Intrapleural fibrinolytics in management of empyema thoracis

Targeting the PAI-1 Mechanism with a Small Peptide Increases the Efficacy of Alteplase in a Rabbit Model of Chronic Empyema

The incidence of empyema is increasing and associated with a mortality rate of 20% in patients older than 65 years. Since 30% of patients with advanced empyema have contraindications to surgical treatment, novel, low-dose, pharmacological treatments are needed. A Streptococcus pneumoniae-induced rabbit model of chronic empyema recapitulates the progression, loculation, fibrotic repair, and pleural thickening of human disease. Treatment with single chain (sc) urokinase (scuPA) or tissue type (sctPA) plasminogen activators in doses 1.0-4.0 mg/kg were only partially effective in this model. Docking Site Peptide (DSP; 8.0 mg/kg), which decreased the dose of sctPA for successful fibrinolytic therapy in acute empyema model did not improve efficacy in combination with 2.0 mg/kg scuPA or sctPA. However, a two-fold increase in either sctPA or DSP (4.0 and 8.0 mg/kg or 2.0 and 16.0 mg/kg sctPA and DSP, respectively) resulted in 100% effective outcome. Thus, DSP-based Plasminogen Activator Inhibitor 1-Targeted Fibrinolytic Therapy (PAI-1-TFT) of chronic infectious pleural injury in rabbits increases the efficacy of alteplase rendering ineffective doses of sctPA effective. PAI-1-TFT represents a novel, well-tolerated treatment of empyema that is amenable to clinical introduction. The chronic empyema model recapitulates increased resistance of advanced human empyema to fibrinolytic therapy, thus allowing for studies of muti-injection treatments.

From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema

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.

Cost-Effectiveness Analysis of Fibrinolysis vs Thoracoscopic Decortication for Early Empyema

BACKGROUND

Surgical decortication is recommended by national guidelines for management of early empyema, but intrapleural fibrinolysis is frequently used as a first-line therapy in clinical practice. This study compared the cost-effectiveness of video-assisted thoracoscopic surgery (VATS) decortication with intrapleural fibrinolysis for early empyema.

METHODS

A decision analysis model was developed. The base clinical case was a 65-year-old man with early empyema treated either by VATS decortication or intrapleural tissue plasminogen activator and deoxyribonuclease. The likelihood of key outcomes occurring was derived from the literature. Medicare diagnosis-related groups and manufacturers' drug prices were used for cost estimates. Successful treatment was defined as complete or nearly complete resolution of empyema on imaging. Effectiveness was defined as health utility 1 year after empyema.

RESULTS

Intrapleural tissue plasminogen activator and deoxyribonuclease were more cost-effective than VATS decortication for treating early empyema for the base clinical case. Surgical decortication had a slightly lower cost than fibrinolysis ($13,345 vs $13,965), but fibrinolysis had marginally higher effectiveness at 1 year (health utility of 0.80 vs 0.71). Therefore, fibrinolysis was the more cost-effective option. Sensitivity analyses found that fibrinolysis as the initial therapy was more cost-effective when the probability of success was greater than 60% or the initial cost was less than $13,000.

CONCLUSIONS

Surgical decortication and intrapleural fibrinolysis have nearly equivalent cost-effectiveness for early empyema in patients who can tolerate both procedures. Surgeons should consider patient-specific factors, as well as the cost and effectiveness of both modalities, when deciding on an initial treatment for early empyema.

Surgical versus non-surgical management for pleural empyema

BACKGROUND

Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment.

OBJECTIVES

To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016).

SELECTION CRITERIA

Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals.

AUTHORS' CONCLUSIONS

Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.

Emergent management of empyema

Empyema is a frankly purulent infection of the pleural space most often occurring secondary to parapneumonic effusion. Imaging, specifically contrast-enhanced computed tomography, plays a critical role in diagnosis with a "split pleura" sign being highly suggestive in the appropriate clinical setting. Diagnostic thoracentesis with culture and Gram stain further guides appropriate antibiotic therapy. Therapeutic drainage with small-bore tube thoracostomy has been shown to be a safe and effective treatment of early stage empyema. Augmentation of tube placement with intrapleural fibrinolytics and mucolytics facilitates catheter drainage by degrading loculations and decreasing fluid viscosity, respectively.

