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Liu J, Li C, Liu Z, Ye L, Shen Q, Hong Q, Song Y, Ye M. Inverted Placement of Endoscopic One-Way Endobronchial Valve Combined with Gelfoam in the Closure of Bronchopleural Fistula with Empyema in a Mechanically Ventilated Patient: A Case Report. Respiration 2024; 103:166-170. [PMID: 38330927 PMCID: PMC10939507 DOI: 10.1159/000535478] [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: 07/16/2023] [Accepted: 11/05/2023] [Indexed: 02/10/2024] Open
Abstract
Bronchopleural fistula (BPF) with empyema caused by severe necrotizing pulmonary infection is a complicated clinical problem that is often associated with poor general condition so surgical interventions cannot be tolerated in most cases. Here, we present the successful management of multiple BPF with empyema in a mechanically ventilated patient with aspiration lung abscess. Occlusion utilizing Gelfoam followed by endobronchial valves (EBVs) implanted inverted via bronchoscope decreased the air leaking significantly and made intrapleural irrigation for empyema achievable and safe. This is the first report of a novel way of EBV placement and the combination use with other occlusive substances in BPF with empyema in a patient on mechanical ventilation. This method may be an option for refractory BPF cases with pleural infection.
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Affiliation(s)
- Jie Liu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China,
- Shanghai Respiratory Research Institute, Shanghai, China,
| | - Chun Li
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Respiratory Research Institute, Shanghai, China
| | - Zilong Liu
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ling Ye
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qinjun Shen
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qunying Hong
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Respiratory Research Institute, Shanghai, China
| | - Yuanlin Song
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Respiratory Research Institute, Shanghai, China
| | - Maosong Ye
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Respiratory Research Institute, Shanghai, China
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2
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Feller-Kopman D. Seeing through the MIST: A Pathway Toward Optimal Intervention for Pleural Infection. Am J Respir Crit Care Med 2023; 208:1261-1263. [PMID: 37934466 PMCID: PMC10765400 DOI: 10.1164/rccm.202310-1822ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/08/2023] Open
Affiliation(s)
- David Feller-Kopman
- Pulmonary and Critical Care Medicine Dartmouth-Hitchcock Medical Center Lebanon, New Hampshire
- Geisel School of Medicine at Dartmouth Hanover, New Hampshire
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3
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Elsheikh A, Bhatnagar M, Rahman NM. Diagnosis and management of pleural infection. Breathe (Sheff) 2023; 19:230146. [PMID: 38229682 PMCID: PMC10790177 DOI: 10.1183/20734735.0146-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/07/2023] [Indexed: 01/18/2024] Open
Abstract
Pleural infection remains a medical challenge. Although closed tube drainage revolutionised treatment in the 19th century, pleural infection still poses a significant health burden with increasing incidence. Diagnosis presents challenges due to non-specific clinical presenting features. Imaging techniques such as chest radiographs, thoracic ultrasound and computed tomography scans aid diagnosis. Pleural fluid analysis, the gold standard, involves assessing gross appearance, biochemical markers and microbiology. Novel biomarkers such as suPAR (soluble urokinase plasminogen activator receptor) and PAI-1 (plasminogen activator inhibitor-1) show promise in diagnosis and prognosis, and microbiology demonstrates complex microbial diversity and is associated with outcomes. The management of pleural infection involves antibiotic therapy, chest drain insertion, intrapleural fibrinolytic therapy and surgery. Antibiotic therapy relies on empirical broad-spectrum antibiotics based on local policies, infection setting and resistance patterns. Chest drain insertion is the mainstay of management, and use of intrapleural fibrinolytics facilitates effective drainage. Surgical interventions such as video-assisted thoracoscopic surgery and decortication are considered in cases not responding to medical therapy. Risk stratification tools such as the RAPID (renal, age, purulence, infection source and dietary factors) score may help guide tailored management. The roles of other modalities such as local anaesthetic medical thoracoscopy and intrapleural antibiotics are debated. Ongoing research aims to improve outcomes by matching interventions with risk profile and to better understand the development of disease.
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Affiliation(s)
- Alguili Elsheikh
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Both authors contributed equally
| | - Malvika Bhatnagar
- Cardiothoracic Unit, Freeman Hospital, Newcastle upon Tyne, UK
- Both authors contributed equally
| | - Najib M. Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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4
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Shiroshita A, Kimura Y, Yamada A, Shirakawa C, Yue C, Suzuki H, Anan K, Sato K, Nakashima K, Takeshita M, Okuno T, Nitawaki T, Igei H, Suzuki J, Tomii K, Ohgiya M, Kataoka Y. Effectiveness of Immediate Video-Assisted Thoracoscopic Surgery for Empyema: A Multicentre, Retrospective Cohort Study. Respiration 2023; 102:821-832. [PMID: 37634506 DOI: 10.1159/000533439] [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: 03/02/2023] [Accepted: 08/02/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Because of limitations in previous randomised controlled trials and observational studies, the effectiveness of immediate video-assisted thoracoscopic surgery (VATS) for patients with empyema in real-world settings remains unclear. OBJECTIVE This study aimed to evaluate whether immediate VATS improves clinical outcomes in patients with empyema. METHODS This multicentre retrospective cohort study included 744 patients with physician-diagnosed empyema from six hospitals between 2006 and 2021. The exposure was VATS performed within 3 days of empyema diagnosis, the primary outcome was 30-day mortality, and secondary outcomes were 90-day mortality, length of hospital stay, and time from diagnosis to discharge. We used propensity score weighting to account for potential confounders. For outcome analyses, we used logistic regression for mortality outcomes and gamma regression for the number of days. RESULTS Among the 744 patients, 53 (7.1%) underwent VATS within 3 days, and 691 (92.9%) initially received conservative treatment. After propensity score weighting, the differences in 30- and 90-day mortalities between the immediate VATS and initial conservative treatment groups were 1.18% (95% confidence interval [CI], -10.7 to 13.0%) and -0.08% (95% CI, -10.3 to 10.2%), respectively. The differences in length of hospital stay and time from diagnosis to discharge were -3.22 (95% CI, -6.19 to -0.25 days) and -5.04 days (95% CI, -8.19 to -1.90 days), respectively. CONCLUSIONS Our real-world study showed that immediate VATS reduced the length of hospital stay and the time from diagnosis to discharge. Considering the small sample and differences in protocols between countries, further large-scale studies are warranted.
