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Karandashova S, Florova G, Idell S, Komissarov AA. From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema. Front Pharmacol 2022; 12:806393. [PMID: 35126140 PMCID: PMC8811368 DOI: 10.3389/fphar.2021.806393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.
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Affiliation(s)
- Sophia Karandashova
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
- *Correspondence: Andrey A. Komissarov,
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Slaats MA, De Dooy J, Van Hoorenbeeck K, Van Schil PEY, Verhulst SL, Hendriks JMH. A combined intrapleural administration of dornase alfa and tissue plasminogen activator is safe in children with empyema - A pilot study. Acta Chir Belg 2021; 121:184-188. [PMID: 31750793 DOI: 10.1080/00015458.2019.1696516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE There is still no consensus regarding the treatment of empyema in children. Intrapleural combination of tissue plasminogen activator and dornase alfa is a promising treatment for empyema in adults. The aim of this pilot study was to determine whether this combination is safe and successful in pediatric empyema. METHODS Previous well children diagnosed with empyema as classified by the British Thoracic Society. After chest tube insertion, intrapleurally dornase alfa 2.5 mg for 2 days and tissue plasminogen activator 0.15 mg/kg for 3 days was given after which the chest tube was clamped for 4 h. Primary outcome was safety. RESULTS Ten consecutive children were included (4 boys, aged 3.2 (1.3-15.0) years old). No serious adverse events were seen. One child developed urticaria but additional intervention or cessation of the trial was not needed. There was no bleeding or mortality and no additional procedures were performed. The median hospital stay after intervention was 7.5 days. CONCLUSIONS The intrapleural treatment of dornase alfa and tissue plasminogen activator as treatment of empyema was safe in ten children with empyema. If confirmed in further studies, this combination of intrapleural therapy may improve the management of pediatric empyema.
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Affiliation(s)
- Monique A. Slaats
- Department of Paediatric Medicine, Antwerp University Hospital, Belgium
| | - Jozef De Dooy
- Department of Paediatric Intensive Care, Antwerp University Hospital Belgium
| | | | - Paul E. Y. Van Schil
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Belgium
| | - Stijn L. Verhulst
- Department of Paediatric Medicine, Antwerp University Hospital, Belgium
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Turan Ciftci T, Akinci D, Unal E, Tanır G, Artas H, Akhan O. Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study. ACTA ACUST UNITED AC 2021; 27:401-407. [PMID: 34003128 DOI: 10.5152/dir.2021.20331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children. METHODS A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months. RESULTS Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001). CONCLUSION Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.
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Affiliation(s)
- Turkmen Turan Ciftci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Devrim Akinci
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Emre Unal
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
| | - Gonul Tanır
- Department of Pediatric Infectious Disease, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Hakan Artas
- Department of Radiology, Firat University School of Medicine, Elazig, Turkey
| | - Okan Akhan
- Department of Radiology, Hacettepe University School of Medicine. Ankara, Turkey
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Kanitra JJ, Thampy CA, Cullen ML. A decade's experience of pediatric lung abscess and empyema at a community hospital. Pediatr Pulmonol 2021; 56:1245-1251. [PMID: 33386780 DOI: 10.1002/ppul.25254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/24/2020] [Accepted: 12/27/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices. METHODS A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed. RESULTS Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst. CONCLUSION Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice.
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Affiliation(s)
- John J Kanitra
- Department of Surgery, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Chelsea A Thampy
- Department of Surgery, Ascension St. John Hospital, Detroit, Michigan, USA
| | - Marc L Cullen
- Division of Pediatric Surgery, Department of Surgery, Ascension St. John Hospital, Detroit, Michigan, USA
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Abstract
BACKGROUND The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis. METHODS Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era. RESULTS A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions. CONCLUSIONS Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.
