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Gehlen M, Fraga JC, Amantea SL, Silveira NP, Kulczynski J, Roesch E, Portal KG, Sanches PR. Alteplase and DNase for the treatment of pleural empyema in rats. Pulm Pharmacol Ther 2019; 55:1-4. [PMID: 30648619 DOI: 10.1016/j.pupt.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 11/18/2018] [Accepted: 01/03/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Adjunctive intrapleural fibrinolytic is an option to treat empyema at fibrinopurulent stage, but there is controversy about which should be use. Our objective is to evaluate the action of alteplase and/or desoxyribonuclease at physical and chemical properties in vitro pus derived from an experimental induced empyema in rats. METHODS Streptococcus pneumoniae was introduced into the pleural cavity by thoracentesis through pleural pressure monitor. Animals were euthanized after 24 h, with macroscopic thoracic evaluation and measurement of amount of intrapleural liquid that was posteriorly stored at -80 °C. Selected samples were randomly distributed into four groups, then thawed at room temperature before exposure to one of the following: G1 = alteplase (n = 12), G2 = DNase (n = 12), G3 = alteplase + DNase (n = 12), or G4 = saline (n = 6). The mean molecular size in the fluid portion of the empyema was evaluated using dynamic light scattering; viscosity of the empyema fluid was measured using the drip method. RESULTS Macroscopic showed purulent liquid, with fibrin and septation, with mean volume of 4.16 ml (0.5-8 ml). All samples were culture-positive for Streptococcus pneumoniae. Comparing with control, all experimental groups presented reduction of larger than 135 nm molecular size, but there was only significant difference with alteplase (p = 0,02). Viscosity reduced at all experimental groups, but increased at control. DNase group presented negative median (-5 mPa/s) of viscosity, and differed significantly from that observed in the control group (p = 0.04). CONCLUSIONS Alteplase, DNase and alteplase + DNase changed significantly physical and chemical properties of experimental empyema at fibrinopurulent phase: alteplase reduced molecular size larger than 135 nm and DNase reduced viscosity.
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Affiliation(s)
- Mario Gehlen
- Pediatric Surgeon, Conceição Children's Hospital and Mãe de Deus University Hospital, Canoas, Brazil
| | - Jose Carlos Fraga
- Department of Surgery, School of Medicine, Federal University of Rio Grande do Sul (UFRGS). Pediatric Surgeon, Head of Pediatric Surgery Service, Pediatric Thoracic Surgery Unit, Clinical Hospital of Porto Alegre (HCPA), Brazil.
| | - Sergio Luis Amantea
- Department of Pediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA). Pediatric Pneumologist, Head of Emergency Department, Santo Antônio Children Hospital, Porto Alegre, Brazil
| | - Nadya P Silveira
- School of Chemistry, Federal University of Rio Grande do Sul. Head of the Rio Grande do Sul State Foundation for Research Support (FAPERGS), Brazil
| | - Jane Kulczynski
- Pathology Department, UFRGS. Head of Pathology Service at the Clinical Hospital of Porto Alegre, Brazil
| | - Eliane Roesch
- Microbiology and Molecular Biology Unit, Clinical Pathology Service, Clinical Hospital of Porto Alegre, Brazil
| | - Kalyana G Portal
- School of Medicine, UFRGS. Research Assistant Scholarship Recipient (PIBIC), Clinical Hospital of Porto Alegre, Brazil
| | - Paulo R Sanches
- Biomedical Engineer, Clinicas Hospital of Porto Alegre, Brazil
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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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Duzhyi ID, Grehsko IY, Duzhyi VI, Oleshchenko GP. [WAYS OF THE SURGICAL MISTAKES OVERCOME IN THE PAIN ABDOMINAL AND THORACIC SYNDROMS]. Klin Khir 2017:43-47. [PMID: 30272914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Experience of differential diagnosis of pleural diseases, accompanied by pleuroabdominal pain syndrome, simulating «an acute abdomen», was summarized. In a pleural exudate syndrome such a course was noted in 17 (3%) patients, of them 7 (1.23%) were operated on; and in a syndrome of spontaneous pneumothorax – in 3 (1.7%), 1 (0.4%) was operated. Diagnostic algorithm was proposed.
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Abbasi A, Bhutto AR, Alam MT, Aurangzaib M, Masroor M. Frequency of Hepatic Hydrothorax and its Association with Child Pugh Class in Liver Cirrhosis Patients. J Coll Physicians Surg Pak 2016; 26:566-569. [PMID: 27504545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 05/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To determine the frequency of hepatic hydrothorax and its association with Child Pugh Class in patients with liver cirrhosis. STUDY DESIGN Descriptive, analytical study. PLACE AND DURATION OF STUDY Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, (Ward- 7), from June 2012 to May 2013. METHODOLOGY All patients with established diagnosis of decompensated chronic liver disease were included. Detailed history, thorough physical examination, routine laboratory investigations, chest X-ray and abdominal ultrasound were carried out in all patients to find out the presence of pleural effusion and ascites, respectively. Fifty milliliters of pleural fluid was aspirated in all patients with pleural effusion using the transthoracic approach, taking ultrasound guidance, wherever required. Fluid was sent for microscopic, biochemical, and microbial analysis. SBEM defined if pleural fluid with polymorphonuclear (PMN) cell count > 500 cells/mm3 or positive culture with PMN cell count > 250 cells/mm3 with exclusion of a parapneumonic effusion. RESULTS Two hundred and six patients met the inclusion criteria, with mean age of 41.25 ±13.59 years. Among them, 149 (72.3%) were males and 57 (27.7%) females. Twenty-three (11.2%) had hydrothorax; right sided involvement was in 18 (78.3%) subjects, 3 (13%) had left sided while bilateral pleural effusion was found in 2 (8.7%) cases. SBEM was found in 07 (30.43%) cases. Mean serum albumin 3.125 ±0.71 gram/dl. There was association between serum albumin levels and hydrothorax. Asignificant association of hydrothorax with Child Pugh scoring system (p=0.018), but not with serum albumin (p=0.15). CONCLUSION The frequency of hepatic hydrothorax has a significant association with hepatic function as assessed by Child Pugh scoring system, but not with serum albumin.
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Affiliation(s)
- Amanullah Abbasi
- Department of Medicine, Dow International Medical College, Karachi
| | | | | | | | - Mohammad Masroor
- Department of Medicine, Dow International Medical College, Karachi
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Drain AJ, Ferguson JI, Sayeed R, Wilkinson S, Ritchie A. Definitive Management of Advanced Empyema by Two-Window Video-Assisted Surgery. Asian Cardiovasc Thorac Ann 2016; 15:238-9. [PMID: 17540995 DOI: 10.1177/021849230701500313] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We describe how 2-window video-assisted thoracoscopic decortication and lung mobilization can provide definitive management of stage III empyema. This technique was used in 52 patients with stage III empyema. None required additional ports or a thoracotomy. Three patients (6%) needed computed tomography-guided drainage of persistent large loculi, but none required further surgery. Chest radiographs at 6 weeks after surgery confirmed full lung expansion and resolution of pleural collection in the other 49 patients (94%).