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Affiliation(s)
- Akihiro Shiroshita
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Yuya Kimura
- Clinical Research Center, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Atsushi Yamada
- Department of Diagnostic Radiology, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Chigusa Shirakawa
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Cong Yue
- Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan
- Department of Thoracic Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hokuto Suzuki
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Keisuke Anan
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Kenya Sato
- Department of Thoracic Medicine, Saiseikai Yokohama-shi Tobu Hospital, Yokohama, Japan
| | - Kiyoshi Nakashima
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Masafumi Takeshita
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Takehiro Okuno
- Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Japan
| | - Tatsuya Nitawaki
- Division of Respiratory Medicine, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Hiroshi Igei
- Department of Respiratory Medicine, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Jun Suzuki
- Department of Diagnostic Imaging, Saitama Medical University International Medical Center, Saitama, Japan
| | - Keisuke Tomii
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Masahiro Ohgiya
- Department of Respiratory Medicine, National Hospital Organization Tokyo Hospital, Tokyo, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University, Kyoto, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
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5
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Brown MR, Boster JM, Goertzen SM, Morris MJ, Manninen ES. Enterococcus faecium Empyema Following Extracorporeal Membrane Oxygenation for COVID-19 Acute Respiratory Distress Syndrome. Cureus 2023; 15:e42789. [PMID: 37664261 PMCID: PMC10469799 DOI: 10.7759/cureus.42789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
A 33-year-old male with severe COVID-19 required prolonged veno-venous extracorporeal membrane oxygenation (ECMO) support. Following decannulation, he developed an Enterococcus faecium empyema. Tube thoracostomy and broad-spectrum antibiotics were initiated, followed by an unsuccessful attempt at pleural irrigation with saline, given the patient had an increased risk of bleeding due to the concomitant requirement for systemic anticoagulation. Subsequently, intrapleural tissue plasminogen activator (tPA) and recombinant human Dornase alfa (DNase) were safely administered with the resolution of empyema. Enterococcus faecium is an uncommon cause of pleural empyema and, to our knowledge, has not previously been reported to be associated with COVID-19 or ECMO.
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Affiliation(s)
- Mark R Brown
- Internal Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Joshua M Boster
- Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Stephen M Goertzen
- Pulmonary and Critical Care, San Antonio Military Medical Center, San Antonio, USA
| | - Michael J Morris
- Pulmonary and Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
| | - Erik S Manninen
- Critical Care Medicine, San Antonio Military Medical Center, San Antonio, USA
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6
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Fitzgerald DB, Polverino E, Waterer GW. Expert Review on Nonsurgical Management of Parapneumonic Effusion: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023; 44:468-476. [PMID: 37429296 DOI: 10.1055/s-0043-1769095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Parapneumonic effusion and empyema are rising in incidence worldwide, particularly in association with comorbidities in an aging population. Also driving this change is the widespread uptake of pneumococcal vaccines, leading to the emergence of nonvaccine-type pneumococci and other bacteria. Early treatment with systemic antibiotics is essential but should be guided by local microbial guidelines and antimicrobial resistance patterns due to significant geographical variation. Thoracic ultrasound has emerged as a leading imaging technique in parapneumonic effusion, enabling physicians to characterize effusions, assess the underlying parenchyma, and safely guide pleural procedures. Drainage decisions remain based on longstanding criteria including the size of the effusion and fluid gram stain and biochemistry results. Small-bore chest drains appear to be as effective as large bore and are adequate for the delivery of intrapleural enzyme therapy (IET), which is now supported by a large body of evidence. The IET dosing regimen used in the UK Multicenter Sepsis Trial -2 has the most evidence available but data surrounding alternative dosing, concurrent and once-daily instillations, and novel fibrinolytic agents are promising. Prognostic scores used in pneumonia (e.g., CURB-65) tend to underestimate mortality in parapneumonic effusion/empyema. Scores specifically based on pleural infection have been developed but require validation in prospective cohorts.
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Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
- Medical School, University of Western Australia, Australia
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain; CIBER de enfermedades respiratorias
| | - Grant W Waterer
- Medical School, University of Western Australia, Australia
- Royal Perth Hospital, Perth, WA, Australia
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7
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Kelley SR, McCall AS, Qian ET, Ely EW. Intrapleural Dakin's Solution for Refractory Empyema in a Critically Ill Patient. J Bronchology Interv Pulmonol 2023; 30:296-298. [PMID: 35969007 DOI: 10.1097/lbr.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Soibhan R Kelley
- Department of Medicine, Vanderbilt University Medical Center, Division of Allergy, Pulmonary, and Critical Care
| | - Abraham Scott McCall
- Department of Medicine, Vanderbilt University Medical Center, Division of Allergy, Pulmonary, and Critical Care
| | - Edward T Qian
- Department of Medicine, Vanderbilt University Medical Center, Division of Allergy, Pulmonary, and Critical Care
| | - Eugene Wesley Ely
- Department of Medicine, Vanderbilt University Medical Center, Division of Allergy, Pulmonary, and Critical Care
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN
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8
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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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9
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Pleural Space Infections. Life (Basel) 2023; 13:life13020376. [PMID: 36836732 PMCID: PMC9959801 DOI: 10.3390/life13020376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Pleural space infections have been a well-recognized clinical syndrome for over 4000 years and continue to cause significant morbidity and mortality worldwide. However, our collective understanding of the causative pathophysiology has greatly expanded over the last few decades, as have our treatment options. The aim of this paper is to review recent updates in our understanding of this troublesome disease and to provide updates on established and emerging treatment modalities for patients suffering from pleural space infections. With that, we present a review and discussion synthesizing the recent pertinent literature surrounding the history, epidemiology, pathophysiology, diagnosis, and management of these challenging infections.
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10
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Akulian J, Bedawi EO, Abbas H, Argento C, Arnold DT, Balwan A, Batra H, Uribe Becerra JP, Belanger A, Berger K, Burks AC, Chang J, Chrissian AA, DiBardino DM, Fuentes XF, Gesthalter YB, Gilbert CR, Glisinski K, Godfrey M, Gorden JA, Grosu H, Gupta M, Kheir F, Ma KC, Majid A, Maldonado F, Maskell NA, Mehta H, Mercer J, Mullon J, Nelson D, Nguyen E, Pickering EM, Puchalski J, Reddy C, Revelo AE, Roller L, Sachdeva A, Sanchez T, Sathyanarayan P, Semaan R, Senitko M, Shojaee S, Story R, Thiboutot J, Wahidi M, Wilshire CL, Yu D, Zouk A, Rahman NM, Yarmus L. Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study. Chest 2022; 162:1384-1392. [PMID: 35716828 PMCID: PMC9773231 DOI: 10.1016/j.chest.2022.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined. RESEARCH QUESTION What is the bleeding complication risk associated with IET use in pleural infection? STUDY DESIGN AND METHODS This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria. RESULTS Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 109/L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare. INTERPRETATION IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment.