Management of pleural effusion, empyema, and lung abscess

Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.

Fibrinolytic therapy for parapneumonic empyema during pregnancy

Pneumonia and parapneumonic complicated effusion during pregnancy is uncommon but poses potentially serious risks to both mother and fetus. Enzymatic debridement of the pleural cavity with fibrinolytic agents is a noninvasive option that can facilitate drainage and prevent the need for surgery. Herein, we describe the cases of two pregnant women with parapneumonic empyema who were successfully treated with intrapleural fibrinolytic therapy.

Intrapleural therapy

Numerous intrapleural therapies have been adopted to treat a vast array of pleural diseases. The first intrapleural therapies proposed focused on the use of fibrinolytics and DNase to promote fluid drainage in empyema. Numerous case series and five randomized controlled trials have been published to determine the outcomes of fibrinolytics in empyema treatment. In the largest randomized trial, the use of streptokinase had no reduction in mortality, decortication rates or hospital days compared with placebo in the treatment of empyema. Criticism over study design and patient selection may have potentially affected the outcomes in this study. The development of dyspnoea is common in the setting of malignant pleural effusions. Pleural fluid evacuation followed by pleurodesis is often attempted. Numerous sclerosing agents have been studied, with talc emerging as the most effective agent. Small particle size of talc should be avoided because of increased systemic absorption potentiating toxicity, such as acute lung injury. Over the past several years, the use of chronic indwelling pleural catheters have emerged as the preferred modality in the treating a symptomatic malignant pleural effusion. For patients with malignant-related lung entrapment, pleurodesis often fails due to the presence of visceral pleural restriction; however, chronic indwelling pleural catheters are effective in palliation of dyspnoea. Finally, the use of staphylococcal superantigens has been proposed as a therapeutic model for the treatment of non-small lung cancer. Intrapleural instillation of staphylococcal superantigens increased median survival by 5 months in patients with non-small cell lung cancer with a malignant pleural effusion.

Massive hemothorax following administration of intrapleural streptokinase

The administration of intrapleural streptokinase (IPSK) is widely practiced in the management of loculated empyema thoracis. To our knowledge, there have been only 4 cases of hemorrhagic complications attributed to the administration of IPSK reported in the literature. In this article, we report a case of a 17-year-old girl who received IPSK and developed shock, anemia, coagulopathy and massive hemothorax. Our discussion focuses on the hemorrhagic complication of chest tube insertion and the role of IPSK in blood clot lysis and inhibition of local hemostasis.

Intrapleural therapy in management of complicated parapneumonic effusions and empyema

Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.

Update on pleural diseases--2007

BACKGROUND

New information is available on pleural diseases. The authors selected articles to make recommendations on diagnostic and treatment aspects of pleural diseases.

MATERIALS AND METHODS

Eleven articles published in the English language between 2004 and 2007 were chosen. The basis of selection of the articles was the impact on daily practice, change in prior thinking of a disease process or specific treatment modality, as well as proper design and execution of the study. 5-Amino-laevulinic acid with fluorescent light combined with white light may allow further diagnostic yield in undiagnosed pleural disease. FDG-PET may allow prognostication of patients with pleural tumors. Utilizing ultrasound by trained Emergency Department physicians is a rapid and effective technique to evaluate non-traumatic pleural effusions in symptomatic patients. Serum osteopontin levels may distinguish patients exposed to asbestos with benign disease from those with pleural mesothelioma. Administration of streptokinase in patients with empyema does not need for surgical drainage, length of hospital stay, or mortality as compared to conventional treatment with chest tube drainage and intravenous antibiotics. Silver nitrate may be an alternative agent to talc for producing pleurodesis. Routine use of graded talc (50% particles greater than 25 microns) is recommended to reduce the morbidity associated with talc pleurodesis. Study design does not permit us to conclude that aspiration of spontaneous pneumothorax is as effective as chest tube drainage. Pleural catheter may prove to be an important palliative modality in treating debilitated patients or patients with trapped lung who show symptomatic improvement with drainage; however, at the present time, these catheters cannot be considered a first line treatment option for patients with malignant pleural effusion. One of the studies reviewed showed no significant difference in tract metastasis in patients with malignant mesothelioma undergoing an invasive pleural procedure with or without irradiation to the procedure site. However, the design of the trial does not allow us to make this conclusion at the present time.

Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema

BACKGROUND

Pleural effusions and empyema may complicate lower respiratory tract infections. Treatment of these collections of pus includes surgical drainage and the use of intra-pleural fibrinolysis to break down fibrin bands that may cause loculation.

OBJECTIVES

To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated para pneumonic effusions and empyema to reduce mortality or the need for subsequent surgical debridement of the pleural space.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in November 2006.

SELECTION CRITERIA

All studies in the review were Randomised Controlled Trials in adult patients with post-pneumonic empyema or complicated parapneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) via an intercostal chest drain (ICD) versus control, or a comparison of the two agents.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data . Study authors were contacted for further information.

MAIN RESULTS

Seven studies met the eligibility criteria of the review, recruiting 761 participants. The only consistent end points in all trials were treatment failure, as gauged by the requirement for additional intervention including surgery or death. In studies where patients had either loculation and empyema, there was no significant difference in the risk of death with fibrinolytics (RR 1.08; 95% CI 0.69 to 1.68). When treatment failure was considered as surgical intervention, fibrinolytics reduced the risk of this outcome (RR 0.63; 95% CI 0.46 to 0.85), but there is discordance between earlier positive studies and the more recent negative study by Maskell.

AUTHORS' CONCLUSIONS

Intrapleural fibrinolytic therapy confers significant benefit in reducing the requirement for surgical intervention for patients in the early studies included in this review but not in the more recently published Maskell study. The reasons for this difference are uncertain. Separate subgroup analysis of proven loculated/septated effusions from the available data in our meta-analysis suggests a potential overall treatment benefit with fibrinolytics, but these results should be treated with caution as the data are incomplete and the benefit is not significant in the subgroup of high quality trials (Cochrane Grade A). Intrapleural fibrinolytics have not been shown to significantly increase adverse events, but the confidence interval is too wide to firmly exclude this possibility.

Adjunctive intrapleural tissue plasminogen activator administered via chest tubes placed with imaging guidance: effectiveness and risk for hemorrhage

PURPOSE

To retrospectively determine the effectiveness of and risk for hemorrhage with intrapleural adjunctive tissue plasminogen activator (tPA) administered via chest tubes placed with imaging guidance.

MATERIALS AND METHODS

This HIPAA-compliant study was approved by the institutional review board of Massachusetts General Hospital, with informed consent waived. A retrospective review of 66 patients (age range, 1-95 years; mean age, 55 years; 44 male, 22 female) who received intrapleural tPA between 2000 and 2006 was performed. Overall effectiveness of tPA was defined as successful drainage without need for additional decortication or video-assisted thoracoscopic surgery. Primary and secondary effectiveness were defined as effectiveness after one and two cycles of tPA, respectively. Imaging findings and complications were recorded. Hemorrhagic complications were noted, and the Fisher exact test was used to show whether concurrent systemic anticoagulation increased bleeding risk.

RESULTS

Fifty-seven (86%) of 66 patients underwent complete drainage with tPA without further surgical procedures. Primary effectiveness was seen in 52 (87%) of 60 patients and secondary effectiveness was seen in five (83%) of six. Loculation of fluid was the most common finding in this selected cohort. Number of fluid pockets, pleural heterogeneity, and pleural thickness were not predictors of effectiveness. There were five major pleural hemorrhages in four patients across five tPA cycles. Hemorrhages occurred only in patients receiving therapeutic anticoagulation (four of 12) and in none of the other patients (P < .001). No hemorrhages occurred in the 38 patients receiving prophylactic anticoagulation.