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Affiliation(s)
- Andrew J Drain
- Department of Surgery, Papworth Hospital, Papworth Everard, Cambridge, CB3 8RE, United Kingdom.
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Hagos G, Esayas R, G/Selassie K. OPEN WINDOW THORACOSTOMY, STILL AN OPTION IN THE MANAGEMENT OF CHRONIC EMPYEMA: EXPERIENCE FROM AYDER REFERRAL HOSPITAL. Ethiop Med J 2016; 54:17-20. [PMID: 27191026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Chronic empyema is a serious problem and is often difficult to manage. Its incidence has dropped worldwide, but continues to pose health problems in low and middle income countries. This study has been conducted to assess the outcome of open thoracic window in patients with neglected chronic thoracic empyemain Ethiopian patients. METHODS A six-year (June 2008 to October 2014) retrospective study was conducted on thirty five patients (ten females and twenty five males, age ranging from 30-70 years). Open window thoracostomy was performed on these patients for chronic empyema with residual lung tissue and with or without bronchopleural fistula who failed to respond to the conventional methods of treatment. RESULTS The etiology was primary empyema in 16 patients, post-traumatic in 12 patients, and post-thoracotomy in seven patients. Spontaneous closure was achieved in 12 patients; simple closure was done on 18 patients; and closure with muscle flap in five patients. In all patients, the cavity cleared from secretions in two to three weeks and the residual space narrowed in seven to nine months. All patients gained weight following the surgery. CONCLUSION Our result has revealed that open thoracic window is still an alternative method for the treatment of chronic empyema when the conventional method of treatment fails.
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Abstract
OBJECTIVE The purpose of this study was to examine pulmonary function tests in children at various time points in their recovery from empyema. DESIGN Cross-sectional study. SETTING Academic Children's Hospital. PATIENTS Pediatric patients with a diagnosis of empyema between 1992-2000. RESULTS A total of 45 pulmonary function tests were carried out in 36 study participants. Within 3 months of hospital discharge, 91% of pulmonary function tests demonstrated a restrictive pattern with a mean forced vital capacity (FVC) of 69.2 +/- 4% and a mean total lung capacity (TLC) of 74.9 +/- 4% of predicted. The incidence of restriction in pulmonary function significantly decreased over time and for patients tested > 1 year from hospital discharge the mean FVC was 87.1 +/- 2% and the mean TLC 95.0 +/- 2% of predicted. However, 19% of the patients tested > 1 year from discharge demonstrated a mild restrictive pattern and 16% demonstrated a mild obstructive changes. Patients with abnormal lung function > 1 year from hospital discharge did not demonstrate any signs or symptoms of respiratory insufficiency . CONCLUSION There is a high incidence of restrictive patterns in lung function for children tested within 3 months from hospital discharge for empyema. The incidence of restrictive patterns decreased significantly over time and most patients tested >1 year from hospital discharge demonstrated normal lung function.
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Affiliation(s)
- Gary L Kohn
- Division of Pulmonary Medicine, Children's Hospital Medical Center, Cincinnati, Ohio, USA.
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Danielian SN, Abakumov MM, Voskresenskiï OV, Chernen'kaia TV. [The surgical treatment of the pleural empyem]. Khirurgiia (Mosk) 2012:4-10. [PMID: 22678530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The treatment results of the 286 patients with pleural empyem after thoracic injuries (n=107) and closed trauma of the pleural cavity (n=179) were retrospectively analyzed. The frequency of pleural empyem was 1.39% by injuries and 1.34% by the closed thoracic trauma. 15 (14%) patients of the first group developed the bronchopleural fistula, whereas the complication was observed in 32 (17.9%) patients of the second group. The adequate pleural drainage with intrapleural enzyme therapy in acute inflammation period allowed recovery in 78% and 71.9% of patients, respectively. Early videothoracoscopic sanation of the pleural cavity shortened the recovery time in more then 1.5 times. The chronization of the empyem was more often observed after the closed thoracic trauma - 14.5% rather than 6.5% after the open thoracic injury. The lethality rate by pleural empyem was 14% after the open injuries and 15.6% after the closed trauma.
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Boultadakis V, Skouras V, Makris D, Damianaki A, Nikoulis DJ, Kiropoulos T, Oikonomidi S, Tsilioni I, Gourgoulianis K. Serum amyloid alpha in parapneumonic effusions. Mediators Inflamm 2011; 2011:237638. [PMID: 21876610 PMCID: PMC3163023 DOI: 10.1155/2011/237638] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Accepted: 06/16/2011] [Indexed: 11/17/2022] Open
Abstract
STUDY OBJECTIVES To assess serum amyloid alpha (SAA) pleural fluid levels in parapneumonic effusion (PPE) and to investigate SAA diagnostic performance in PPE diagnosis and outcome. METHODS We studied prospectively 57 consecutive patients with PPE (empyema (EMP), complicated (CPE), and uncomplicated parapneumonic effusion (UPE)). SAA, CRP, TNF-α, IL-1β, and IL-6 levels were evaluated in serum and pleural fluid at baseline. Patients were followed for 6-months to detect pleural thickening/loculations. RESULTS Pleural SAA levels (mg/dL) median(IQR) were significantly higher in CPE compared to UPE (P < 0.04); CRP levels were higher in EMP and CPE compared to UPE (P < 0.01). There was no significant difference between IL-1β, IL-6, TNF-α level in different PPE forms. No significant association between SAA levels and 6-month outcome was found. At 6-months, patients with no evidence of loculations/thickening had significantly higher pleural fluid pH, glucose levels (P = 0.03), lower LDH (P = 0.005), IL-1β levels (P = 0.001) compared to patients who presented pleural loculations/thickening. CONCLUSIONS SAA is increased in complicated PPE, and it might be useful as a biomarker for UPE and CPE diagnosis. SAA levels did not demonstrate considerable diagnostic performance in identifying patients who develop pleural thickening/loculations after a PPE.