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Affiliation(s)
- Jason Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England.
| | - Hawazin Abbas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Christine Argento
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David T Arnold
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Akshu Balwan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Hitesh Batra
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Juan Pablo Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam Belanger
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kristin Berger
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Allen Cole Burks
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Jiwoon Chang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Ara A Chrissian
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - David M DiBardino
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Yaron B Gesthalter
- Division of Pulmonary, Critical Care, Allergy and Sleep, The University of California San Francisco, San Francisco, CA
| | - Christopher R Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Kristen Glisinski
- Division of Pulmonary and Critical Care, National Jewish Health, Denver, CO
| | - Mark Godfrey
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Jed A Gorden
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Horiana Grosu
- Division of Pulmonary and Critical Care, The University Texas MD Anderson Cancer Center, Houston, TX
| | - Mridul Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kevin C Ma
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, England
| | - Hiren Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Joshua Mercer
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John Mullon
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Darlene Nelson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Elaine Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - Edward M Pickering
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan Puchalski
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Chakravarthy Reddy
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT
| | - Alberto E Revelo
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lance Roller
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Trinidad Sanchez
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Priya Sathyanarayan
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roy Semaan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michal Senitko
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Samira Shojaee
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Ryan Story
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jeffrey Thiboutot
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Momen Wahidi
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Candice L Wilshire
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Diana Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Aline Zouk
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Mismetti V, Froudarakis ME. Medical management of pleural infection: Why not saline intrapleural lavage? THE CLINICAL RESPIRATORY JOURNAL 2022; 16:693-695. [PMID: 36173249 PMCID: PMC9629991 DOI: 10.1111/crj.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/18/2022] [Accepted: 09/20/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Valentine Mismetti
- Department of Pulmonology and Thoracic Oncology, North HospitalUniversity Hospital of Saint‐EtienneSaint‐Priest‐en‐JarezFrance
| | - Marios E. Froudarakis
- Department of Pulmonology and Thoracic Oncology, North HospitalUniversity Hospital of Saint‐EtienneSaint‐Priest‐en‐JarezFrance
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12
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Ciani O, Manyara AM, Taylor RS. Surrogate end points in cardio-thoracic trials: a call for better reporting and improved interpretation of trial findings. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 62:6702080. [PMID: 36112148 DOI: 10.1093/ejcts/ezac449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/28/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Oriana Ciani
- Center for Research on Health and Social Care Management, SDA Bocconi School of Management, Milan, Italy
| | - Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.,Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK
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13
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Porcel JM. Nonmalignant Pleural Effusions. Semin Respir Crit Care Med 2022; 43:570-582. [PMID: 36104027 DOI: 10.1055/s-0042-1748186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Although the potential causes of nonmalignant pleural effusions are many, the management of a few, including complicated pleural infections and refractory heart failure and hepatic hydrothoraces, can be challenging and requires the assistance of interventional pulmonologists. A pragmatic approach to complicated parapneumonic effusions or empyemas is the insertion of a small-bore chest tube (e.g., 14-16 Fr) through which fibrinolytics (e.g., urokinase and alteplase) and DNase are administered in combination. Therapeutic thoracenteses are usually reserved for small to moderate effusions that are expected to be completely aspirated at a single time, whereas video-assisted thoracic surgery should be considered after failure of intrapleural enzyme therapy. Refractory cardiac and liver-induced pleural effusions portend a poor prognosis. In cases of heart failure-related effusions, therapeutic thoracentesis is the first-line palliative therapy. However, if it is frequently needed, an indwelling pleural catheter (IPC) is recommended. In patients with hepatic hydrothorax, repeated therapeutic thoracenteses are commonly performed while a multidisciplinary decision on the most appropriate definitive management is taken. The percutaneous creation of a portosystemic shunt may be used as a bridge to liver transplantation or as a potential definitive therapy in nontransplant candidates. In general, an IPC should be avoided because of the high risk of complications, particularly infections, that may jeopardize candidacy for liver transplantation. Even so, in noncandidates for liver transplant or surgical correction of diaphragmatic defects, IPC is a therapeutic option as valid as serial thoracenteses.
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Affiliation(s)
- José M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
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14
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Ishihara T, Sato S, Manabe S, Ozawa H. Complications of cerebral air embolism associated with pleural lavage for empyema. BMJ Case Rep 2022; 15:e249618. [PMID: 35760513 PMCID: PMC9237889 DOI: 10.1136/bcr-2022-249618] [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] [Indexed: 11/03/2022] Open
Abstract
Standard initial treatment for acute empyema involves antibiotic administration and chest tube drainage; however, pleural lavage with saline is another treatment that mitigates the need for surgical drainage. Although this treatment is recognised as non-invasive and safe, the complications of cerebral air embolism are less recognised.In this case, a man in his late 40s was diagnosed with acute empyema and treated with chest tube (28 Fr) drainage and antibiotics. Empyema remained on follow-up chest imaging; thus intrapleural fibrinolytic therapy (urokinase 120 000 units/day for a total of 3 days) and pleural lavage (0.9% saline 1000 mL/day daily) were administered. During the 10th pleural lavage, the patient suddenly became unconscious. Head imaging revealed a cerebral air embolism. Consequently, he received urgent hyperbaric oxygen therapy and improved without any neurological sequelae.Clinicians should be aware of the complications of sudden cerebral air embolism due to pleural lavage for empyema.
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Affiliation(s)
- Toru Ishihara
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Shota Sato
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Saki Manabe
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Hideki Ozawa
- Division of General Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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15
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The Volume of Thoracic Irrigation Is Associated With Length of Stay in Patients With Traumatic Hemothorax. J Surg Res 2022; 279:62-71. [PMID: 35724544 DOI: 10.1016/j.jss.2022.05.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/15/2022] [Accepted: 05/21/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Irrigation of the thoracic cavity at tube thoracostomy (TT) placement may decrease the rate of a retained hemothorax (RHTX); however, other resource utilization outcomes have not yet been quantified. This study evaluated the association of thoracic irrigation during TT with the length of stay and outcomes in patients with traumatic hemothorax (HTX). METHODS A retrospective chart review was performed of adult patients receiving a TT for HTX at a single, urban Level 1 Trauma Center from January 2019 to December 2020. Those who underwent irrigation during TT at the discretion of the trauma surgeon were compared to a control of standard TT without irrigation. Death within 30 d, as well as TTs, placed at outside hospitals, during traumatic arrest or thoracic procedures, and for isolated pneumothoraces were excluded. The primary outcome was the length of stay as hospital-free, ICU-free, and ventilator-free days (30-day benchmark). Subgroup analysis by irrigation volume was conducted using one-way ANOVA testing with P < 0.05 considered statistically significant. RESULTS Eighty-two (41.4%) of 198 patients underwent irrigation during TT placement. Secondary interventions, thoracic infections, and TT duration were not statistically different in the irrigated cohort. Hospital-free and ICU-free days were higher in the irrigated patients than in the controls. Groups irrigated with ≥1000 mL had significant more hospital-free days (P = 0.007) than those receiving less than 1000 mL. CONCLUSIONS Patients with traumatic HTX who underwent thoracic irrigation at the time of TT placement had decreased hospital and ICU days compared to standard TT placement alone. Specifically, our study demonstrated that patients irrigated with a volume of at least 1000 mL had greater hospital-free days compared to those irrigated with less than 1000 mL.