CONCLUSION

Intrapleural tPA is effective in improving drainage of loculated effusions not drained with catheters alone; prophylactic systemic anticoagulation does not increase bleeding risk with intrapleural tPA, but therapeutic anticoagulation is associated with a significantly increased risk of pleural hemorrhage.

Diagnosis and management of parapneumonic effusions and empyema

Approximately 1 million patients develop parapneumonic effusions (PPEs) annually in the United States. The outcome of these effusions is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. Pleural fluid analysis provides diagnostic information and guides therapy. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, >7.30), it is highly likely that antibiotic treatment alone will be effective. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH <7.20, and loculated pleural fluid suggest the need for pleural space drainage. The presence of pus (empyema) aspirated from the pleural space always requires drainage. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.

Intrapleural heparin or heparin combined with human recombinant DNase is not effective in the treatment of empyema in a rabbit model

OBJECTIVE AND BACKGROUND

The aim of this study was to investigate the effectiveness of intrapleural heparin or heparin combined with human recombinant DNase in the treatment of empyema.

METHODS

Empyema was induced in rabbits with an intrapleural injection of 10(9)Pasteurella multicoda organisms in infusion agar via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered drugs via the chest tube. There were three treatment groups each with six rabbits. One group was given 1000 IU heparin, a second group was given 1000 IU heparin plus 1 mg of human recombinant DNase via chest tube and the control group received saline. The rabbits received treatment every 12 h for a total of six treatments and the volume of each treatment was 3 mL. The animals were sacrificed at day 10 and the amount of empyema and pleural thickening was scored macroscopically on a scale of 0-6.

RESULTS

The total volume of pleural effusion aspirated was significantly higher in the heparin group (25.8+/-10.7 mL) compared with either saline (8+/-8.9) or heparin plus human recombinant DNase (6.8+/-6.1) groups (P=0.003). The mean empyema and pleural thickening scores did not differ significantly between the groups (P=0.8, P=0.5 respectively). A weak correlation was found between total volume of aspirated pleural fluid and pleural parameters of white blood cell counts and LDH levels (r=0.546 and P=0.02, r=0.631 and P=0.02 respectively).

CONCLUSION

The intrapleural administration of 1000 IU heparin alone or in combination with 1 mg of human recombinant DNase is no more effective than saline in the treatment of empyema in rabbits. Intrapleural heparin significantly increased the drainage of pleural fluid compared with the combination and saline group.

A study of loculated tuberculous pleural effusions treated with intrapleural urokinase

AIM

To assess the effect of intrapleural urokinase, vis-à-vis simple pleural drainage, on residual pleural thickening in a series of patients suffering from loculated tuberculous pleural effusion.

PATIENTS AND METHOD

Twenty-nine patients (21 males and 8 females) with loculated pleural effusion were studied. These patients were randomly allocated to one of two groups: one group received intrapleural urokinase (n=12) and the other was treated by simple drainage with suction (n=17). The urokinase (125,000 UI) was administered into the pleural cavity via an intrathoracic tube. This procedure was repeated every 12h until the quantity of pleural fluid obtained was less than 50 cm3, at which point the intrathoracic tube was removed.

RESULTS

In both groups, the biochemical analysis of the pleural fluid was an exudate and the fluid had a serous appearance. Pleural thickening when the drainage tube was removed was 8.09+/-3.36 mm for the group treated with urokinase, and 14.78+/-17.20mm (P>0.05) for the control group. Residual pleural thickening measured upon completion of medical treatment at 6 months was 1.45+/-0.89 mm for the group treated with urokinase and 7.47+/-10.95 mm for the control group (P<0.05). In the control group, only two patients presented over 10mm of residual pleural thickening. The mean quantity of fluid drained in the two groups was 1.487+/-711 ml for the patients with urokinase, and 795+/-519 ml for the control group (P<0.01).

CONCLUSION

Our study shows that patients with loculated tuberculous pleural effusion treated with urokinase suffered less from residual pleural thickening, as measured after six months, than those treated by simple drainage. It is therefore suggested that the administration of intrapleural urokinase is a safe and effective treatment for those patients who drain a larger quantity of pleural fluid.