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Affiliation(s)
- Vagelis Boultadakis
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
| | - Vasilis Skouras
- “Sismanoglio” General Hospital of Attica, 15126 Athens, Greece
| | - Demosthenes Makris
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
- Intensive Care Unit, University Hospital of Thessaly, Biopolis, 41110 Larissa, Greece
| | | | - Dimitrios J. Nikoulis
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
| | - Theodoros Kiropoulos
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
| | - Smaragda Oikonomidi
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
| | - Irene Tsilioni
- Respiratory Department, University Hospital of Larissa, Biopolis, 41110 Larissa, Greece
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Moffett K, Tantoco AM. Report of increased number of children with parapneumonic empyema as a complication of bacterial pneumonia in West Virginia in 2005. W V Med J 2011; 107:14-19. [PMID: 21476472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
MESH Headings
- Adolescent
- Anti-Infective Agents/administration & dosage
- Anti-Infective Agents/adverse effects
- Child
- Child, Preschool
- Empyema, Pleural/diagnosis
- Empyema, Pleural/epidemiology
- Empyema, Pleural/etiology
- Empyema, Pleural/physiopathology
- Empyema, Pleural/therapy
- Female
- Humans
- Infant
- Length of Stay
- Male
- Pneumococcal Vaccines/immunology
- Pneumococcal Vaccines/pharmacology
- Pneumonia, Bacterial/complications
- Pneumonia, Bacterial/microbiology
- Pneumonia, Bacterial/physiopathology
- Pneumonia, Bacterial/therapy
- Retrospective Studies
- Risk Factors
- Streptococcus pneumoniae/drug effects
- Streptococcus pneumoniae/immunology
- Streptococcus pneumoniae/isolation & purification
- Streptococcus pneumoniae/pathogenicity
- Thoracoscopy
- West Virginia/epidemiology
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Balandina IA, Amarantov DG. [Pleural drainage for the treatment of the acute empyema]. Khirurgiia (Mosk) 2011:33-36. [PMID: 21378704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Treatment of 675 patients with the acute pleural empyema was analyzed and supplemented with anatomometric investigations of costophrenic sinus in 60 male corpses. Technical features of effective pleural drainage were fundamentally substantiated and depicted in pictures and schemes. The original method of the retrograde thoracoscopic drainage with the original device were suggested.
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Kondov G, Colanceski R, Kondova Topuzovska I, Spirovski Z, Caeva Jovkovska B, Kokareva A, Popovska A, Petrusevska Marinkovic S, Kondov B. Analysis of lung function test in patients with pleural empyema treated with thoracotomy and decortication. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2011; 32:259-271. [PMID: 22286629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
UNLABELLED The fibrinopurulent phase of pleural empyema has very often been treated with thoracotomy and decortications. MATERIAL AND METHODS We analyzed the lung function of 19 surgically treated patients in the last 3 years. The lung function was followed up at least 6 months after surgery. RESULTS Before surgery the expected mean forced vital capacity (FVC) was 4650 ml, the expected mean forced expiratory volume in the first second (FEV1) was 3450 ml, the realized mean FVC was 2850 ml, and the realized mean FEV1 was 1750 ml. The mean FVC 3 months after surgery was 3430 ml, and the mean FEV1 was 1700 ml. The mean FVC 6 months after surgery was 3850 ml, and the mean FEV1 was 2950 ml. DISCUSSION Early detection and treatment is essential in the treatment of empyema, where the use of thoracic drainage with or without streptokinase or the use of video-assisted thoracoscopic (VATS) decortication were methods of choice in treatment. Later, thoracotomy with decortication was the only treatment solution of the fibrinopurulent phase of empyema, where a trapped lung was frequently detected. CONCLUSION Thoracotomy with decortication is a useful method of treatment of the fibrinopurulent phase of empyema, which solved the problem and also significantly improved lung function, especially at the follow-up after 6 months.
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Affiliation(s)
- G Kondov
- University Thoracic and Vascular Surgery Clinic, Clinical Centre, Medical Faculty, Skopje, R. Macedonia
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Arsalane A, Zidane A, Atoini F, Traibi A, Ameziane N, Kabiri EH. [Pulmonary decortication: value of lung function recovery]. Rev Pneumol Clin 2009; 65:279-286. [PMID: 19878801 DOI: 10.1016/j.pneumo.2009.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 11/21/2008] [Accepted: 03/05/2009] [Indexed: 05/28/2023]
Abstract
PURPOSE Based on the experience in the thoracic surgery unit at Hôpital Militaire d'Instruction Mohammed-V in Rabat, this study analyses the indications as well as the results of pulmonary decortication. MATERIALS AND METHODS Twenty-five cases of pulmonary decortication were examined over a period of 5 years ranging from January 2002 to December 2006. The aetiology of chronic pyothorax was dominated by non tubercular causes. The clinical symptomatology mainly involved fever and dyspnoea (48% and 44% respectively). Pachypleuritis, collapse of the lung and pleural effusion account for most of the lesions found on the thoracic imaging. Surgery was indicated after failure in the medical treatment after four months on the average. RESULTS The respiratory function was assessed in 20 patients three months after the intervention. The improvement in the spirometry was good in 85% of the cases (n=17), was not highly satisfactory in 10% of the cases (n=2) and a deterioration was noted in 5% of the cases (n=1). This unfavourable evolution was correlated with the tubercular aetiology and the poor state of the pulmonary parenchyma. CONCLUSION Non tubercular causes, early diagnosis and absence of parenchymatous lesion seem to be predictive factors of good results after decortication.
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Affiliation(s)
- A Arsalane
- Service de Chirurgie Thoracique, Hôpital Militaire d'Instruction Mohamed-V, Avenue des Forces-Armées-Royales, Hay Riad, Rabat, Morocco.
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Aydoğan M, Aydoğan A, Ozcan A, Tugay M, Gokalp AS, Arisoy ES. Intrapleural streptokinase treatment in children with empyema. Eur J Pediatr 2008; 167:739-44. [PMID: 17710434 DOI: 10.1007/s00431-007-0580-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 07/10/2007] [Accepted: 07/11/2007] [Indexed: 10/22/2022]
Abstract
Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.
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Affiliation(s)
- Metin Aydoğan
- Department of Pediatric Allergy, School of Medicine, Kocaeli University, Kocaeli, Turkey.
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Grotenhuis BA, Janssen PJH, Eerenberg JP. The surgical treatment of stage III empyema: the effect on lung function. MINERVA CHIR 2008; 63:23-27. [PMID: 18212724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
AIM The aim of this study was to evaluate the surgical treatment of stage III empyema. METHODS Between 2002 and 2005, 30 patients underwent surgery for treatment of diagnosed stage III empyema preoperatively. Patients were referred for spirometry to evaluate lung function postoperatively. RESULTS Twenty nine patients underwent primary thoracotomy because of an extended stage III empyema, 1 patient video-assisted thoracoscopic surgery (VATS). Mean age was 62 years. Mean period from onset of symptoms until hospital admission was 29 days and mean time interval between admission and surgery was 11 days. Intraoperative complication happened in one patient (3%), in whom a phrenic nerve lesion was diagnosed. Overall mortality rate was 3%. In 17 patients postoperative spirometry was performed, showing normal vital capacity in 59% of the patients. CONCLUSION There was no reluctance in performing primary thoracotomy in our population with a stage III empyema. Decortication by means of thoracotomy restored the complete expansion of the lung; the authors claim that vital capacity returned to normal values, as it was shown by the spirometry results postoperatively. Early referral to the respiratory department in case of a non-responding pneumonia and early surgical consultation in case of a parapneumonic effusion, will prevent progression to an extensive organized stage III empyema requiring decortication by thoracotomy.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Data Interpretation, Statistical
- Empyema, Pleural/diagnosis
- Empyema, Pleural/diagnostic imaging
- Empyema, Pleural/mortality
- Empyema, Pleural/physiopathology
- Empyema, Pleural/surgery
- Female
- Follow-Up Studies
- Humans
- Male
- Middle Aged
- Radiography, Thoracic
- Spirometry
- Thoracic Surgery, Video-Assisted
- Thoracoscopy
- Time Factors
- Tomography, X-Ray Computed
- Vital Capacity
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Affiliation(s)
- B A Grotenhuis
- Department of Surgery, Hilversum Hospital, Hilversum, The Netherlands
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Cremonesini D, Thomson AH. How should we manage empyema: antibiotics alone, fibrinolytics, or primary video-assisted thoracoscopic surgery (VATS)? Semin Respir Crit Care Med 2007; 28:322-32. [PMID: 17562502 DOI: 10.1055/s-2007-981653] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Empyema is a well-recognized complication of pneumonia and its prevalence is increasing in the childhood population. The management of these patients requires a strategy for diagnosis and treatment that results in prompt resolution of infection and discharge with minimal morbidity. Traditionally conservative treatment has been the standard with insertion of a chest drain and intravenous antibiotics and, for those who fail to respond, an open thoracotomy and formal decortication. Since the 1990s two new treatment modalities have been described; fibrinolysis (promoting pleural drainage and circulation) and early VATS (video-assisted thoracoscopic surgery). Many institutions are now using one of these methods as first-line therapy. Both of these treatments result in shorter hospital stay and fewer complications than the conservative approach. In this review we will appraise the evidence for all three treatments and consider which treatment is optimal in children.