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16
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Popowicz N, Ip H, Lau EPM, Piccolo F, Dootson K, Yeoh C, Phu WY, Brown R, West A, Ahmed L, Lee YCG. Alteplase Dose Assessment for Pleural infection Therapy (ADAPT) Study-2: Use of 2.5 mg alteplase as a starting intrapleural dose. Respirology 2022; 27:510-516. [PMID: 35441458 DOI: 10.1111/resp.14261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Intrapleural tissue plasminogen activator/deoxyribonuclease (tPA/DNase) therapy is increasingly used in pleural infection. Bleeding risks and costs associated with tPA remain the clinical concerns. Our dose de-escalation series aims to establish the lowest effective dosing regimen for tPA/DNase. This study assesses the intrapleural use of 2.5 mg tPA/5 mg DNase for pleural infection. METHODS Consecutive patients with pleural infection treated with a starting regime of 2.5 mg tPA/5 mg DNase were included from two centres in Australia and UK. Escalation of tPA dose was permitted if clinical response was inadequate. RESULTS Sixty-nine patients (mean age 61.0 years) received intrapleural 2.5 mg tPA/5 mg DNase. Most (88.4%) were treated successfully and discharged from hospital without surgery by 90 days. Patients received a median of 5 [interquartile range [IQR] = 3-6] doses of tPA/DNase. Total amount of tPA used per patient was 12.5 mg [median, IQR = 7.5-15.0]. Seventeen patients required dose escalation of tPA; most (n = 12) for attempted drainage of distant non-communicating locule(s). Treatment success was corroborated by clearance of pleural opacities on radiographs (from median 27.0% [IQR = 17.1-44.5] to 11.0% [IQR = 6.4-23.3] of hemithorax, p < 0.0001), increased pleural fluid drainage (1.98 L [median, IQR = 1.38-2.68] over 72 h following commencement of tPA/DNase) and reduction of serum C-reactive protein level (by 45.0% [IQR = 39.3-77.0] from baseline at day 5, p < 0.0001). Two patients required surgery. Six patients with significant comorbidities (e.g., advanced cancer) had ongoing infection when palliated and died. Two patients experienced self-limiting pleural bleeding and received blood transfusion. CONCLUSION A starting intrapleural regime of 2.5 mg tPA/5 mg DNase, with up-titration if needed, can be effective and deserves further exploration.
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Affiliation(s)
- Natalia Popowicz
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hugh Ip
- Respiratory Medicine, Royal Free Hospital, London, UK
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Francesco Piccolo
- Respiratory Medicine, St John of God Midland, Perth, Western Australia, Australia
| | - Kirstie Dootson
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Cindy Yeoh
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Wint Ywe Phu
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Rebecca Brown
- Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Alex West
- Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Liju Ahmed
- Respiratory Medicine, King Faisal Specialist Hospital and Research Centre Madinah, Riyadh, Saudi Arabia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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17
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Aliaga F, Grosu HB, Vial MR. Overview of Bronchopleural Fistula Management, with a Focus on Bronchoscopic Treatment. CURRENT PULMONOLOGY REPORTS 2022. [DOI: 10.1007/s13665-022-00289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Christensen TD, Bendixen M, Skaarup SH, Jensen JU, Petersen RH, Christensen M, Licht P, Neckelmann K, Bibby BM, Møller LB, Bodtger U, Borg MH, Saghir Z, Langfeldt S, Harders SMW, Bedawi EO, Naidu B, Rahman N, Laursen CB. Intrapleural fibrinolysis and DNase versus video-assisted thoracic surgery (VATS) for the treatment of pleural empyema (FIVERVATS): protocol for a randomised, controlled trial - surgery as first-line treatment. BMJ Open 2022; 12:e054236. [PMID: 35264347 PMCID: PMC8915266 DOI: 10.1136/bmjopen-2021-054236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Pleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can be given. A potential better alternative is surgery in terms of video-assisted thoracoscopic surgery (VATS) as first-line treatment. The aim of this study is to determine the difference in outcome in patients diagnosed with complex parapneumonic effusion (stage II) and pleural empyema (stage III) who are treated with either VATS surgery or TUS-guided drainage and intrapleural therapy (fibrinolytic (Alteplase) with DNase (Pulmozyme)) as first-line treatment. METHODS AND ANALYSIS A national, multicentre randomised, controlled study. Totally, 184 patients with a newly diagnosed community acquired complicated parapneumonic effusion or pleural empyema are randomised to either (1) VATS procedure with drainage or (2) TUS-guided pigtail catheter placement and intrapleural therapy with Actilyse and DNase. The total follow-up period is 12 months. The primary endpoint is length of hospital stay and secondary endpoints include for example, mortality, need for additional interventions, consumption of analgesia and quality of life. ETHICS AND DISSEMINATION All patients provide informed consent before randomisation. The research project is carried out in accordance with the Helsinki II Declaration, European regulations and Good Clinical Practice Guidelines. The Scientific Ethics Committees for Denmark and the Danish Data Protection Agency have provided permission. Information about the subjects is protected under the Personal Data Processing Act and the Health Act. The trial is registered at www. CLINICALTRIALS gov, and monitored by the regional Good clinical practice monitoring unit. The results of this study will be published in peer-reviewed journals and presented at various national and international conferences. TRIAL REGISTRATION NUMBER NCT04095676.
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Affiliation(s)
- Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Bendixen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Helbo Skaarup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Jens-Ulrik Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rene Horsleben Petersen
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Merete Christensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Kirsten Neckelmann
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Bo Martin Bibby
- Department of Public Health, Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Lars B Møller
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Uffe Bodtger
- Department of Internal Medicine & Department of Respiratory Medicine, Zealand University Hospital, Naestved-Slagelse Hospital, Naestved, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Morten Hornemann Borg
- Department of Respiratory Medicine & Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Zaigham Saghir
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Langfeldt
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Eihab O Bedawi
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Najib Rahman
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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19
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Karandashova S, Florova G, Idell S, Komissarov AA. From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema. Front Pharmacol 2022; 12:806393. [PMID: 35126140 PMCID: PMC8811368 DOI: 10.3389/fphar.2021.806393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.