Intrapleural fibrinolytic therapy for pleural infection

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

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

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

Intrapleural Fibrinolytic Agents for Empyema and Complicated Parapneumonic Effusions

BACKGROUND

Randomized controlled trials have shown conflicting findings about the role of intrapleural fibrinolytic therapy for the treatment of empyema and complicated parapneumonic effusions in adult patients.

OBJECTIVES

To assess the clinical efficacy and summarize the current evidence of intrapleural fibrinolytic use in patients with empyema and complicated parapneumonic effusions in adult patients.

METHODS

We performed a meta-analysis of all properly randomized trials comparing intrapleural fibrinolytic agents with placebo in adult patients with empyema and complicated parapneumonic effusions. Outcome of primary interest was the reduction of death and surgical intervention.

RESULTS

We included five trials totaling 575 patients. The number of enrolled patients for each trial was small, except for the recent trial by Multicenter Intrapleural Sepsis Trial (MIST1) group. Compared with placebo, intrapleural fibrinolytic therapy was associated with a nonsignificant reduction in death and need for surgery (27.6% of the treatment group vs 32.8% of the control group; random-effects pooled risk ratio, 0.55; 95% confidence interval, 0.28 to 1.07; heterogeneity, p = 0.023). A separate analysis for outcomes on either death or need for surgery also showed nonsignificant results.

CONCLUSION

Our meta-analysis does not support the routine use of fibrinolytic therapy for all patients who require chest tube drainage for empyema or complicated parapneumonic effusions. However, there was significant heterogeneity of the treatment effects among the trials. Selected patients might benefit from the treatment.

Percutaneous management of parapneumonic effusions

Parapneumonic effusions continue to be a significant source of morbidity and mortality. Treatment at earlier stages before fibrous peel and loculations occur has a much better prognosis. Using image guidance, addition of intracavitary fibrinolytic instillation, close follow-up with drainage of residual or new collections are some of the other factors that improve prognosis. In this article, we discussed treatment strategies, percutaneous management of parapneumonic effusions, its alternatives and results.

Pharmacotherapy in complicated parapneumonic pleural effusions and thoracic empyema

Parapneumonic pleural effusions (PPE) and pleural empyema (PE) present a frequently diagnostic and therapeutic challenge in clinical practice. Although pleural diseases have received increased attention during the past decade, there are still many unanswered questions concerning the diagnosis and treatment of PPE and PE. A lack of controlled studies concerning the management of PPE and PE was noted in recent guidelines. The use of fibrinolytics intrapleurally appears to enhance intercostals tube drainage, reducing the requirement for subsequent surgical mechanical debridement. Recently, there has been interest in other intrapleural agents including combination drugs consisting of streptokinase and streptodornase-alpha, Dnase. Factors to be considered in evaluating whether or not intrapleural instillation of fibrinolytics is effective include an assessment of clinical responses. This review discusses the use of fibrinolytic agents as a novel therapeutic options for treating the various stages of parapneumonic effusions and empyemas.

The management of pleural space infections

Pleural infection is responsible for significant morbidity and mortality worldwide, and its clinical management is challenging. The diagnosis of empyema and tuberculous pleurisy may be difficult, and these conditions may be confused with other causes of exudative pleural effusions. Complicated parapneumonic effusion or empyema may present with 'atypical' clinical features; delays in diagnosis are common and may contribute to the high mortality of these infections. Pleural aspiration is the key diagnostic step; pleural fluid that is purulent or that has a pH < 7.2, or organisms on Gram stain or culture, is an indication for formal intercostal drainage. In order to achieve a definitive diagnosis of tuberculous pleurisy, Mycobacterium tuberculosis must be isolated in the culture of pleural fluid, pleural tissue or sputum; demonstration of granulomas in pleural tissue is also suggestive of tuberculosis. The use of pleural fluid biochemical markers, such as adenosine deaminase, in the diagnosis of tuberculous pleurisy varies among clinicians; the diagnostic value of such markers is affected by the background prevalence of tuberculosis and the likelihood of an alternative diagnosis. Uncertainties also remain regarding the treatment of pleural infection. Treatment of complicated parapneumonic effusion and empyema involves prolonged courses of antibiotics and attention to the patient's nutritional state. The role of intrapleural fibrinolytics and the optimal timing of surgical intervention are unknown. The lack of clear predictors of clinical outcome in empyema contributes to the difficulty in treating this condition. The pharmacological treatment of tuberculous pleurisy is the same as for pulmonary tuberculosis; the precise role of steroids in the treatment of tuberculous pleurisy remains uncertain.