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Affiliation(s)
- David Cremonesini
- Department of Pediatric Respiratory Medicine, Oxford Children's Hospital, The John Radcliffe, Oxford, United Kingdom
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Chan DTL, Sihoe ADL, Chan S, Tsang DSF, Fang B, Lee TW, Cheng LC. Surgical Treatment for Empyema Thoracis: Is Video-Assisted Thoracic Surgery “Better” Than Thoracotomy? Ann Thorac Surg 2007; 84:225-31. [PMID: 17588418 DOI: 10.1016/j.athoracsur.2007.03.019] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Revised: 03/02/2007] [Accepted: 03/07/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Operations for empyema thoracis are conventionally performed by open thoracotomy, whereas the video-assisted thoracic surgery (VATS) approach remains controversial. This study compares the radiologic and functional outcomes of decortication using the two approaches. METHODS During a 5-year period, 77 consecutive patients underwent decortication for empyema thoracis at two university teaching hospitals. The choice of surgical approach was decided by surgeon preference. Preoperative and postoperative empyema management was the same in all patients. Postoperative radiologic improvements were graded by a radiologist blinded to the approach used. Functional improvements were assessed by a questionnaire-based survey conducted at a mean of 36 months after the surgical procedure. RESULTS The VATS approach was used in 41 patients and the thoracotomy approach in 36 patients. Patients in the two groups had similar preoperative demographic and clinical features. No patients required conversion from VATS to thoracotomy or reintervention for empyema. Intraoperative blood loss, duration of chest drain, lengths of hospital stay, and postoperative complication rates were all similar in the two groups. The mean operation time in the VATS group was significantly shorter (2.5 versus 3.8 hours, p < 0.001). Decortication using both approaches gave similar degrees of postoperative radiologic and functional improvements. Of the 42 patients available for follow-up, the 21 who received the VATS approach reported significantly less postoperative pain (p = 0.04), greater satisfaction with the wounds (p < 0.0001), and greater satisfaction with the operation overall (p = 0.006). CONCLUSIONS VATS allows equally effective decortication for empyema as thoracotomy. However, the VATS approach gives less pain and greater patient acceptance.
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Affiliation(s)
- Daniel T L Chan
- Division of Cardiothoracic Surgery, Grantham Hospital, Hong Kong, China
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18
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Abstract
In patients with bilateral bullous disease and empyema in one lung, controlled ventilation may be hazardous and result in severe hypoxia. A 50-year-old man with bullous disease and thoracic empyema on the left side was operated on under general anesthesia with spontaneous respiration using differential lung ventilation.
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Affiliation(s)
- Murali Chakravarthy
- Wockhardt Heart Institute, 14 Cunningham Road, Bangalore 560052, Karnataka, India.
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19
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Abstract
PURPOSE OF REVIEW Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention. RECENT FINDINGS We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy. SUMMARY We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.
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Affiliation(s)
- Megan K Fuller
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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20
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Kalfa N, Allal H, Lopez M, Saguintaah M, Guibal MP, Sabatier-Laval E, Forgues D, Counil F, Galifer RB. Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors. J Pediatr Surg 2006; 41:1732-7. [PMID: 17011279 DOI: 10.1016/j.jpedsurg.2006.05.066] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision. METHODS From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization. RESULTS The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia. CONCLUSION The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.
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Affiliation(s)
- Nicolas Kalfa
- Visceral Pediatric Surgery Department, Lapeyronie-Arnaud de Villeneuve Hospital, Montpellier Cedex 5 34295, France
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21
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Abstract
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.
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Affiliation(s)
- Demosthenes Bouros
- Department of Pneumonology, Medical School University of Thrace, Alexandroupolis 68100, Greece.
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22
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Abstract
Pneumonia with complicated parapneumonic effusion and empyema is increasing in incidence and continues to be a source of morbidity in children seen in our institution. Current diagnostic modalities include chest radiographs and CT scanning with ultrasound being helpful in some situations. Exact management of empyema remains controversial. Although open thoracotomy drainage is well accepted in children, video-assisted thoracoscopic surgery (VATS) drainage has become more prevalent in the current era. Over the last 4 years, we have treated 58 children with intrapleural placement of pigtail catheters and administration fibrinolytics consisting of tissue plasminogen activator (tPA). Successful drainage and resolution of 54 of the 58 effusions was achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5 to 21) and mean chest catheter removal was 6 days post placement (range 1.5 to 20). Of the four patients that failed percutaneous tube therapy, 3 underwent video assisted thoracic surgery (VATS), and one had open thoracotomy with decortication. Based on our experience, tPA administered through a small bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice. We reserve VATS for treatment failures and open thoracotomy and decortication for patients with VATS failure.
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Affiliation(s)
- John A Hawkins
- Department of Cardiothoracic Surgery, Primary Children's Medical Center, and the University of Utah, Salt Lake City, UT 84113, USA.