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Affiliation(s)
- Sophia Karandashova
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
- *Correspondence: Andrey A. Komissarov,
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20
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Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery. Respir Med 2021; 191:106706. [PMID: 34896966 DOI: 10.1016/j.rmed.2021.106706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/11/2021] [Accepted: 11/24/2021] [Indexed: 11/24/2022]
Abstract
Pleural effusion is a frequent complication of acute pulmonary infection and can affect its morbidity and mortality. The possible evolution of a parapneumonic pleural effusion includes 3 stages: exudative (simple accumulation of pleural fluid), fibropurulent (bacterial invasion of the pleural cavity), and organized stage (scar tissue formation). Such a progression is favored by inadequate treatment or imbalance between microbial virulence and immune defenses. Biochemical features of a fibrinopurulent collection include a low pH (<7.20), low glucose level (<60 mg/dl), and high lactate dehydrogenase (LDH). A parapneumonic effusion in the fibropurulent stage is usually defined "complicated" since antibiotic therapy alone is not enough for its resolution and an invasive procedure (pleural drainage or surgery) is required. Chest ultrasound is one of the most useful imaging tests to assess the presence of a complicated pleural effusion. Simple parapneumonic effusions are usually anechoic, whereas complicated effusions often have a complex appearance (non-anechoic, loculated, or septated). When simple chest tube placement fails and/or patients are not suitable for more invasive techniques (i.e. surgery), intra-pleural instillation of fibrinolytic/enzymatic therapy (IPET) might represent a valuable treatment option to obtain the lysis of fibrin septa. IPET can be used as either initial or subsequent therapy. Further studies are ongoing or are required to help fill some gaps on the optimal management of parapneumonic pleural effusion. These include the duration of antibiotic therapy, the risk/benefit ratio of medical thoracoscopy and surgery, and new intrapleural treatments such as antibiotic-eluting chest tubes and pleural irrigation with antiseptic agents.
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21
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Abstract
The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.
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Affiliation(s)
- Dinesh N Addala
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK.
| | - Eihab O Bedawi
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, Headington OX3 9DU, UK
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22
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Bhalla AS, Jana M, Naranje P, Singh SK, Banday I. Challenges in Image-Guided Drainage of Infected Pleural Collections: A Review. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1734374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractInfected pleural fluid collections (IPFCs) commonly occur as a part of bacterial, fungal, or tubercular pneumonia or due to involvement of pleura through hematogenous route. Management requires early initiation of therapeutic drugs, as well as complete drainage of the fluid, to relieve patients’ symptoms and prevent pleural fibrosis. Image-guided drainage plays an important role in achieving these goals and improving outcomes. Intrapleural fibrinolytic therapy (IPFT) is also a vital component of the management. The concepts of image-guided drainage procedures, IPFT, and nonexpanding lung are discussed in this review.
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Affiliation(s)
- Ashu S. Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Swish K. Singh
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Irshad Banday
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
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23
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Oblizajek NR, Kamath PS. Resolution of Loculated Chylous Ascites Using Intraperitoneal Fibrinolytic Therapy. Hepatology 2021; 74:2293-2295. [PMID: 33738838 DOI: 10.1002/hep.31816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/07/2021] [Accepted: 03/08/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Nicholas R Oblizajek
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Guinde J, Laroumagne S, Chollet B, Trias-Sabrià P, Dutau H, Astoul P. Saline lavage for the management of severe pleural empyema: A cohort study. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:1097-1103. [PMID: 34216522 DOI: 10.1111/crj.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/10/2021] [Accepted: 06/29/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite advances in the treatment of pleural infection, up to 20% of patients die. So far, studies assessing the role of intrapleural saline lavage for the management of all stage pleural infections are very scarce, usually excluding patients with cancer. METHODS The method used was a retrospective cohort study including pleural empyema managed with a pleural lavage of saline solution through a small-bore chest tube. The primary outcome was the rate of failure at 3 months (surgical referral or additional pleural manoeuver due to recurrent infection or all-cause mortality). Secondary outcomes were hospital stay, the change of the chest radiograph and inflammatory biomarkers, and complications. RESULTS Thirty patients with pleural empyema were included, 11 (36.7%) with an active cancer. The overall rate of failure at 3 months was 13.3% (surgical referral = 0; additional pleural manoeuver = 3; mortality = 1). Median length of pleural lavage and hospital stay were, respectively, 14 days (7-28) and 17 days (11-42). Inflammatory markers and size of the effusion on chest radiograph significantly decreased for Day 0 to Day 14. No chest tube blockade was reported, but seven (23.3%) accidentally withdrew. No other side effects were reported. CONCLUSIONS Intrapleural saline lavage is efficient and safe for the management of pleural empyema, even in severe status patients with cancer, at the cost of a prolonged hospitalization.
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Affiliation(s)
- Julien Guinde
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France.,Aix-Marseille University, Marseille, France
| | - Sophie Laroumagne
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France
| | - Bertrand Chollet
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France
| | - Pere Trias-Sabrià
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France
| | - Hervé Dutau
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France
| | - Philippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Marseille, France.,Aix-Marseille University, Marseille, France
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Comparing the outcomes of intrapleural fibrinolytic and DNase therapy versus intrapleural fibrinolytic or DNase therapy: A systematic review and meta-analysis. Pulm Pharmacol Ther 2021; 71:102081. [PMID: 34571093 DOI: 10.1016/j.pupt.2021.102081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/04/2021] [Accepted: 09/22/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Multiple studies describing the benefits of intrapleural fibrinolytic over placebo and DNase therapy have been published, but few have been published on intrapleural fibrinolytic and DNase therapy. OBJECTIVE Our meta-analysis aims to compare the outcomes of surgical intervention, mortality, and hospital length of stay between intrapleural fibrinolytic and DNase therapy with either intrapleural fibrinolytic or DNase therapy alone in patients with pleural space infections. METHODS We searched Pubmed, EMBASE, Web of Science, and Cochrane library databases for observational studies and randomized controlled trials (RCTs) containing comparative data for hospitalized adults and children with pleural infections receiving intrapleural therapy of fibrinolytic and DNase versus those receiving intrapleural fibrinolytic or DNase alone. Meta-analysis was performed using the Review Manager software, and heterogeneity was tested using I2 statistics. RESULTS A total of 2 cohorts and 2 RCTs involving 362 adult and children was included. There was significant reduction in surgical intervention requirement among patients who received intrapleural fibrinolytic and DNase (OR 0.30; 95% CI 0.11-0.83; I2 = 31%; P = 0.02) than those receiving either intrapleural fibrinolytic or DNase alone. No difference was observed for mortality (OR 0.72; 95% CI 0.31-1.71; I2 = 0%; P = 0.46) and complication rates (OR 3.09; 95% CI 0.75-12,74; I2 = 54%; P = 0.12). The hospital length of stay (mean 13.70 vs. 16.67 days; P = 0.19) and duration of chest tube drainage (mean 6.47 vs. 6.30 days; P = 0.58) was similar between the two groups. CONCLUSION Combination of intrapleural fibrinolytic and DNase, compared to single-agent intrapleural therapy alone, is associated with a lesser need for surgical interventions. However, no difference was found in mortality, hospital length of stay, and chest tube drainage duration.