Intrapleural fibrinolytic treatment of multiloculated pediatric empyemas

Our objective was to compare the efficacy of adjunctive intrapleural fibrinolytic agents (IPFA) (streptokinase, urokinase) on fibrinopurulent stage empyema and chronic stage empyema in children. IPFA were used in 78 pediatric patients with empyema (36 fibrinopurulent stage empyemas, 42 chronic stage empyemas) between December 1994 and September 2002. Pleural biopsy was done for staging in all cases. Streptokinase 250,000 units in 100 ml normal saline (62 patients) or 100,000 units urokinase in 100 ml normal saline (16 patients) was instilled daily into the patient's chest tube, and the tube was clamped for 4 h, followed by suction. This treatment was continued daily for 2-8 days until resolution was demonstrated by chest radiographs and/or computed chest tomography. Success of treatment was 97.2% (complete response 24/36, partial response 11/36) in the fibrinopurulent stage and 9.4% (complete response 2/42, partial response 2/42) in chronic empyema cases. In one patient with fibrinopurulent empyema, the treatment was stopped due to allergic reaction and pleural hemorrhage; this patient died 1 day later in a septic condition. Although an invasive method, the pleural biopsy technique may be an alternative way of more properly staging thoracic empyema in selected children in whom staging based on radiographic and biochemical findings is doubtful. Intrapleural fibrinolytic treatment is an effective and safe therapy of choice and may have significant benefit in most children with fibrinopurulent phase empyema, except for those with bronchopleural fistula. IPFA do not seem to be effective in children with chronic phase empyema.

Recent advances in parapneumonic effusion and empyema

PURPOSE OF REVIEW

Complicated parapneumonic effusion and empyema continue to account for significant morbidity and mortality, and uncertainties remain regarding their optimal management. This review describes recent advances in this field, as well as areas for future research.

RECENT FINDINGS

Recent advances have addressed the pathogenesis, bacteriology, and treatment of pleural infection. Key areas for research in the development of empyema include the interplay between inflammatory and coagulation cascades and development of fibrosis within the pleural space. The varied bacteriology of empyema has been more clearly defined, and in particular the differences between community- and hospital-acquired infection highlighted. Studies of treatment have focused particularly on the roles of intrapleural fibrinolytics and surgery.

SUMMARY

Increased understanding of the pathogenesis of empyema may ultimately yield novel therapeutic targets. Comprehensive descriptions of the bacteriology of empyema aids antibiotic choice, and the use of intrapleural DNase shows promise in facilitating drainage of infected pleural fluid. Uncertainties remain, such as the role of intrapleural fibrinolytics and the optimal timing of surgical intervention.

Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas

BACKGROUND

Progression of empyema, with the development of fibrinous adhesions and loculations, makes simple drainage difficult or impossible. The appropriate management remains controversial. Intrapleural fibrinolytic treatment to facilitate drainage of loculated empyema instead of open thoracotomy has been advocated since the 1950s. The aim of this study was to assess the effectiveness of intrapleural fibrinolytic treatment in postpneumonic pediatric empyemas.

METHODS

In our clinic, we used intrapleural fibrinolytic agents in 72 pediatric patients with multiloculated empyema between 1994 and 2002. Streptokinase, 250,000 U in 100 mL of 0.9% saline solution (59 patients), and urokinase, 100,000 U in 100 mL of 0.9% saline solution (13 patients), were instilled daily into the chest tube, and the tube was clamped for 4 hours followed by suction. This treatment was continued daily for 2 to 10 days until resolution was demonstrated by chest radiograms or computed chest tomography.

