions in the intensive care unit (ICU) varies depending on the screening method used, from about 8% for physical examination to more than 60% for routine ultrasonography. In the absence of clinical parameters to exclude infection pleurocentesis remains an essential aspect of management and is not contraindicated mechanical ventilation. This review of the diagnosis and management of pleural effusions in ICU patients reports the most recent data from the literature. Pleurocentesis can be performed safely in the ICU, even in mechanically ventilated patients. The absence of reliable clinical or laboratory test criteria for determining the cause of pleural effusions and the potentially devastating consequences of failing to diagnose and treat pleural infection are strong reasons to perform pleurocentesis in patients with clinically detectable pleural effusions and no contraindication to the procedure.

PERSPECTIVES

Although the data reviewed indicate that the diagnosis and treatment of pleural effusions should follow the same rules in the ICU as they do elsewhere, several incompletely resolved issues deserve further investigation. These are summarised in an agenda for future research.

Treatment of Sonographically Stratified Multiloculated Thoracic Empyema by Medical Thoracoscopy

INTRODUCTION

In cases of empyema, some form of intervention, either chest tube drainage, thoracoscopy, video-assisted thoracic surgery (VATS), or thoracotomy, with or without pleural fibrinolysis, is required. What the best approach is and when and how to intervene is a matter of debate.

STUDY OBJECTIVE

To analyze the safety and outcome of medical thoracoscopy in the treatment of multiloculated empyema.

METHODS

We report a retrospective series of 127 patients with thoracic empyema treated with medical thoracoscopy from 1989 to 2003 in three hospitals in Switzerland and Italy. All patients had multiloculated empyema as identified by chest ultrasonography. In the absence of multiloculation, or in case of fibrothorax, simple chest tube drainage or surgical VATS/thoracotomy were performed, respectively.

RESULTS

Mean age +/- SD was 58 +/- 18 years (range, 9 to 93 years). In 47%, a microbiological diagnosis was made. Complications occurred in 9% of patients (subcutaneous emphysema, n = 3; air leak of 3 to 7 days, n = 9). No mortality was observed. Forty-nine percent of patients received postinterventional intrapleural fibrinolysis. Medical thoracoscopy was primarily successful in 91% of cases. In four patients, the insertion of an additional chest tube or a second medical thoracoscopy was required. Finally, 94% of patients were cured by nonsurgical means. Six percent of patients required surgical pleurectomy, mostly through thoracotomy.

CONCLUSION

Multiloculated empyema as stratified by ultrasonography can safely and successfully be treated by medical thoracoscopy.

Community-Acquired Thoracic Empyema in Older People

OBJECTIVES

To compare the clinical characteristics of community-acquired thoracic empyema in older and younger patients and to analyze the effect of various factors on outcome.

DESIGN

A retrospective, comparative observational study.

SETTING

A university-affiliated tertiary medical center.

PARTICIPANTS

Forty-six patients aged 65 and older (older group) and 86 patients aged 18 to 64 (younger group).

MEASUREMENTS

Demographic, clinical, and microbiological data were reviewed.

RESULTS

Older patients were more likely to have dyspnea but less likely to have chest pain or fever (P<.05 for all). The causative organisms were similar between the two groups, with anaerobes and facultative streptococci the most common pathogens. Older patients had increased morbidity and longer hospital stay (median 29.5 vs 20 days, P<.001), but the in-hospital mortality was not significantly different between the two groups (13% vs 8%, P=.37). Multivariate analysis showed that coexisting malignancy (odds ratio (OR)=10.33, P=.01), lack of fever higher than 38 degrees C (OR=17.97, P=.03), and isolation of fungi from pleural fluid (OR=32.66, P=.01) were independently and significantly associated with in-hospital deaths.

CONCLUSION

The microbiology and mortality of community-acquired thoracic empyema were similar between the two age groups. Difference in chronological age did not explain in-hospital death. This finding highlights the importance of effective treatment to obtain better outcomes for older patients.

Utilidad de la urocinasa intrapleural en el tratamiento del derrame pleural paraneumónico

INTRODUCTION

Intrapleural fibrinolytic instillation has been used in the treatment of loculated pleural effusions and empyemas and has reduced the need for surgical intervention. Currently, the most commonly used fibrinolytic is urokinase, although the doses have not yet been standardized in children. The aim of the present study was to evaluate the utility of urokinase in the treatment of infectious pleural effusions in children.

MATERIAL AND METHODS

A retrospective study was performed of children with infectious pleural effusions admitted to the pediatric intensive care unit (PICU) between January 2000 and December 2003. Age, sex, clinical features, laboratory tests, response to urokinase treatment and clinical course during hospital stay were analyzed.