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Hu K, Chopra A, Kurman J, Huggins JT. Management of complex pleural disease in the critically ill patient. J Thorac Dis 2021; 13:5205-5222. [PMID: 34527360 PMCID: PMC8411157 DOI: 10.21037/jtd-2021-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 11/08/2022]
Abstract
Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.
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Affiliation(s)
- Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Jonathan Kurman
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Terrill Huggins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
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Thakore S, Alraiyes AH, Kheir F. Medical thoracoscopy in intensive care unit. J Thorac Dis 2021; 13:5232-5241. [PMID: 34527362 PMCID: PMC8411134 DOI: 10.21037/jtd-2019-ipicu-02] [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: 01/18/2020] [Accepted: 05/04/2020] [Indexed: 11/06/2022]
Abstract
During the last decade, there has been a tremendous effort towards making procedures less invasive, which could reduce complications, decrease hospital stay and minimize overall health care cost. Medical thoracoscopy (MT) or pleuroscopy is a minimally invasive procedure commonly performed by interventional pulmonologist in United States. It has a favorable safety profile allowing access to the pleural cavity with a thoracoscope via a small chest wall incision to perform diagnostic or therapeutic interventions under direct visualization. MT allows the physician to perform pleural biopsy with high accuracy, drain loculated pleural effusion, guide chest tube placement and perform pleurodesis. As compared to video-assisted thoracoscopic surgery (VATS), MT is less invasive, does not require single lung ventilation, has a comparable diagnostic yield, and better tolerated in high-risk patients. MT can also be performed at bedside in critically ill patients. Although MT is generally safe, a multi-disciplinary discussion between the interventional pulmonologist, intensive care team, anesthesiologist and thoracic team is necessary to ensure best clinical practice as well as minimize complications for such high-risk patients. The purpose of this article is to review technique, diagnostic and therapeutic indications, as well as contraindications of performing bedside MT in intensive care unit. It aims to review both advantages and limitations of performing MT in intensive care unit.
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Affiliation(s)
- Sanket Thakore
- Division of Pulmonary Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdul Hamid Alraiyes
- Department of Pulmonary, Interventional Pulmonology, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Fayez Kheir
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, LA, USA
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28
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Evaluation and management of pleural sepsis. Respir Med 2021; 187:106553. [PMID: 34340174 DOI: 10.1016/j.rmed.2021.106553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/22/2021] [Accepted: 07/26/2021] [Indexed: 11/21/2022]
Abstract
Pleural sepsis stems from an infection within the pleural space typically from an underlying bacterial pneumonia leading to development of a parapneumonic effusion. This effusion is traditionally divided into uncomplicated, complicated, and empyema. Poor clinical outcomes and increased mortality can be associated with the development of parapneumonic effusions, reinforcing the importance of early recognition and diagnosis. Management necessitates a multimodal therapeutic strategy consisting of antimicrobials, catheter/tube thoracostomy, and at times, video-assisted thoracoscopic surgery.
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Hassan M, Patel S, Sadaka AS, Bedawi EO, Corcoran JP, Porcel JM. Recent Insights into the Management of Pleural Infection. Int J Gen Med 2021; 14:3415-3429. [PMID: 34290522 PMCID: PMC8286963 DOI: 10.2147/ijgm.s292705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 01/15/2023] Open
Abstract
Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.
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Affiliation(s)
- Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Shefaly Patel
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Ahmed S Sadaka
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - John P Corcoran
- Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - José M Porcel
- Department of Internal Medicine, Arnau de Vilanova University Hospital, Lleida, Spain
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30
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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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31
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Chaddha U, Agrawal A, Feller-Kopman D, Kaul V, Shojaee S, Maldonado F, Ferguson MK, Blyth KG, Grosu HB, Corcoran JP, Sachdeva A, West A, Bedawi EO, Majid A, Mehta RM, Folch E, Liberman M, Wahidi MM, Gangadharan SP, Roberts ME, DeCamp MM, Rahman NM. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. THE LANCET RESPIRATORY MEDICINE 2021; 9:1050-1064. [PMID: 33545086 DOI: 10.1016/s2213-2600(20)30533-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.
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Affiliation(s)
- Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Abhinav Agrawal
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, New Hyde Park, NY, USA
| | - David Feller-Kopman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viren Kaul
- Department of Pulmonary and Critical Care Medicine, Crouse Health-SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samira Shojaee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark K Ferguson
- Section of Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kevin G Blyth
- Institute of Cancer Sciences and Glasgow Pleural Disease Unit, University of Glasgow, Glasgow, UK
| | - Horiana B Grosu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John P Corcoran
- Interventional Pulmonology Service, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD, USA
| | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Adnan Majid
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Ravindra M Mehta
- Department of Pulmonary and Critical Care, Apollo Hospitals, Bangalore, India
| | - Erik Folch
- Complex Chest Disease Center, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, Montreal, QC, Canada
| | - Momen M Wahidi
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, NC, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Mark E Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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Del Magno S, Foglia A, Golinelli L, De Bastiani D, Cola V, Pisoni L, Grassato L, Pelizzola M, Troia R, Giunti M. The use of small-bore wire-guided chest drains for the management of feline pyothorax: A retrospective case series. Open Vet J 2020; 10:443-451. [PMID: 33614440 PMCID: PMC7830175 DOI: 10.4314/ovj.v10i4.12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 11/14/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Pyothorax in cats is routinely managed, at least initially, with thoracic tube placement associated with systemic antimicrobial administration. Traditionally, large-bore trocar-type thoracostomy tubes have preferentially been used for the drainage of thick material from the pleural space. In recent years, the use of small-bore wire-guided thoracic drains has increased in both small animals and in humans. Few studies have highlighted the efficacy of small-bore wire-guided thoracostomy tubes. Aim: The purpose of this study was to describe the use of small-bore wire-guided thoracostomy tubes in feline pyothorax in terms of efficacy, safety, and outcome. Methods: Cats with pyothorax managed with small-bore thoracostomy tubes (SBTTs) (2015–2018) were retrospectively studied. The number of drains inserted, the need for anesthesia and analgesia for chest tube placement and maintenance, and related major and minor complications were reviewed. Clinical data, diagnostic results, treatment, and outcome were recorded. Results: Ten cats were enrolled. Thoracostomy tube placement was unilateral in 7/10 cats, despite the presence of bilateral effusion in 9/10 cats, and required sedation (8/10) or anesthesia (2/10). Three cats experienced minor complications during the chest tube insertion, including self-limiting pneumothorax (1/3) and malpositioning (2/3). One cat had a major complication (non-functional malposition) requiring reposition of the drain. Pain management was adequately achieved using opioids (8/10) or opioids plus nonsteroidal anti-inflammatory drugs (2/10). Partial chest tube occlusion occurred in three cases and it was resolved with lavage. In one case, the occlusion was complete, requiring drain removal. Three out of 10 cats were treated medically, combining thoracostomy tubes and antibiotics, while 7/10 cats underwent surgery. All the cats survived. Conclusion: SBTTs represent a safe and effective option for the initial management of feline pyothorax. In fact, mainly minor complications were reported during insertion and usage. The SBTTs were well tolerated by the cats with a satisfactory performance in terms of exudate drainage in most cases. The combined use of a small-bore thoracostomy drain together with the common practice of surgical treatment might have resulted in the successful management of the cases presented.