RESULTS

The rate of drainage after fibrinolytic treatment was increased 73.77%. Treatment was ineffective in 14 (19.44%) of 72 patients who underwent fibrinolytic instillation. Treatment was discontinued because of allergic reaction and pleural hemorrhage in 1 patient, and because of development of bronchopleural fistula in another one. The regimen was completely successful in 43 (59.72%) patients, and partially successful in another 15 (20.83%). Twelve of those patients who had failure eventually required decortication and recovered completely. One patient died of sepsis and pleural hemorrhage; another patient died because of food aspiration.

CONCLUSIONS

In all patients with loculations except those with a bronchopleural fistula, intrapleural fibrinolytic treatment should be tried. Thus, the majority of children with loculated empyemas can be treated successfully without invasive interventions, such as thoracoscopic debridements or open surgery.

Management of complicated parapneumonic effusions in children

Pneumonia with complicated parapneumonic effusion is a significant source of morbidity in children seen in our institution. This affords us the opportunity to evaluate new treatment options. In an effort to ensure that we provide quality care to these pediatric patients presenting with complicated parapneumonic effusions, we performed a retrospective review of patient records as well as our interventional radiology database. Fifty-eight patients were identified who were treated with intrapleural placement of pigtail catheters and administration of tPA. Successful drainage and resolution of 54 of the 58 effusions were achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5-21). On average, the chest catheter was removed on day 6 postplacement (range 1.5-20). tPA was administered intrapleurally, utilizing a standardized hospital protocol developed conjointly by Interventional Radiology and Thoracic Surgery. Patients were afebrile within 72 hours. In most patients, one catheter was placed. However, five patients had more than one catheter placed initially. Of the four patients that failed percutaneous tube therapy, three underwent video-assisted thoracic surgery (VATS) and one had open thoracotomy with decortication. The complication associated with this treatment was an average drop in hemoglobin of 2 g/mL. Based on our experience, tPA administered through a small-bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice.

Empyema thoracis

Parapneumonic effusion and empyema thoracis remains a significant source of morbidity in children, though the overall incidence of empyema thoracis has decreased in the past two decades. These conditions pose a dilemma regarding evaluation and treatment for the treating physician. This article discusses the practical strategies in the management of empyema thoracis in children.

Descending necrotizing mediastinitis in early childhood: favorable outcome after aggressive treatment

OBJECTIVE

To report a case of descending necrotizing mediastinitis (DNM), an unusual illness in childhood that develops as a complication of oropharyngeal infection.

DESIGN

Descriptive case report.

SETTING

Pediatric intensive care unit.

PATIENT

A 19-month-old boy with a DNM that resulted from a pharyngeal abscess.

INTERVENTIONS

Aggressive surgical debridement; intravenous therapy with broad-spectrum antibiotics.

MEASUREMENTS AND MAIN RESULTS

Simple chest radiograph and computed tomographic scan, and routine culture were used to assess the patient. Administration of broad-spectrum antibiotics and surgical drainage resulted in clinical resolution of symptoms.

CONCLUSIONS

An aggressive approach (broad-spectrum antibiotics and surgical debridement) can improve the prognosis of DNM in children.

Minimally invasive surgery in the treatment of empyema: intraoperative decision making

BACKGROUND

Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest.

METHODS

A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the chi(2) test.

RESULTS

Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit.

CONCLUSIONS

Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.

Use of urokinase in childhood pleural empyema

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.

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

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

Management of complicated parapneumonic effusions and thoracic empyema

The optimal management of loculated parapneumonic effusions and empyema includes breakdown of adhesions to effect drainage of infected pleural fluid. The use of fibrinolytics intrapleurally appears to enhance intercostal tube drainage, reducing the requirement for subsequent surgical mechanical debridement. This article discusses the evidence for intrapleural fibrinolytics, their good safety profile and the practicalities of dose and administration. It also reviews early surgical intervention, which may be indicated for medical treatment failure and, some would argue, as a suitable alternative to other medical interventions.