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23
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Tu CY, Hsu WH, Hsia TC, Chen HJ, Chiu KL, Hang LW, Shih CM. The changing pathogens of complicated parapneumonic effusions or empyemas in a medical intensive care unit. Intensive Care Med 2006; 32:570-6. [PMID: 16479377 DOI: 10.1007/s00134-005-0064-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2005] [Accepted: 12/27/2005] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To assess the incidence, pathogens, and outcome of complicated parapneumonic effusions or empyemas in a medical intensive care unit (MICU) patients with pleural effusions. DESIGN AND SETTING Prospective study of febrile MICU patients with pleural effusion carried out in a tertiary care hospital between April 2001 and September 2003. PATIENTS The study included 175 patients with a temperature above 38 degrees for more than 8 h with evidence of pleural effusion confirmed by chest radiography and ultrasound. INTERVENTION Routine thoracentesis and effusion cultures. RESULTS The prevalence of complicated parapneumonic effusions or thoracic empyemas in febrile MICU patients with pleural effusions was 45% (78/175). A total of 78 micro-organisms were isolated from the pleural fluid of 58 patients (positive microbiological culture 74%) including aerobic Gram-negative (n=45), aerobic Gram-positive (n=23), anaerobic (n=5), Myobacterium tuberculosis (n=3), and Candida (n=2). The infection-related mortality rate of complicated parapneumonic effusions or empyemic patients in the MICU was 41% (32/78). CONCLUSION The development of complicated parapneumonic effusions or thoracic empyemas in MICU patients is a high-mortality disease. The increasing incidence of aerobic Gram-negative pathogens in empyema has become a more urgent problem.
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Affiliation(s)
- Chih-Yen Tu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
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24
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Abstract
Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hospital-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmonologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can additionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural effusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.
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Affiliation(s)
- H Hamm
- Rehabilitationsklinik für Atemwegs- und Tumorerkrankungen der Asklepios Nordseeklinik, Westerland/Sylt.
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25
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Krawczyk-Sulisz I. [Scintigraphic assessment of ventilation and perfusion after late decortication of the lung due to chronic empyema]. Ann Acad Med Stetin 2005; 51:41-7. [PMID: 16496602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE The purpose of this work was to assess ventilation and perfusion and to determine the ventilation/perfusion ratio in patients managed with decortication due to chronic pleural empyema. MATERIAL AND METHODS The study group comprised 28 patients, including 22 with left-side and 6 with right-side decortication. The period from onset of disease to surgery ranged from 23 to 290 days. Postoperative follow-up ranged from 9 to 183 months. All patients underwent basic laboratory tests, spirometric measurements, gasometry of arterialised blood at rest and a chest X-ray examination. Lung ventilation was examined with the isotope method using 99m-Tc (Technetium) labeled albumin microspheres. Lung perfusion was examined using 99m-Tc (Technetium) labeled macroaggregates of human albumin given intravenously. Perfusion and ventilation were assessed and the ratio of ventilation to perfusion on the operated and contralateral sides was calculated. Spirometry values (FVC, FEVI, FEVI%FVC) were within normal. RESULTS The results show a reduction in ventilation and perfusion on the decorticated side and compensatory increase on the opposite side. Concurrently, a reduction in the ventilation/perfusion ratio on the operated side was found. Decortication of the chronic pleural empyema is supposed to improve ventilation on the operated side. Functional results of surgery have so far been assessed in the literature basing solely on the spirometric test. The present findings suggest that contrary to expectations after this type of surgery, perfusion and ventilation remain considerably impaired on the operated side.
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Affiliation(s)
- Iwona Krawczyk-Sulisz
- Katedra Pneumonologii Pomorskiej Akademii Medycznej ul. Sokołowskiego 11, 70-981 Szczecin
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26
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Choi SS, Kim DJ, Kim KD, Chung KY. Change in pulmonary function following empyemectomy and decortication in tuberculous and non-tuberculous chronic empyema thoracis. Yonsei Med J 2004; 45:643-8. [PMID: 15344205 DOI: 10.3349/ymj.2004.45.4.643] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Chronic empyema thoracis results from various etiologies. Improvement in pulmonary function after empyemectomy and decortication has proved difficult to predict when the etiology of chronic empyema thoracis is tuberculosis. The purpose of this study was to confirm the changes in pulmonary function according to the etiology after an operation. Sixty-five patients were classified into two groups according to their etiology: Group A (tuberculous) and Group B (non-tuberculous), and they were retrospectively evaluated with regard to their forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), percentage of predicted normal value of FEV1 (% FEV1) and FVC (%FVC). Empyemectomy and decortication was performed for all the patients and the two groups were similar in age, gender and preoperative spirometric parameters. In Group A (n=41), the pre- and postoperative mean values were 2.31 L and 2.8 L in FEV1, 65.8% and 80.5% in %FEV1, 2.62 L and 2.55 L in VC, 61.9% and 71.8% in %VC, respectively. In Group B (n=24), the pre- and postoperative mean values were 2.13 L and 2.49 L in FEV1, 66.4% and 73.8% in %FEV1, 2.55 L and 2.95 L in FVC, 64.9% and 71.8% in %FVC, respectively. All the spirometric parameters improved significantly in both groups compared to their preoperative values. However, no significance was shown in the rate of increase of the spirometric parameters between the two groups. In conclusion, improvement of lung function is expected after empyemectomy and decortication, regardless of the etiology of the chronic empyema thoracis.
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Affiliation(s)
- Sung-Sil Choi
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, Korea
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Shigemura N, Akashi A, Nakagiri T. A novel approach to life-threatening cardiorespiratory distress from mediastinum exclusion type chronic empyema. Surg Today 2004; 34:214-9. [PMID: 14999532 DOI: 10.1007/s00595-003-2684-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2002] [Accepted: 07/08/2003] [Indexed: 11/24/2022]
Abstract
PURPOSE Mediastinal exclusion type of empyema (MEE) is known as a type of chronic matrical empyema with no retention of pus. However, the number of patients with this condition who undergo treatment is still very limited because the indications for a panpleuropneumonectomy, namely the main surgical treatment for MEE, are extremely rare due to their unfavorable conditions. As a result, most cases of this disease are left untreated. METHODS From April 2000 to December 2002, we experienced four cases of MEE, in which the conditions were so aggravated that cardiorespiratory insufficiencies were involved with them. All of them had been receiving oxygen therapy at home and the severity of symptoms were rated as III or IV according to the Hugh-Jones classification. The patients required surgical treatment as a semiemergency. RESULTS We successfully performed safe and effective treatment in all cases through a novel approach with a devised incision and the severance of the osseous thorax for a panpleuropneumonectomy. CONCLUSION We hope our newly devised operative method discussed herein will improve the outcome and postoperative management of chronic MEE patients.
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Affiliation(s)
- Norihisa Shigemura
- Division of the General Thoracic Surgery, Takarazuka Municipal Hospital, Hyogo, Japan
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28
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Abstract
Parapneumonic effusions can be diagnosed in about 40 - 50 % of patients with bacterial pneumonia, and therefore should be considered as a frequent condition. Despite their prevalence, there is limited consensus about diagnostic pathways and therapeutic procedures due to the lack of evidence-based data available. The classification of parapneumonic effusions is based on morphological, chemical and bacteriological criteria. Dependent on the complexity of the effusion, available management approaches include observation without intervention, thoracentesis, chest tube drainage with or without local fibrinolysis and the surgical options VATS and thoracotomy. This overview summarizes the actual aspects of classification, diagnosis and treatment of the parapneumonic effusion and draws conclusions for the daily management of this condition.