RESULTS

Thirty-one children were treated. The mean age was 38.1 months (SD: 22). There were 18 boys and 13 girls. The most frequent month of diagnosis was November and the number of admission significantly increased from 2002 onwards. The most frequent antibiotic therapy used before admission to the PICU was cefotaxime associated with vancomycin (41 %), followed by cefotaxime alone (16 %). Positive cultures for Streptococcus pneumoniae were found in 11 patients (35 %). Pleural loculation was found in 14 patients (45 %). Treatment with intrapleural urokinase was used in 23 patients (74 %). The mean chest tube drainage was 140 ml (SD: 175) in the 24 hours before urokinase instillation and was 406 ml (SD: 289) in the 48 hours after fibrinolytic therapy (p < 0.05). Twenty-one patients (91 %) who received urokinase treatment had a good response. There were no complications during the treatment. The mean length of stay in the PICU was 5.8 days (SD: 2.6).

CONCLUSIONS

The incidence of complicated pleural effusions due to S. pneumoniae has increased in the last few years, despite antibiotic therapy. Intrapleural urokinase is an effective treatment, including in empyemas without loculation. None of our patients required thoracotomy and there were few adverse effects.

Pathogenesis of pleural fibrosis

Pleural fibrosis resembles fibrosis in other tissues and can be defined as an excessive deposition of matrix components that results in the destruction of normal pleural tissue architecture and compromised function. Pleural fibrosis may be the consequence of an organised haemorrhagic effusion, tuberculous effusion, empyema or asbestos-related pleurisy and can manifest itself as discrete localised lesions (pleural plaques) or diffuse pleural thickening and fibrosis. Although the pathogenesis is unknown, it is likely that the complex interactions between resident and inflammatory cells, profibrotic mediators and coagulation, and fibrinolytic pathways are integral to pleural remodelling and fibrosis. It is generally considered that the primary target cell for pleural fibrosis is the subpleural fibroblast. However, increasing evidence suggests that mesothelial cells may also play a significant role in the pathogenesis of this condition, both by initiating inflammatory responses and producing matrix components. A greater understanding of the interactions between pleural and inflammatory cells, cytokines and growth factors, and blood derived proteins is required before adequate therapies can be developed to prevent pleural fibrosis from occurring.

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.

Intrapleural Streptokinase for Empyema and Complicated Parapneumonic Effusions

We conducted a single-center, randomized, placebo-controlled trial to determine whether streptokinase instillations adjunctive to chest tube drainage reduce the need for surgery and improve outcome in patients with pleural empyema. Fifty-three patients (frank pus aspirated, 81%; microbiological agent cultured, 62%; mean effusion pH, 6.6 +/- 0.4) received antibiotic treatment, chest tube drainage, and once-daily pleural rinses with either normal saline or normal saline with streptokinase (250,000 IU). Nine patients were excluded for various reasons before pleural rinses were started. Streptokinase (n = 22) was instilled over 4.5 +/- 2 days and saline (n = 22) was instilled over 3 +/- 1.3 days. One patient in each group died during treatment. Clinical treatment success and need for referral to surgery were the main outcome measures. No difference was observed after 3 days. After 7 days, streptokinase-treated patients had a higher clinical success rate (82 vs. 48%, p = 0.01) and fewer referrals for surgery (45 vs. 9%, p = 0.02). No significant radiologic or functional differences were observed between groups during follow-up over 6 months. We conclude that intrapleural streptokinase adjunctive to chest tube drainage reduces the need for surgery and improves the clinical treatment success in patients with pleural empyema.

Toracocentese esvaziadora com irrigação e uso de antimicrobiano intrapleural no tratamento do empiema

INTRODUÇÃO: O empiema é uma doença grave caracterizada classicamente pela presença de pus na cavidade pleural. Seu reconhecimento precoce exige tratamento imediato, porém ainda existe grande controvérsia em relação à melhor terapêutica. OBJETIVO: Analisar o tratamento do empiema através de toracocentese, irrigação do espaço pleural, e uso de antimicrobiano intrapleural. MÉTODO: Foram avaliados dezessete pacientes com diagnóstico de empiema pleural livre ou septado, no período de janeiro de 1999 a maio de 2000, nos quais foi realizada toracocentese esvaziadora, seguida de lavagem exaustiva da cavidade pleural com solução isotônica e administração intrapleural de agente antimicrobiano não irritante à pleura. RESULTADOS: Foram analisados 15 homens e 2 mulheres com idade média de 44 anos. Os sinais clínicos mais freqüentes foram febre, tosse produtiva, dor torácica e dispnéia. A causa mais comum foi pneumonia. Macroscopicamente, 12 pacientes apresentavam líquido pleural francamente purulento. O agente etiológico foi identificado em quatro casos (26,67%), sendo o mais frequente o Staphylococcus sp. Dois pacientes foram encaminhados para decorticação pulmonar e foram excluídos do estudo. O tempo médio de internação foi de 15,1 dias, sendo que três pacientes realizaram o protocolo ambulatorialmente. Não observamos recidiva com o método e todos os pacientes sobreviveram. CONCLUSÃO: Essa abordagem diminuiu a necessidade de outros procedimentos invasivos. Mostrou-se eficaz, segura e com baixa morbi-mortalidade em comparação com as demais modalidades terapêuticas.

