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Sridharan K, Sivaramakrishnan G. Intrapleural Thrombolytics for Parapneumonic Effusion: A Network Metaanalysis. Curr Rev Clin Exp Pharmacol 2024; 19:204-212. [PMID: 36173062 DOI: 10.2174/2772432817666220928123845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 08/10/2022] [Accepted: 09/05/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intrapleural thrombolytics have been trialed for facilitating pleural fluid drainage in patients with complicated parapneumonic effusion. The present study is a network metaanalysis of randomized clinical trials (RCTs) that have evaluated these thrombolytics. METHODS Electronic databases (Medline, Cochrane CENTRAL, and Google Scholar) were searched for appropriate RCTs evaluating the therapeutic effect of thrombolytics in patients with complicated parapneumonic effusion. Mortality, the proportion of patients referred for surgical intervention, and serious adverse events were the outcome measures. Random-effects model was used for generating direct and mixed treatment comparison pooled estimates. Grading of the evidence for key comparisons was carried out. Odds ratio with 95% confidence intervals was used to represent the pooled estimates. RESULTS Seventy-six studies were retrieved with the search strategy, of which 16 were included. No significant differences were observed in mortality. Compared to normal saline, significantly less proportion of patients was referred for surgical intervention with streptokinase (0.4, 0.2 to 0.8), urokinase (0.4, 0.2 to 0.8), alteplase (0.3, 0.1 to 0.7), and alteplase + DNase (0.2, 0.1 to 0.7). DNase alone increased the risk of referral to surgical intervention (3.4, 1.5 to 7.6). Only streptokinase was observed with an increased risk of serious adverse events compared to normal saline (2.8, 1.1 to 7.1) and alteplase (6.7, 1.1 to 39.9). Moderate quality of evidence was observed for streptokinase with normal saline for the proportion of patients referred for surgical intervention, while either low or very low quality strength was observed for all other comparisons. CONCLUSION Streptokinase, urokinase, alteplase, and alteplase + DNase were observed in patients referred for surgical interventions when used intrapleural in patients with parapneumonic effusion. Alteplase + DNase is likely to outperform others as it was observed with the least risk of patients referred for surgical interventions. Until additional data emerges that changes the pooled estimates, thrombolytics other than streptokinase are preferred due to the increased risk of serious adverse events.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
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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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de Benedictis FM, Kerem E, Chang AB, Colin AA, Zar HJ, Bush A. Complicated pneumonia in children. Lancet 2020; 396:786-798. [PMID: 32919518 DOI: 10.1016/s0140-6736(20)31550-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/20/2020] [Accepted: 06/10/2020] [Indexed: 12/13/2022]
Abstract
Complicated community-acquired pneumonia in a previously well child is a severe illness characterised by combinations of local complications (eg, parapneumonic effusion, empyema, necrotising pneumonia, and lung abscess) and systemic complications (eg, bacteraemia, metastatic infection, multiorgan failure, acute respiratory distress syndrome, disseminated intravascular coagulation, and, rarely, death). Complicated community-acquired pneumonia should be suspected in any child with pneumonia not responding to appropriate antibiotic treatment within 48-72 h. Common causative organisms are Streptococcus pneumoniae and Staphylococcus aureus. Patients have initial imaging with chest radiography and ultrasound, which can also be used to assess the lung parenchyma, to identify pleural fluid; CT scanning is not usually indicated. Complicated pneumonia is treated with a prolonged course of intravenous antibiotics, and then oral antibiotics. The initial choice of antibiotic is guided by local microbiological knowledge and by subsequent positive cultures and molecular testing, including on pleural fluid if a drainage procedure is done. Information from pleural space imaging and drainage should guide the decision on whether to administer intrapleural fibrinolytics. Most patients are treated by drainage and more extensive surgery is rarely needed; in any event, in low-income and middle-income countries, resources for extensive surgeries are scarce. The clinical course of complicated community-acquired pneumonia can be prolonged, especially when patients have necrotising pneumonia, but complete recovery is the usual outcome.
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Affiliation(s)
| | - Eitan Kerem
- Department of Pediatrics, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Anne B Chang
- Child Health Division, Menzies School of Health Research, Darwin, NT, Australia; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia; Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Andrew A Colin
- Division of Pediatric Pulmonology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross Children's Hospital, Cape Town, South Africa; MRC Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Andrew Bush
- Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK; National Heart and Lung Institute, Imperial School of Medicine, Imperial College London, London, UK.
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Baram A, Yaldo F. Pediatric Thoracic Empyema-Outcomes of Intrapleural Thrombolytics: Ten Years of Experience. Glob Pediatr Health 2020; 7:2333794X20928200. [PMID: 32551331 PMCID: PMC7281637 DOI: 10.1177/2333794x20928200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction. Pediatric thoracic empyema is a special entity with increasing frequency. Consensus regarding the best management strategy is still evolving. We describe our single-center 10-year experience adopting intrapleural thrombolytics using tissue plasminogen activator as first-line treatment following failure of simple thoracostomy drainage techniques. Methods. Observational prospective study included all children from 1 day to 18 years admitted for parapneumonic effusion and treated with intrapleural thrombolytics. Results. From January 2008 to December 2018, 95 patients were treated by intrapleural thrombolytics for different stages of empyema thoracis. Number of thrombolytic doses required is 2.1 (range = 1-3), and mean amount of drainage is 1050 mL (range = 400-2500 mL). Mean total days of hospitalization is 7.3 days. Complete re-expansion was the primary outcome in 94 patients (98.9%). Conclusion. Intrapleural thrombolytics in complicated pediatric thoracic empyema results in excellent outcome and should be encouraged particularly in limited resource countries.