Imaging guided thoracic interventions

Interventional Radiology is a technique based medical specialty, using all available imaging modalities (fluoroscopy, ultrasound, computed tomography, magnetic resonance, angiography) for guidance of interventional techniques for diagnostic or therapeutic purposes. Actual, percutaneous transthoracic needle biopsy includes core needle biopsy besides fine needle aspiration. Any pleural, pulmonary or mediastinal fluid or gas collection is amenable to percutaneous pulmonary catheter drainage. Treatment of haemoptysis of the bronchial artery or pulmonary artery origin, transcatheter embolization of pulmonary arteriovenous malformations and pseudoaneurysms, angioplasty and stenting of the superior vena caval system and percutaneous foreign body retrieval are well established routine procedures, precluding unnecessary surgery. These techniques are safe and effective in experienced hands. Computed tomography is helpful in pre- and postoperative imaging of patients being considered for endobronchial stenting. Many procedures can be performed on an outpatient basis, thus increasing the cost-effectiveness of radiologically guided interventions in the thorax.

Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline

OBJECTIVE

A panel was convened by the Health and Science Policy Committee of the American College of Chest Physicians to develop a clinical practice guideline on the medical and surgical treatment of parapneumonic effusions (PPE) using evidence-based methods.

OPTIONS AND OUTCOMES CONSIDERED

Based on consensus of clinical opinion, the expert panel developed an annotated table for evaluating the risk for poor outcome in patients with PPE. Estimates of the risk for poor outcome were based on the clinical judgment that, without adequate drainage of the pleural space, the patient with PPE would be likely to have any or all of the following: prolonged hospitalization, prolonged evidence of systemic toxicity, increased morbidity from any drainage procedure, increased risk for residual ventilatory impairment, increased risk for local spread of the inflammatory reaction, and increased mortality. Three variables, pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry, were used in this annotated table to categorize patients into four separate risk levels for poor outcome: categories 1 (very low risk), 2 (low risk), 3 (moderate risk), and 4 (high risk). The panel's consensus opinion supported drainage for patients with moderate (category 3) or high (category 4) risk for a poor outcome, but not for patients with very low (category 1) or low (category 2) risk for a poor outcome. The medical literature was reviewed to evaluate the effectiveness of medical and surgical management approaches for patients with PPE at moderate or high risk for poor outcome. The panel grouped PPE management approaches into six categories: no drainage performed, therapeutic thoracentesis, tube thoracostomy, fibrinolytics, video-assisted thoracoscopic surgery (VATS), and surgery (including thoracotoiny with or without decortication and rib resection). The fibrinolytic approach required tube thoracostomy for administration of drug, and VATS included post-procedure tube thoracostomy. Surgery may have included concomitant lung resection and always included postoperative tube thoracostomy. All management approaches included appropriate treatment of the underlying pneumonia, including systemic antibiotics. Criteria for including articles in the panel review were adequate data provided for >/=20 adult patients with PPE to allow evaluation of at least one relevant outcome (death or need for a second intervention to manage the PPE); reasonable assurance provided that drainage was clinically appropriate (patients receiving drainage were either category 3 or category 4) and drainage procedure was adequately described; and original data were presented. The strength of panel recommendations on management of PPE was based on the following approach: level A, randomized, controlled trials with consistent results or individual randomized, controlled trial with narrow confidence interval (CI); level B, controlled cohort and case control series; level C, historically controlled series and case series; and level D, expert opinion without explicit critical appraisal or based on physiology, bench research, or "first principles."

EVIDENCE

The literature review revealed 24 articles eligible for full review by the panel, 19 of which dealt with the primary management approach to PPE and 5 with a rescue approach after a previous approach had failed. Of the 19 involving the primary management approach to PPE, there were 3 randomized, controlled trials, 2 historically controlled series, and 14 case series. The number of patients included in the randomized controlled trials was small; methodologic weaknesses were found in the 19 articles describing the results of primary management approaches to PPE. The proportion and 95% CI of patients suffering each of the two relevant outcomes (death and need for a second intervention to manage the PPE) were calculated for the pooled data for each management approach from the 19 articles on the primary management approach. (ABST