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Affiliation(s)
- M Kolditz
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Dresden
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29
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Abstract
Hepatic hydrothorax occurs in approximately 5 to 12% of patients with cirrhosis and portal hypertension. Various therapeutic modalities ranging from dietary and pharmacologic interventions to surgical approaches are available for the management of this condition. Treatment must be individualized based on the patient's response to conservative management as well as the severity of the underlying liver disease. Hepatic hydrothorax may be complicated by spontaneous bacterial empyema, which portends a poor prognosis with a mortality rate of up to 20%. All patients with hepatic hydrothorax should be evaluated for possible liver transplantation.
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Affiliation(s)
- Nelson Garcia
- Division of Gastroenterology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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30
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Sese E, Xiol X, Castellote J, Rodríguez-Fariñas E, Tremosa G. Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema. J Clin Gastroenterol 2003; 36:75-7. [PMID: 12488714 DOI: 10.1097/00004836-200301000-00020] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
GOALS To analyze the pleural fluid factors that might cause spontaneous bacterial empyema (SBEM) in patients with cirrhotic hydrothorax. BACKGROUND Pathogenic mechanism of SBEM of cirrhotic patients is probably similar to that of spontaneous bacterial peritonitis, but local factors affecting pleural fluid have not been studied. STUDY Determination of C3, C4, and opsonic activity levels of pleural fluid in a cohort of patients with pleural effusions of different causes. RESULTS Forty-eight patients had hepatic hydrothorax; 8, heart failure and 45, exudates (9, tuberculosis; 21, malignancies; 10, other). Of the 48 cirrhotic patients, 15 developed SBEM on admission. The pleural fluid of cirrhotic patients showed significantly lower levels of total protein, complement, and opsonic activity than did the fluids of patients with other causes of SBEM. Patients who developed SBEM had lower concentrations of pleural fluid total protein and C3 and had a higher Child-Pugh score than patients who did not develop the infection. CONCLUSION Cirrhotic patients with hepatic hydrothorax have lower pleural fluid opsonic activity and C3 levels than those found in the pleural fluid of patients with other causes. Patients who develop SBEM have lower levels of pleural fluid C3, pleural fluid total protein, and a higher Child-Pugh score than those who do not develop SBEM.
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Affiliation(s)
- Eva Sese
- Department of Gastroenterology, Hospital Arnau de Vilanova, Lleida, Spain
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31
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Demetriou JL, Foale RD, Ladlow J, McGrotty Y, Faulkner J, Kirby BM. Canine and feline pyothorax: a retrospective study of 50 cases in the UK and Ireland. J Small Anim Pract 2002; 43:388-94. [PMID: 12238503 DOI: 10.1111/j.1748-5827.2002.tb00089.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- J L Demetriou
- Department of Veterinary Clinical Studies, University of Edinburgh, Hospital for Small Animals, Roslin, Midlothian
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32
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Abstract
This article summarizes the pathogenesis, clinical presentation, radiological manifestations, and treatment options of patients with parapneumonic effusions or empyema. Emphasis is placed on an expeditious workup and appropriate selection of the multiple therapeutic options.
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Affiliation(s)
- Alberto de Hoyos
- Division of Cardiothoracic Surgery, Northwestern University Medical School, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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33
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Abstract
OBJECTIVE The aim of the present study is to evaluate the lung function before and after the lung decortication in patients with chronic pleural empyema (CPE). METHODS Twenty-six patients with diagnosis of CPE were evaluated in a prospective manner by lung perfusion scintigraphy, blood gas analysis and spirometry before and 35 weeks (+/-17) after the lung decortication. RESULTS Preoperative scintigraphy showed reduction of lung perfusion on the affected side to 24.5% (+/-12.6%) in 11 right side empyemas (predicted value 55%) and to 18% (+/-8%) in 15 left side empyemas (predicted value 45%). The postoperative measurements showed improvement in perfusion to 45.2% (+/-7.7%) in patients with right side empyema and 34.1% (+/-8.5%) with the left side affection. The preoperative vital capacity (VC) was reduced to 62.3% (+/-13.8%) of the predicted value and forced expiratory volume in 1s (FEV1) to 50% (+/-15.5%) of the predicted value. Postoperatively, slight improvement was achieved to 79.8 % (+/-12.9%) for VC and 69.2% (+/-12.7%) for FEV1. Blood gas analysis showed decreased values in majority of the patients before operation and significant improvement in postoperative evaluation. CONCLUSIONS Perfusion and spirometry improves significantly in patients with CPE after the lung decortication but function of the affected lung remains impaired. There was no influence of the age, gender, side of the disease, bacteriology or duration of the empyema before operation on lung function.
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Affiliation(s)
- Witold Rzyman
- Department of Thoracic Surgery, Medical University of Gdańsk, Gdańsk, Poland.
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34
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Abstract
STUDY OBJECTIVE To investigate the effects of streptokinase and deoxyribonuclease (DNase) on the viscosity of pus to assess whether the DNase in the old preparation of streptokinase-streptodornase used intrapleurally to treat empyema was contributing to easier drainage of pus compared with purified streptokinase. DESIGN In vitro measurement of pus viscosity. PATIENTS Pus from three patients with surgically drained soft tissue abscesses and from six patients with empyema thoracis of varying etiology was studied. INTERVENTIONS Pus samples were incubated with saline solution as control and with streptokinase, streptokinase-streptodornase, human recombinant DNase, and a mixture of streptokinase and DNase in concentrations approximating those achieved in clinical practice. RESULTS Purified streptokinase had little effect on pus viscosity, with a mean reduction of 11.1% in the surgical specimens and 1.7% in the empyema samples. Streptokinase-streptodornase reduced viscosity by a mean of 52.8% in the surgical samples and 94.8% in the empyema samples. Human recombinant DNase reduced viscosity by a mean of 32. 79% in surgical samples and 93.4% in empyema samples. Adding streptokinase to human recombinant DNase produced no further reduction in viscosity. Final viscosities in samples treated with DNase were very similar whatever the starting viscosity. CONCLUSIONS DNase significantly reduces pus viscosity, whereas streptokinase has little or no effect, and in empyema may work simply by breaking down loculations. Clinical studies should be undertaken to see if these in vitro changes produce clinical benefits. The simple viscometer devised for these experiments may also prove useful in other contexts.
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Affiliation(s)
- G Simpson
- Department of Thoracic Medicine, Cairns Base Hospital, Queensland.
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35
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Sonobe M, Miyazaki M, Nakagawa M, Ikegami N, Suzumura Y, Nagasawa M, Shindo T. Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: report of a case. Surg Today 2000; 29:1287-9. [PMID: 10639715 DOI: 10.1007/bf02482226] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.