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Affiliation(s)
- Sara Del Magno
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | - Armando Foglia
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | - Linda Golinelli
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | | | - Veronica Cola
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | - Luciano Pisoni
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | - Lisa Grassato
- Fitzpatrick Referrals -Orthopaedics & Neurology, Surrey, UK
| | | | - Roberta Troia
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
| | - Massimo Giunti
- Department of Veterinary Medical Sciences, Alma Mater Studiorum, University of Bologna, Ozzano dell'Emilia, Italy
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Abstract
The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.
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Pleural Infection—a Growing Problem in the Elderly. CURRENT GERIATRICS REPORTS 2020. [DOI: 10.1007/s13670-020-00320-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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35
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Zhou J, Liu C, Man S, Lyu M, Liao H, Chen N, Cheng Y, Liu L. Comparison of the clinical benefits for non-small cell lung cancer patients between different volume of pleural lavage fluid following video-assisted thoracoscopic lobectomy and systematic mediastinal lymph node dissection: study protocol for a randomized controlled trial. Trials 2020; 21:232. [PMID: 32106877 PMCID: PMC7047403 DOI: 10.1186/s13063-020-4146-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 02/06/2020] [Indexed: 02/08/2023] Open
Abstract
Background Pleural lavage is regularly performed before closing the chest wall in pulmonary surgeries to prevent pleural implantation of tumor cells and postoperative infection. However, scant data could be found in the literature regarding the optimal regimen for performing pleural lavage. To establish a proper volume of pleural lavage, we herein designed a protocol for a randomized controlled trial. Methods A total of 400 participants with non-small cell lung cancer undergoing video-assisted thoracoscopic surgery (VATS) lobectomy and systematic mediastinal lymph node dissection (MLND) will be randomly assigned to one of two groups: group A (500 mL pleural lavage fluid) and group B (3000 mL pleural lavage fluid). The primary outcomes include the levels of leukocytes, neutrophils, and inflammatory factors on the first postoperative day. The secondary outcomes include (i) the levels of leukocytes, neutrophils, and inflammatory factors on the second and third postoperative days; (ii) the incidence of postoperative fever on the first, second, and third postoperative days; (iii) the volumes of chest drainage within the first 3 operative days, the duration of drainage, and postoperative hospitalization; and (iv) the incidence of postoperative complications (incision infection, pain, atelectasis, hemorrhage, etc.) and the incidence of pleural effusion requiring thoracic puncture or drainage within 30 days after surgery. The main content of the analysis includes effectiveness and safety analysis. We will perform subgroup analyses to identify potential influence factors. Discussion As far as we know, this will be the first randomized controlled trial to compare the clinical outcomes between different volumes of pleural lavage fluid following VATS and MLND. Findings from this trial will determine the appropriate amount of pleural lavage before chest wall closure. Trial registration This study was registered with the Chinese Clinical Trial Registry ( on 17 March 2019. ChiCTR 1900021950).
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Affiliation(s)
- Jian Zhou
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Chengwu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Shulei Man
- West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Mengyuan Lyu
- West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Hu Liao
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Nan Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.,West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Yuhui Cheng
- West China School of Medicine, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Lunxu Liu
- Department of Thoracic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China. .,Western China Collaborative Innovation Center for Early Diagnosis and Multidisciplinary Therapy of Lung Cancer, Sichuan University, No. 37, Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Intrapleural Fibrinolytic Therapy for Empyema and Pleural Loculation: Knowns and Unknowns. Ann Am Thorac Soc 2019; 15:515-517. [PMID: 29361235 DOI: 10.1513/annalsats.201711-848ps] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cargill TN, Hassan M, Corcoran JP, Harriss E, Asciak R, Mercer RM, McCracken DJ, Bedawi EO, Rahman NM. A systematic review of comorbidities and outcomes of adult patients with pleural infection. Eur Respir J 2019; 54:13993003.00541-2019. [PMID: 31391221 PMCID: PMC6860993 DOI: 10.1183/13993003.00541-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022]
Abstract
Background Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection. Methods Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility. Results 211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality. Conclusion Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward. In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL
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Affiliation(s)
- Tamsin N Cargill
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK.,Joint first authors
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK .,Joint first authors
| | - John P Corcoran
- Interventional Pulmonology Service, Respiratory Medicine Dept, University Hospitals Plymouth, Plymouth, UK
| | - Elinor Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
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Kanellakis NI, Wrightson JM, Hallifax R, Bedawi EO, Mercer R, Hassan M, Asciak R, Hedley E, Dobson M, Dong T, Psallidas I, Rahman NM. Biological effect of tissue plasminogen activator (t-PA) and DNase intrapleural delivery in pleural infection patients. BMJ Open Respir Res 2019; 6:e000440. [PMID: 31673364 PMCID: PMC6797395 DOI: 10.1136/bmjresp-2019-000440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 09/07/2019] [Accepted: 09/12/2019] [Indexed: 11/03/2022] Open
Abstract
Background Pleural infection (PI) is a major global disease with an increasing incidence, and pleural fluid (PF) drainage is essential for the successful treatment. The MIST2 study demonstrated that intrapleural administration of tissue plasminogen activator (t-PA) and DNase, or t-PA alone increased the volume of drained PF. Mouse model studies have suggested that the volume increase is due to the interaction of the pleura with the t-PA via the monocyte chemoattractant protein 1 (MCP-1) pathway. We designed a study to determine the time frame of drained PF volume induction on intrapleural delivery of t-PA±DNase in humans, and to test the hypothesis that the induction is mediated by the MCP-1 pathway. Methods Data and samples from the MIST2 study were used (210 PI patients randomised to receive for 3 days either: t-PA and DNase, t-PA and placebo, DNase and placebo or double placebo). PF MCP-1 levels were measured by ELISA. One-way and two-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to estimate statistical significance. Pearson's correlation coefficient was used to assess linear correlation. Results Intrapleural administration of t-PA±DNase stimulated a statistically significant rise in the volume of drained PF during the treatment period (days 1-3). No significant difference was detected between any groups during the post-treatment period (days 5-7). Intrapleural administration of t-PA increased MCP-1 PF levels during treatment; however, no statistically significant difference was detected between patients who received t-PA and those who did not. PF MCP-1 expression was not correlated to the drug given nor the volume of drained PF. Conclusions We conclude that the PF volume drainage increment seen with the administration of t-PA does not appear to act solely via activation of the MCP-1 pathway.