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Ramasli Gursoy T, Sismanlar Eyuboglu T, Onay ZR, Aslan AT, Tapisiz Aktas A, Tezer H, Boyunaga O, Budakoglu II. Pleural Thickening after Pleural Effusion: How can we Follow-Up in Children? J Trop Pediatr 2020; 66:85-94. [PMID: 31204435 DOI: 10.1093/tropej/fmz036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION No clear information exists about the factors affecting pleural thickening following parapneumonic effusion in children. We aimed to investigate factors that affect the resolving time of pleural thickening after parapneumonic effusion. METHODS Between the years of 2007-18, 91 patients, which were followed due to diagnosis of pleural thickening after parapneumonic effusion, were assessed. Ages, complaints, physical examination findings, laboratory results, chest x-ray and ultrasonography findings, treatments, duration of treatment and recovery time of the patients were examined terms in of pleural thickening resolving time. RESULTS The mean age of patients was 7.5 ± 5.0 years. Pleural thickening resolving time was 151 ± 6.8 days. The resolving time for pleural thickening was delayed with older ages, longer duration of complaints, fever before hospital admission and treatment, lower oxygen saturation at the time of admission, crackles in the physical examination, higher white blood cell count and pleural fluid density (p = 0.018, p = 0.001, p = 0.021, p = 0.020, p = 0.024, p = 0.025, p = 0.021, p = 0.019). In addition, the amount of effusion measured by thorax ultrasonography, fibrinolytic usage, and complications had a role in the delayed resolving time (p = 0.034, p = 0.001, p = 0.034). Pleural thickening resolved in 80% of the patients. CONCLUSION In this report, 80% of pleural thickening, following parapneumonic effusion resolved within 5 months. Patients who do not have a complication during follow-up are not required to monitor with frequent chest x-ray. Patients with a higher amount of pleural effusion, complications and need for fibrinolytic treatment should be followed more carefully.
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Affiliation(s)
- Tugba Ramasli Gursoy
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Tugba Sismanlar Eyuboglu
- Department of Pediatric Pulmonology, Dr Sami Ulus Maternity and Children Research and Training Hospital, 06080 Ankara, Turkey
| | - Zeynep Reyhan Onay
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayse Tana Aslan
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Anil Tapisiz Aktas
- Department of Pediatric Infectious Disease, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Hasan Tezer
- Department of Pediatric Infectious Disease, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Oznur Boyunaga
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Irem Isil Budakoglu
- Department of Medical Education, Gazi University Medicine Faculty, Ankara, Turkey
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Shah JH, Whitmore MJ. Interventional Radiology's Role in the Treatment of Pediatric Thoracic Disease. Semin Roentgenol 2019; 54:395-406. [PMID: 31706372 DOI: 10.1053/j.ro.2019.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jay H Shah
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Atlanta, GA; Department of Radiology and Imaging Sciences, Division of Pediatric Radiology, Emory University School of Medicine, Emory + Children's Pediatric Institute, Children's Healthcare of Atlanta at Egleston, Atlanta, GA.
| | - Morgan J Whitmore
- Department of Radiology and Imaging Sciences, Division of Interventional Radiology and Image-Guided Medicine, Emory University School of Medicine, Atlanta, GA
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Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-acquired Bacterial Pneumonia. Pediatr Rev 2017; 38:394-409. [PMID: 28864731 DOI: 10.1542/pir.2016-0183] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Amanda Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Sarah Parker
- Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
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James CA, Braswell LE, Pezeshkmehr AH, Roberson PK, Parks JA, Moore MB. Stratifying fibrinolytic dosing in pediatric parapneumonic effusion based on ultrasound grade correlation. Pediatr Radiol 2017; 47:89-95. [PMID: 27709281 DOI: 10.1007/s00247-016-3711-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/29/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Complicated pleural effusion prolongs the hospital course of pneumonia. Chest tube placement with instillation of fibrinolytic medication allows efficient drain output and decreases hospital stay. OBJECTIVE To evaluate experience with lower fibrinolytic dose for parapneumonic effusions and to assess potential dose stratification based on a simple ultrasound grading system. MATERIALS AND METHODS We retrospectively reviewed the medical record to identify children and young adults who received fibrinolytic therapy for parapneumonic effusion and had chest tube placement by an interventional radiology service at a single children's hospital. We assessed tissue plasminogen activator (tPA) dosing and treatment duration, as well as the need for a second pleural procedure or surgical drainage. Diagnostic US images were classified as showing less than 50% pleural echogenicity (grade 1) or greater than 50% pleural echogenicity (grade 2) and were correlated with clinical parameters. RESULTS Of 32 patients with parapneumonic effusion, all except one received at least some 1-mg tPA doses. Dosing was solely 1-mg tPA in 81% of subjects; 19% of subjects also received 2-mg tPA doses. Mean fibrinolytic duration was 3.1 days for grade 1 effusions compared to 5.4 days for grade 2 effusions. A second pleural procedure was required in 15.6% of children. Pleural drainage with fibrinolytic therapy was successful in 97%; only one child required surgical drainage. Grade 2 US differed significantly from grade 1 US, with grade 2 occurring in younger patients (P < 0.0001), smaller patients (P < 0.0001), those needing a second procedure (P = 0.001), those with positive pleural culture or polymerase chain reaction test (P = 0.006), and those with longer treatment duration (P = 0.03). CONCLUSION A lower 1-mg dosing regimen of tissue plasminogen activator was effective in all children with less complex (grade 1 US imaging) parapneumonic effusions. Grade 2 US images correlated with younger and smaller children, presence of a pleural organism, and longer or more complicated chest tube duration.