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Affiliation(s)
- M Sonobe
- Department of Thoracic Surgery, Tenri Hospital, Nara, Japan
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36
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Tseĭmakh EA. [Importance of microcirculatory disorders in combined treatment of acute pleural empyema and pyopneumothorax]. TERAPEVT ARKH 1999; 71:40-3. [PMID: 10515035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
AIM To investigate responses to application of quick-frozen or cryosupernatant plasma, heparin and proteinases inhibitors of DIC-syndrome in patients with pleural empyema and pyopneumothorax. MATERIALS AND METHODS Transfusions of quick-frozen or cryosupernatant plasma, injections of heparin and inhibitors of proteinases were used as an adjuvant to conventional treatment in 548 patients with acute pleural empyema and pyopneumothorax. RESULTS The addition of cryoplasm-antienzyme complex to conventional treatment of acute pleural empyema resulted in reduced number of lethal outcomes compared to the conventional treatment alone (5.9 vs 14.4%, respectively). CONCLUSION Transfusion of quick-frozen or cryosupernatant plasma, injection of heparin and inhibitors of proteinases improve microcirculation around the inflammatory focus. In addition to antibiotic therapy and evacuation of the pus from the pleural cavity, the above methods contribute to better outcomes of pleural empyema and pyopneumothorax.
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37
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Kemper P, Köhler D. [Current value of intrapleural fibrinolysis in the treatment of exudative fibrinous pleural effusions in pleural empyema and hemothorax]. Pneumologie 1999; 53:373-84. [PMID: 10483276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Intrapleural administration of fibrinolytic agents has been in use for fifty years; it has, however, been of clinical importance only for the last twenty years. Parallel to clinical reports procoagulant and fibrinolytic activities in pleural effusions are studied. Most types of pleural injury are characterised by fibrin deposition in the pleural space promoted by concurrent local abnormalities of pathways of fibrin formation and its clearance. Many of the studies of intrapleural fibrinolytics are uncontrolled and retrospective or small and are therefore of limited statistical value. Only five of the studies which are presented in the table are controlled and comparative studies. Intrapleural fibrinolytic therapy was used in exudative fibrinous multi-loculated pleural effusions, pleural empyemas and haemothorax. The global success rate of the studies cited were between 44% and 100%, in most cases more than 80%. The great differences in success rates are due to variations in the pleural diseases and stages of the clinical course, different success criteria, different dosages of fibrinolytic agents, different durations of clamped chest tube drainage and different starting points of therapy during the hospital course. The number of patients enrolled in each study ranged from 8 to 98, the number of children ranged from 2 to 9. Intrapleural fibrinolytic treatment is associated with rare adverse effects. There is no significant systemic fibrinolytic activity of intrapleural fibrinolysis. Intrapleural administration of streptokinase has been reported to lead to antibody formation. Hence, intrapleural fibrinolytic therapy is a useful adjunct in the management of exudative fibrinous multi-loculated pleural effusions, pleural empyemas and haemothorax. There is an increased volume of pleural fluid drainage during the treatment phase, and intrapleural fibrinolysis may reduce the need for more invasive surgical procedures. On the basis of the data of literature we recommend to use a single daily dose of 250,000 U streptokinase or 100,000 U urokinase in 50-100 ml normal saline instilled into a chest tube and to maintain dwell times of 2 to 4 hours. Therapy can be continued up to 2 weeks. The pleural space can be drained by large bore chest tubes or small drainage catheters, both radiologically guided, without preference for one method.
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Affiliation(s)
- P Kemper
- Fachkrankenhaus Kloster Grafschaft, Zentrum für Pneumologie, Beatmungs- und Schlafmedizin, Schmallenberg
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Antony VB, Mohammed KA. Pathophysiology of pleural space infections. Semin Respir Infect 1999; 14:9-17. [PMID: 10197393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The pleura responds to the presence of infecting organisms with a vigorous inflammatory response associated with an exudation of white blood cells and proteins. Changes in pleural permeability lead to formation of an exudative pleural effusion. The pleural mesothelial cell is the primary cell lining the pleural space and, when activated by the presence of organisms, initiates the inflammatory response by releasing a battery of chemokines and cytokines. Mesothelial cells are actively phagocytic and also release oxidants and proteases. The acute inflammatory process may resolve with appropriate antibiotic therapy and drainage leaving minimal fibrosis. However, under certain circumstances vigorous pleural fibrosis with scarring and loss of delineation of pleural surfaces can occur. Recognition of the stage of development of the empyema is an important clinical judgement that can affect outcome. The pathogenesis of infections of the pleural space and the role played by the various cell types is delineated in this article.
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Affiliation(s)
- V B Antony
- Department of Medicine, Indiana University School of Medicine, Indianapolis 46202, USA
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Abstract
Hepatic hydrothorax is the accumulation of ascitic fluid in the pleural space and requires the same treatment as ascites: salt restriction, diuretics, and paracentesis. Refractory hydrothorax appears when there is no response to those measures and its management is not well established. Videothoracoscopy is a promising therapy that permits the detection and closure of diaphragmatic defects, and when used with pleurodesis resulted in long-lasting control of hydrothorax in six of eight patients without appreciable morbidity. The transjugular intrahepatic portosystemic shunt is an effective therapy in more than 75% of refractory hydrothorax cases. Hepatic encephalopathy and worsening of liver function in some patients are the main adverse effects. Spontaneous bacterial empyema, the infection of a hydrothorax, was reported in 13% of 120 cirrhotic patients with hydrothorax. Forty percent of the episodes of spontaneous bacterial empyema were not associated with spontaneous bacterial peritonitis. The sensibility of pleural fluid culture improves inoculating pleural fluid into a blood culture bottle at the bedside. Patients with refractory hydrothorax or those having an episode of spontaneous bacterial empyema should be considered candidates for liver transplantation.
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Affiliation(s)
- X Xiol
- Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Sáez Roca G, Fernández E, Díez JM, García P, Castillo C, Sanbonmatsu S. Splenic abscess and empyema due to Lactobacillus species in an immunocompetent host. Clin Infect Dis 1998; 26:498-9. [PMID: 9502480 DOI: 10.1086/517092] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- G Sáez Roca
- Department of Pneumology, Hospital Universitario Virgen de las Nieves, Granada, Spain
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Goldstein LS, McCarthy K, Mehta AC, Arroliga AC. Is direct collection of pleural fluid into a heparinized syringe important for determination of pleural pH? A brief report. Chest 1997; 112:707-8. [PMID: 9315803 DOI: 10.1378/chest.112.3.707] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION It has long been believed that pleural fluid must be directly aspirated into a heparinized syringe to obtain an accurate value. Many operators aspirate 30 to 60 mL of pleural fluid into a syringe without heparin, and then place 1 mL into a heparinized syringe from which the pH is determined. We postulated that this technique does not cause a clinically significant difference in pleural pH values. METHODS Patients undergoing thoracentesis in the outpatient clinic, general ward, and medical ICU were eligible. After the initial entry of the needle into the pleural space, a heparinized syringe was used to obtain pleural fluid for pH determination. A 60-mL syringe was then used to aspirate additional pleural fluid for biochemical analysis and culture. At the end of the procedure, a second aliquot of pleural fluid was placed into a heparinized syringe for pH determination. A difference of 0.1 in pH was taken as clinically important. RESULTS Twenty-one pleural fluid samples were obtained from 20 patients. Pleural fluid pH determinations were within 0.1 in all but one patient. The mean pH for the directly collected group was 7.39 (25%: 7.35; 75%: 7.45). The mean for the indirectly collected group was 7.41 (25%: 7.35; 75%: 7.45). The difference between the two means (0.02; 95% confidence interval, 0.0368 to 0.00131) was statistically significant but clinically unimportant (p=0.037). CONCLUSIONS Pleural fluid can be collected in a large syringe and then placed into a heparinized syringe to assess pH. This is useful information because the use of just one syringe saves time and reduces the risk of iatrogenic complications.