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Affiliation(s)
- Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rob Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rachel Mercer
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Emma Hedley
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Tao Dong
- Centre for Translational Immunology, Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
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Bedawi EO, Hassan M, Rahman NM. Recent developments in the management of pleural infection: A comprehensive review. CLINICAL RESPIRATORY JOURNAL 2018; 12:2309-2320. [PMID: 30005142 DOI: 10.1111/crj.12941] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. DATA SOURCE Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included. RESULTS A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. CONCLUSION Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Bedawi EO, Yarmus L, Rahman NM. The ongoing struggle with empyema management: is surgery really the answer? J Thorac Dis 2018; 10:S4122-S4125. [PMID: 30631571 DOI: 10.21037/jtd.2018.10.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Meyer CN, Armbruster K, Kemp M, Thomsen TR, Dessau RB. Pleural infection: a retrospective study of clinical outcome and the correlation to known etiology, co-morbidity and treatment factors. BMC Pulm Med 2018; 18:160. [PMID: 30314475 PMCID: PMC6186131 DOI: 10.1186/s12890-018-0726-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 09/25/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We explored the hypothesized importance of early knowledge of microbiological etiology in patients with pleural infection, including comorbidity and treatment factors in the outcome analyses. METHODS Data from the medical records of a large cohort of 437 consecutive patients in 9 hospitals in East-Denmark were included retrospectively. RESULTS Microbiology, co-morbidity, therapy and outcome are described in detail. Patient groups with microbiology negative and known bacterial etiology had a similar 30-day and 90-day mortality. There were no differences in initial antibiotic treatment regimens, antibiotic treatment duration, rate of intra-pleural fibrinolysis treatment, surgical referral rate, and ICU admittance rate. Patients with microbiology negative etiology were younger (60.8 vs 64.3 years) and fewer had predisposing risk factors (59% vs 71%), but pleural drainage was more often delayed (49% vs 36%). Mortality was similar in patients treated with either of the two nationally recommended initial antibiotic regimens. However, higher 90-day mortality (22.5% vs 9.7%), disease severity (31.5% vs 6.2%), and ICU admittance rate (21.3% vs 2.9%) was observed in a sub-group with initial broad-spectrum treatment compared to patients receiving the nationally recommended initial treatments, irrespective of knowledge of etiology. Several factors correlated independently to 90-day mortality, including age, predisposing risk factors, surgical referral (Odds-Ratios > 1), drainage delay and intra-pleural fibrinolysis (ORs < 1). CONCLUSIONS No difference was found between patients with microbiology negative and known bacterial etiology regarding outcome or treatment parameters. Treatment factors and predisposing factors independently relating to mortality were found in the cohort. Broad-spectrum antibiotics were initially used for treatment of patients with more severe illness and poorer outcome.
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Affiliation(s)
- Christian Niels Meyer
- Department of Internal Medicine, Zealand University Hospital Roskilde, Sygehusvej 10, 4000, Roskilde, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Karin Armbruster
- Department of Respiratory Medicine, Copenhagen University Hospital Gentofte, Gentofte, Denmark
| | - Michael Kemp
- Department of Clinical Microbiology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Trine Rolighed Thomsen
- Danish Technological Institute, Life Science, Århus and Section of Biotechnology, Aalborg University, Aalborg, Denmark
| | - Ram Benny Dessau
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark
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Ferreiro L, Porcel JM, Bielsa S, Toubes ME, Álvarez-Dobaño JM, Valdés L. Management of pleural infections. Expert Rev Respir Med 2018; 12:521-535. [DOI: 10.1080/17476348.2018.1475234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Lucía Ferreiro
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - José M. Porcel
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - Silvia Bielsa
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - María Elena Toubes
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
| | - José Manuel Álvarez-Dobaño
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - Luis Valdés
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
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Porcel JM. Minimally invasive treatment of complicated parapneumonic effusions and empyemas in adults. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:1361-1366. [DOI: 10.1111/crj.12730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- José M. Porcel
- Pleural Medicine Unit, Department of Internal MedicineArnau de Vilanova University Hospital, IRBLleidaLleidaSpain
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Affiliation(s)
- David Feller-Kopman
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
| | - Richard Light
- From the Division of Pulmonary, Critical Care, and Sleep Medicine, Johns Hopkins University, Baltimore (D.F.-K.); and the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University, Nashville (R.L.)
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Corcoran JP, Hallifax RJ, Psallidas I, Rahman NM. Pleural Diseases: Saline Irrigation in Pleural Infection, Epidemiology of Pneumothorax, and Bevacizumab in Mesothelioma. Am J Respir Crit Care Med 2017; 196:382-385. [PMID: 28598211 DOI: 10.1164/rccm.201608-1676rr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- John P Corcoran
- 1 University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom; and
| | - Robert J Hallifax
- 1 University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom; and
| | - Ioannis Psallidas
- 1 University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom; and
| | - Najib M Rahman
- 1 University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,2 Oxford Centre for Respiratory Medicine, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom; and.,3 National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Ngu RC, Ebogo-Ngwa T, Feteh VF, Dimala CA. Empyema Thoracis Caused by Drug-Resistant Staphylococcus aureus in an Adult Female: A Case Report. Pulm Ther 2017. [DOI: 10.1007/s41030-017-0034-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Manual Intrapleural Saline Flushing Plus Urokinase: A Potentially Useful Therapy for Complicated Parapneumonic Effusions and Empyemas. Lung 2016; 195:135-138. [PMID: 27866276 DOI: 10.1007/s00408-016-9964-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/09/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE We sought to evaluate the safety profile and effectiveness of manual pleural saline flushing, in addition to urokinase, for managing complicated parapneumonic effusions and empyemas. METHODS Retrospective comparative review of 23 consecutive patients with complicated parapneumonic effusions or empyemas who received saline flushing plus urokinase through small-bore chest catheters, and 39 who were only treated with fibrinolytics. Both groups had similar baseline characteristics and treatments were mostly protocol-driven. RESULTS As compared with patients only receiving urokinase, those additionally treated with saline flushing needed less fibrinolytic doses (a single dose being sufficient in 15 vs 44%, p = 0.019), chest tube duration (5 vs 2 days, p < 0.01), and length of hospital stay (8 vs 6 days, p = 0.011). There were no adverse events attributed to saline therapy. CONCLUSIONS Manual pleural saline flushing via chest tube, in addition to urokinase, is a safe and potentially beneficial therapy in patients with pleural infection.
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Vorster MJ, Koegelenberg CF. Breaking Down the Barriers in Complicated Pleural Sepsis. Respiration 2016; 91:99-100. [DOI: 10.1159/000443992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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