Adult respiratory distress syndrome: do selective anticoagulants help?

The adult respiratory distress syndrome (ARDS) is a form of acute lung injury that is characterized by florid extravascular fibrin deposition. Thrombosis in the pulmonary vasculature and disseminated intravascular coagulation have also been observed in association with ARDS. Fibrin deposition does not occur in the normal lung but is virtually universal in acute lung injury induced by disparate insults. A large body of basic and preclinical evidence further implicates abnormalities of pathways of fibrin turnover in the pathogenesis of acute inflammation and fibrotic repair. Coagulation is locally upregulated in the injured lung, while fibrinolytic activity is depressed. These abnormalities occur concurrently and favor alveolar fibrin deposition. The systemic derangements of fibrin turnover in sepsis are similar to those that occur in the injured lung. Recent clinical trials demonstrate that interventions using selective anticoagulation can provide a mortality advantage and that selective anticoagulants differ in their ability to provide clinical benefit. Preclinical trials in primates with sepsis-induced ARDS now indicate that anticoagulant interventions that block the extrinsic coagulation pathway can protect against the development of pulmonary fibrin deposition as well as lung dysfunction and acute inflammation. These observations provide proof of principle that key steps in the coagulation cascade are appropriate therapeutic targets to prevent the development of acute lung injury in ARDS. Ongoing studies and prior publications also support the hypothesis that reversal of the fibrinolytic defect in ARDS could protect against the development of acute lung injury. In all, these studies suggest that fibrin deposition in the injured lung as well as abnormalities of coagulation and fibrinolysis are integral to the pathogenesis of ARDS. The ability of selective anticoagulants to effectively and safely alter clinical outcome in ARDS remains to be determined.

Treatment of Complicated Parapneumonic Pleural Effusion With Intrapleural Streptokinase in Children

OBJECTIVE

To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children.

DESIGN

Prospective comparative study.

SETTING

Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan.

PATIENTS AND METHODS

We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics.

RESULTS

More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation.

CONCLUSION

Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.

Surgical versus nonsurgical treatment of empyema thoracis: an outcomes analysis

BACKGROUND

Empyema thoracis (ET) is associated with substantial morbidity and mortality. The optimal means for draining the pleural space remains controversial but there may be increasing bias for less invasive strategies. This study compared outcome after a nonsurgical versus a surgical approach to ET.

METHODS

Patients with ET over a 10-year period (n = 93) were reviewed and stratified into nonsurgical (thoracentesis and/or closed tube thoracostomy) and surgical (thoracotomy, decortication, and/or open window thoracostomy) groups based on pleural drainage techniques. Hospital course was analyzed except when altered by death (n = 12), noncompliance (n = 3), or severe comorbidities (n = 3).

RESULTS

Seventy-five patients were stratified into nonsurgical (n = 32) and surgical (n = 43) groups. Demographics, comorbidities, signs and symptoms, and causative organisms were similar between groups. Mortality did not significantly differ in nonsurgical (16%) versus surgical (10%) groups (P = 0.7). Although delay in diagnosis and number of therapeutic interventions were nearly identical, the time to definitive therapy was longer in the surgical versus the nonsurgical group (18 +/- 3.8 versus 8.5 +/- 3.8 days, P = 0.023). The time to discharge after definitive therapy (20.0 +/- 3.5 versus 35.6 +/- 14.0 days, P < 0.001), and overall hospital stay (40.6 +/- 5.3 versus 47.4 +/- 15 days, P = 0.01) was significantly decreased in the surgical versus nonsurgical treatment groups, respectively.

CONCLUSION

The treatment of ET is complex. Failure to adequately evacuate the pleural space and/or persistent signs of infection should prompt surgical intervention. Surgical therapy is preferred for advanced stages of ET. Delaying definitive surgical treatment is largely responsible for prolonging hospital course.