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Affiliation(s)
- L S Goldstein
- Department of Pulmonary and Critical Care Medicine, The Cleveland Clinic Foundation, OH 44195, USA
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Abstract
A case of early neonatal septicaemia with pneumonia and pleural empyema is reported. The causal microorganism was beta-haemolytic Streptococcus pyogenes group A originating from the mother, who had a perineal infection and bacteraemia.
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Affiliation(s)
- J Thaarup
- Department of Pediatrics, Herning County Hospital, Denmark
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Affiliation(s)
- M F Muers
- Department of Medicine, Killingbeck Hospital, Leeds, UK
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Galea JL, De Souza A, Beggs D, Spyt T. The surgical management of empyema thoracis. J R Coll Surg Edinb 1997; 42:15-8. [PMID: 9046136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Empyema thoracis remains a common thoracic problem with challenging management strategies. We analysed retrospectively 107 consecutive patients treated for empyema thoracic over a 5-year period. The majority of patients (75%) were male with a mean age of 51 years. Common presenting symptoms were cough, dyspnoea, chest pain and pyrexia. The mean duration of pre-admission symptoms was 7.5 weeks. The causes of empyema were pneumonia, malignancy, iatrogenic injury and trauma. The most frequently isolated organism was Streptococcus milleri. In 71% of patients there was an underlying systemic disorder. Forty-nine patients (46%) underwent an unsuccessful therapeutic procedure prior to admission to the surgical units. In the units, 24 patients received closed intercostal chest tube drainage, 14 of whom required further intervention. Two patients were treated with repeated thoracocentesis. The majority of patients underwent a surgical procedure in the first instance: rib resection and drainage (5), decortication (22), and more extensive procedures (9) with only two patients requiring further surgery. The mean post-operative stay was 16 days and the hospital mortality was 13%. We recommend early referral of all empyema patients to thoracic units, where assessment and definitive procedures can be performed with high chances of success and moderate risk of morbidity and mortality.
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Affiliation(s)
- J L Galea
- Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester, UK
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Lee-Chiong TL, Matthay RA. Current diagnostic methods and medical management of thoracic empyemas. Chest Surg Clin N Am 1996; 6:419-38. [PMID: 8818414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Infections can invade the normally sterile pleural space leading to the development of parapneumonia effusions or empyemas. Pneumonia, thoracic surgery, and trauma, together, are responsible for most cases of empyemas. Pneumococci and staphylococci remain the predominant etiologic organisms. In addition, gram-negative aerobic bacteria and anaerobes are emerging as important pathogens. Most parapneumonic pleural effusions, regardless of their underlying etiology and bacteriology, evolve through definable stages. For each stage of the disease, specific therapeutic measures, either medical or surgical, are available.
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Affiliation(s)
- T L Lee-Chiong
- Intensive Care Unit, Cardiopulmonary Services, Androscoggin Valley Hospital, Berlin, New Hampshire, USA
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Bouros D, Schiza S, Tzanakis N, Drositis J, Siafakas N. Intrapleural urokinase in the treatment of complicated parapneumonic pleural effusions and empyema. Eur Respir J 1996; 9:1656-9. [PMID: 8866590 DOI: 10.1183/09031936.96.09081656] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Intrapleural urokinase has not been evaluated systemically in terms of efficacy, safety, and cost of treatment in a large series of patients with complicated (parapneumonic) pleural effusions (CPE) and pleural empyemas (PE). Furthermore, the optimal dose and duration of treatment is not known. Twenty consecutive patients with multiloculated parapneumonic effusions (13 with CPE and 7 with PE), in whom a single chest tube failed to drain the fluid, were studied prospectively. The age of the patients ranged 15-92 yrs (median 51 yrs). Urokinase was administered intrapleurally, in a low single daily dose of 50,000 U in 100 mL normal saline via the chest tube. Previous intrapleural instillation of 100 mL normal saline failed to promote drainage in all patients. Urokinase enhanced drainage in all patients. Clinical and radiological improvement was noted in all but one patient. The mean (SD) volume of fluid significantly increased in the first 24 h post-urokinase (p<0.001). The number of urokinase instillations ranged 3-7 (median 5). Radiological evaluation showed excellent improvement in 13 of the 20 (65%) patients. Urokinase was well-tolerated in all patients. The clinical course of patients was uneventful at a mean follow-up of 15 months (range 6-30 months) later. Mean total cost of treatment was $530 +/- 34.6. Our results show that intrapleural instillation of small doses of urokinase is a cost-effective and safe mode of treatment of complicated pleural effusions and pleural empyema and could be the fibrinolytic of choice.
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Affiliation(s)
- D Bouros
- Dept of Thoracic Medicine, Medical School, University of Crete, Heraklion, Greece
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Thurer RJ. Decortication in thoracic empyema. Indications and surgical technique. Chest Surg Clin N Am 1996; 6:461-90. [PMID: 8818416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Decortication for empyema is a well-established procedure and is based on sound surgical principles. When applied in properly selected patients, rapid recovery with a good functional result is to be expected. Best results are obtained when the optimal time for surgical intervention is chosen, usually relatively early in the course of the process for which it is employed. Although modern supportive care and antibiotic therapy are important, a properly performed operation, employed at the proper time, is a major determinant of a successful outcome.
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Affiliation(s)
- R J Thurer
- Division of Cardiothoracic Surgery, University of Miami School of Medicine, Florida, USA
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Abstract
The element Zn is the metal component or activator of many important enzymes. The tissue concentrations and activities of Zn metalloenzymes direct the rate of protein and nucleic acid syntheses, thereby influencing tissue growth and reperative processes. Most of the serum Zn is normally bound to circulating proteins. Low serum Zn concentrations might result from depletion of Zn-binding proteins. Serum protein and Zn concentrations have been reported to be depressed in patients with acute and chronic diseases. We compare the serum protein and Zn values of patients with thoracic empyema (n = 20) with those of a control group (n = 20). The values obtained in the empyema group were significantly lower than those in the control group before the study. Test group administered 220 mg zinc sulfate (ZnSO4.7H2O) over 20 d and there was a significant increase in the values for serum protein and Zn after the oral administration of the zinc sulfate.
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Affiliation(s)
- M E Balkan
- Department of Thoracic Surgery, Atatürk Chest Diseases and Surgical Center, Keçiören, Ankara
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Affiliation(s)
- R E Bryant
- Infectious Diseases Division, Oregon Health Sciences University, Portland 97201, USA
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