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Affiliation(s)
- Charles A James
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA.
| | - Leah E Braswell
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Amir H Pezeshkmehr
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
| | - Paula K Roberson
- Biostatistics Department, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - James A Parks
- Pharmacy Department, Arkansas Children's Hospital, Little Rock, AR, USA
| | - Mary B Moore
- Radiology Department, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 105, Little Rock, AR, 72202, USA
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Taylor JL, Liu M, Hoff DS. Retrospective analysis of large-dose intrapleural alteplase for complicated pediatric parapneumonic effusion and empyema. J Pediatr Pharmacol Ther 2015; 20:128-37. [PMID: 25964730 DOI: 10.5863/1551-6776-20.2.128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Medical treatment of complicated parapneumonic effusion or empyema in pediatric patients includes antibiotics and pleural space drainage. Intrapleural fibrinolysis may facilitate pleural drainage; however, there is a lack of consensus regarding the optimal dosing regimen. The primary purpose of this study was to evaluate the efficacy and safety of a large-dose intrapleural alteplase regimen in pediatric patients. Secondarily, this investigation sought to differentiate the clinical characteristics of responders and non-responders to intrapleural alteplase therapy. METHODS All patients with parapneumonic effusions treated with intrapleural alteplase between June 2003 and December 2011 were reviewed retrospectively. Efficacy was assessed by comparing chest tube output, in mL/hr and mL/kg/hr, for 24 hours before and after the first dose of alteplase. Additional efficacy outcomes included duration of in situ chest tubes, a need for surgical intervention for pleural effusion, and length of hospital stay. Safety was assessed by frequency and severity of adverse events. Non-responders and responders were compared based on demographic and disease characteristics. Responders were defined as patients who did not require surgical intervention after intrapleural alteplase therapy. RESULTS Seventy-three patients, aged 0.5 to 22.5 years, received intrapleural alteplase to facilitate pleural drainage. Median alteplase dose was 7 mg (range, 3 to 10 mg; median 0.38 mg/kg). Chest tube output increased from 10.7 to 24.2 mL/hr (p = 0.006), and median length of hospital stay was 9 days. Eighty-four percent of patients were responders. The most common adverse events were pain (20.5%) and oxygen desaturation greater than 10% from baseline (16.4%). High-flow nasal cannula was the most common intervention for oxygen desaturation to 80% to 90%. Nine patients (12%) required a blood transfusion during the study. CONCLUSION Large-dose intrapleural alteplase is effective in facilitating pleural drainage in pediatric patients with complicated parapneumonic effusion or empyema. Common adverse effects include pain and oxygen desaturation. The potential for bleeding warrants clinical monitoring.
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Affiliation(s)
- Jessica L Taylor
- Department of Pharmacy, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Meixia Liu
- Department of Healthcare Economics, Medica, Hopkins, Minnesota
| | - David S Hoff
- Department of Pharmacy, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
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