Pleural effusions in the intensive care unit

The incidence of pleural effusions in the intensive care unit varies depending on the screening methods, from approximately 8% for physical examination to more than 60% for routine ultrasonography. Several factors contribute to the occurrence of pleural effusions in intensive care unit patients: large amounts of intravenous fluid are often administered, pneumonia is common, and heart failure, atelectasis, extravascular catheter migration, hypoalbuminemia, or liver disease are present in many intensive care unit patients. In surgical intensive care units, cardiac or abdominal surgery is often followed by pleural effusions, and in trauma patients, hemothorax is a dreaded event. Because no clinical parameter excludes pleural infection, and because of the impact of thoracentesis on diagnosis and treatment, this procedure should be performed unless contraindicated. Thoracentesis is safe in mechanically ventilated patients. The author discusses the following points regarding pleural effusions in the intensive care unit: screening intensive care unit patients for pleural effusion, safety of thoracentesis in patients receiving invasive mechanical ventilation, distinguishing exudates from transudates, and diagnosing and managing infected pleural effusions in critically ill patients. Lastly, the author suggests a research agenda for pleural effusions in intensive care unit patients.

Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions

BACKGROUND

Streptokinase is widely used IV for the treatment of myocardial infarction and intrapleurally for the treatment of loculated pleural effusions. IV administration of streptokinase is known to cause the production of antistreptokinase antibodies.

OBJECTIVE

The aim of this study was to evaluate whether the intrapleural administration of streptokinase results in a similar elevation of the serum antistreptokinase antibody level.

METHODS

During 1 year, venous blood samples were taken from 16 consecutive patients (10 men and 6 women; age range, 22 to 60 years) requiring intrapleural streptokinase administration (250,000 IU once a day, for 2 to 6 days). Blood samples were taken before treatment, on day 5, and day 14. Antistreptokinase antibodies were measured using enzyme-linked immunosorbent assay (ELISA) and were expressed in arbitrary ELISA units. Four patients with myocardial infarction treated with IV streptokinase (1,500,000 IU) were included as control subjects for the method.

RESULTS

Before treatment, the median antistreptokinase antibody level in patients with loculated pleural effusions was 729 ELISA units (range, 196 to 13,529 ELISA units) and increased to 9,240 ELISA units (range, 1,456 to 77,389 ELISA units) by day 14 (p < 0.0001). In the control group, the median pretreatment level was 119 ELISA units, and by day 14 it had increased to 20,495 ELISA units. Four patients who developed an elevated body temperature after intrapleural administration of streptokinase had a significantly higher pretreatment antistreptokinase antibody level compared to other patients.

CONCLUSIONS

The intrapleural administration of streptokinase results in the elevation of the serum antistreptokinase antibody level, which is similar to the case with IV administration. An increased pretreatment antistreptokinase antibody level does not influence the result of intrapleural fibrinolysis but can cause an elevation of body temperature after the administration of streptokinase.

Single-chain urokinase alone or complexed to its receptor in tetracycline-induced pleuritis in rabbits

Intrapleural loculation can increase morbidity in hemothoraces or parapneumonic effusions. Intrapleural fibrin precedes visceral-parietal pleural adhesions. We speculated that single-chain urokinase plasminogen activator alone or bound to its receptor could prevent these adhesions by their relative resistance to local inhibition by plasminogen activator inhibitors. We found that recombinant human single-chain urokinase-bound rabbit pleural mesothelial cells or lung fibroblasts with kinetics similar to that reported for human cells (kD of approximately 5 nM). The receptor-bound fibrinolysin maintained in vitro fibrinolytic activity in the presence of pleural fluids from rabbits with tetracycline-induced pleural injury over 24 hours. In rabbits given intrapleural single-chain urokinase 24 and 48 hours after intrapleural tetracycline (n = 10 animals), adhesions were prevented, whereas the receptor-complexed form (n = 12) attenuated adhesions versus vehicle/tetracycline-treated rabbits (n = 22, p <or= 0.005 in both cases). There were more adhesions in the complex than the single-chain urokinase group (p = 0.02). Residual antigenic but not functional evidence of the interventional agents remained in pleural fluids at 72 hours after tetracycline. No local or systemic bleeding occurred because of either interventional agent. The data demonstrate that single-chain urokinase inhibits, whereas lysin-receptor complexes attenuate, adhesion formation in tetracycline-induced pleural injury in rabbits.

Canine and feline pyothorax: a retrospective study of 50 cases in the UK and Ireland

Fifty cases (36 dogs and 14 cats) with a confirmed diagnosis of pyothorax were evaluated from five referral institutions in the UK and Ireland. Aetiology, clinical presentation, diagnosis, treatment and outcome of all cases were examined. The underlying cause of pyothorax was determined in 18 per cent of cases. Positive bacteriological cultures of the pleural fluid were obtained in 68.7 per cent of the animals. Treatment modalities included surgery and medical management, involving thoracostomy tube placement, thoracic aspiration, thoracic lavage and antimicrobial therapy. A successful outcome was achieved in 86 per cent of patients.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.