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Affiliation(s)
- Aram Baram
- University of Sulaimani, Sulaymaniyah, Kurdistan, Iraq
| | - Fitoon Yaldo
- Kurdistan Board for Medical Specialties, Erbil, Kurdistan Region, Iraq
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Lewis MR, Micic TA, Doull IJM, Evans A. Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children - 16-year, single-centre experience of radiologically placed drains. Pediatr Radiol 2018; 48:1410-1416. [PMID: 29951836 PMCID: PMC6105150 DOI: 10.1007/s00247-018-4171-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion. OBJECTIVE To evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital. MATERIALS AND METHODS This was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre. RESULTS Three hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery. CONCLUSION Our technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.
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Affiliation(s)
- Megan R. Lewis
- Department of Postgraduate Medical and Dental Education at Cardiff University, Heath Park Way, Cardiff, UK CF14 4YU
| | - Thomas A. Micic
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
| | - Iolo J. M. Doull
- Department of Paediatric Respiratory Medicine, Children’s Hospital for Wales, Cardiff, UK CF14 4XW
| | - Alison Evans
- Department of Paediatric Radiology, Children’s Hospital for Wales, Heath Park, Cardiff, UK CF14 4XW
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Course CW, Hanks R, Doull I. Question 1 What is the best treatment option for empyema requiring drainage in children? Arch Dis Child 2017; 102:588-590. [PMID: 28468869 DOI: 10.1136/archdischild-2017-312938] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/31/2017] [Accepted: 03/31/2017] [Indexed: 11/03/2022]
Affiliation(s)
| | - Ruth Hanks
- Department of Paediatric Respiratory Medicine, Children's Hospital for Wales, Cardiff, UK
| | - Iolo Doull
- Department of Paediatric Respiratory Medicine, Noah's Ark Children's Hospital for Wales, Cardiff, UK
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Empyema in Children: Update of Aetiology, Diagnosis and Management Approaches. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0161-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Auten R, Schwarze J, Ren C, Davis S, Noah TL. Pediatric Pulmonology year in review 2015: Part 1. Pediatr Pulmonol 2016; 51:733-9. [PMID: 27124279 DOI: 10.1002/ppul.23423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 02/04/2023]
Abstract
Our journal covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review covers articles on neonatal lung disease, pulmonary physiology, and respiratory infection. Pediatr Pulmonol. 2016;51:733-739. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Jurgen Schwarze
- Department of Child Life and Health, The University of Edinburgh, Edinburgh, United Kingdom
| | - Clement Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie Davis
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Hafen GM, Grenzbach AC, Moeller A, Rochat MK. Lack of concordance in parapneumonic effusion management in children in central Europe. Pediatr Pulmonol 2016; 51:411-7. [PMID: 26291694 DOI: 10.1002/ppul.23263] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/14/2015] [Accepted: 06/05/2015] [Indexed: 11/08/2022]
Abstract
Treatment of parapneumonic effusion in children remains controversial in the literature and in clinical practice. The aim of this study was to determine whether mutual consensus exists in the diagnosis and treatment of parapneumonic effusion in Central European countries. A questionnaire was sent to all directors of pediatric respiratory units in four adjacent Central European countries (Austria, France, Germany, Switzerland). The response rate was 61.8%. Responses reflected acceptable agreement regarding initial diagnostic procedures, as most centers performed chest X-ray and biological exams, followed by ultrasound, thoracocentesis, or computed tomography. However, antibiotic regimens were very heterogeneous, and the survey revealed complete lack of agreement on the indications and effusion volume threshold for invasive procedures, such as fibrinolytic instillation and thoracoscopy. In conclusion, apart from initial diagnostic procedures, this study showed a lack of mutual consensus among the four countries regarding the management of pediatric parapneumonic effusion. Multicenter prospective trials are clearly needed to acquire more evidence on the management of childhood parapneumonic effusion, enabling the development of evidence-based algorithms that could help to avoid unnecessary examinations with potential long-term side effects, such as radiation exposure at a young age.
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Affiliation(s)
- Gaudenz M Hafen
- Department of Pediatrics, Respiratory Unit, Lausanne University Hospital, Lausanne, Switzerland
| | - Andrea-Claudia Grenzbach
- Department of Pediatric Pulmonology, Clinic for Pediatric and Adolescent Medicine, University of Luebeck, Luebeck, Germany
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Mascha K Rochat
- Department of Pediatrics, Lausanne University Hospital, Lausanne, Switzerland
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