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Ferreiro L, Toubes ME, Suárez-Antelo J, Rodríguez-Núñez N, Valdés L. Clinical overview of the physiology and pathophysiology of pleural fluid movement: a narrative review. ERJ Open Res 2024; 10:00050-2024. [PMID: 39351376 PMCID: PMC11440405 DOI: 10.1183/23120541.00050-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/21/2024] [Indexed: 10/04/2024] Open
Abstract
In physiological conditions, the pleural space couples the lung with the chest wall and contains a small amount of fluid in continuous turnover. The volume of pleural fluid is the result from the balance between the entry of fluid through the pleural capillaries and drainage by the lymphatics in the most dependent areas of the parietal pleura. Fluid filtration is governed by Starling forces, determined by the hydrostatic and oncotic pressures of the capillaries and the pleural space. The reabsorption rate is 28 times greater than the rate of pleural fluid production. The mesothelial layer of the inner lining of the pleural space is metabolically active and also plays a role in the production and reabsorption of pleural fluid. Pleural effusion occurs when the balance between the amount of fluid that enters the pleural space and the amount that is reabsorbed is disrupted. Alterations in hydrostatic or oncotic pressure produce a transudate, but they do not cause any structural damage to the pleura. In contrast, disturbances in fluid flow (increased filtration or decreased reabsorption) produce an exudate via several mechanisms that cause damage to pleural layers. Thus, cellular processes and the inflammatory and immune reactions they induce determine the composition of pleural fluid. Understanding the underlying pathophysiological processes of pleural effusion, especially cellular processes, can be useful in establishing its aetiology.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela-IDIS), Santiago de Compostela, Spain
| | - María E Toubes
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Juan Suárez-Antelo
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Nuria Rodríguez-Núñez
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - Luis Valdés
- Servicio de Neumología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Health Research Institute of Santiago de Compostela (Instituto de Investigación Sanitaria de Santiago de Compostela-IDIS), Santiago de Compostela, Spain
- Departamento de Medicina, Facultad de Medicina, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
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Lau EP, Eshraghi M, Dootson K, Yeoh C, Ywe Phu W, Lee YG, Popowicz ND. An international survey on the use of intrapleural tissue plasminogen activator/DNase therapy for pleural infection. ERJ Open Res 2021; 8:00590-2021. [PMID: 35141321 PMCID: PMC8819248 DOI: 10.1183/23120541.00590-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/16/2021] [Indexed: 01/20/2023] Open
Abstract
Introduction Intrapleural tissue plasminogen activator (tPA) combined with human recombinant DNase (DNase) could be an effective alternative to surgery in managing pleural infection, as demonstrated in the Multi-centre Intrapleural Sepsis Trial (MIST)-2. However, the optimal delivery regimen is still unknown. The aim of this survey was to identify the current practice of tPA/DNase use by physicians with published interests in pleural infection, and their opinions on dose de-escalation of tPA/DNase therapy. Methods Potential participants were identified using four search strategies. Only practising physicians who were managing patients with pleural infections and either actively involved in pleural research and publications, or were members of relevant pleural disease guideline panels at the time of survey were included. Results An invitation email with the questionnaire was sent to 102 participants, of whom 49 (48%) responded. Most respondents (90%, n=44) have used tPA/DNase to manage pleural infection, but the dosing and delivery regimens employed varied. Many (86%, 38 out of 44) respondents have used 10 mg tPA, while 73% (n=32), 16% (n=7) and 9% (n=4) have used 5 mg, 2.5 mg and 1 mg doses, respectively. Most respondents instilled tPA/DNase concurrently (61%, n=27) and routinely administered six doses of tPA/DNase (52%, n=23) twice daily (82%, n=36). Respondents would consider using a lower starting dose of tPA (with the possibility of escalation if clinically needed) if a median 80% (interquartile range 50–80%) of patients could be successfully treated at that dose. Conclusion This survey observed a large variation in the current treatment protocol of intrapleural tPA/DNase therapy worldwide and the need for more data on this subject. This international survey observed a large variation in the delivery of tPA/DNase therapy for pleural infection. Respondents were open to the concept of starting with a lower (<10 mg) dose of tPA (with the possibility of escalation) if evidence accumulates.https://bit.ly/2ZfPRrL
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Sundaralingam A, Banka R, Rahman NM. Management of Pleural Infection. Pulm Ther 2021; 7:59-74. [PMID: 33296057 PMCID: PMC7724776 DOI: 10.1007/s41030-020-00140-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/16/2020] [Indexed: 12/16/2022] Open
Abstract
Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16-27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient's specific 'fibrinolytic potential', in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
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4
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von Schirnding C, Giopanou I, Hermawan A, Wehl L, Ntaliarda G, Illes B, Datz S, Geisslinger F, Bartel K, Sommer AK, Lianou M, Weiß V, Feckl J, Vollmar AM, Bräuchle C, Stathopoulos GT, Wagner E, Roidl A, Bein T, Engelke H. Synergistic Combination of Calcium and Citrate in Mesoporous Nanoparticles Targets Pleural Tumors. Chem 2021. [DOI: 10.1016/j.chempr.2020.11.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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5
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Gregory P, Rahman NM, Lee YCG. Osler Centenary Papers: Management of pleural infection: Osler's final illness and recent advances. Postgrad Med J 2020; 95:656-659. [PMID: 31754057 DOI: 10.1136/postgradmedj-2018-135893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/24/2019] [Accepted: 08/06/2019] [Indexed: 12/16/2022]
Abstract
Sir William Osler's great work and achievements are extensively documented. Less well known is his prolonged battle with postinfluenza pneumonia, lung abscess and pleural infection that eventually led to his demise. At the age of 70, he was a victim of the global Spanish influenza epidemic, and subsequently developed pneumonia. In the era before antibiotics, he received supportive care and opium for symptom control. The infection extended to the pleura and he required repeated thoracentesis which failed to halt his deterioration. He proceeded to open surgical drainage involving rib resection. Unfortunately, he died shortly after the operation from massive pleuropulmonary haemorrhage. In this article, we review the events leading up to Osler's death and contrast his care 100 years ago with contemporary state-of-the-art management in pleural infection.
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Affiliation(s)
- Prudence Gregory
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, University of Oxford, Oxford, UK
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia .,School of Medicine & Centre for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia
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Beckert L, Brockway B, Simpson G, Southcott AM, Lee YG, Rahman N, Light RW, Shoemaker S, Gillies J, Komissarov AA, Florova G, Ochran T, Bradley W, Ndetan H, Singh KP, Sarva K, Idell S. Phase 1 trial of intrapleural LTI-01; single chain urokinase in complicated parapneumonic effusions or empyema. JCI Insight 2019; 5:127470. [PMID: 30998508 PMCID: PMC6542611 DOI: 10.1172/jci.insight.127470] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/12/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Current dosing of intrapleural fibrinolytic therapy (IPFT) in adults with complicated parapneumonic effusion (CPE) / empyema is empiric, as dose-escalation trials have not previously been conducted. We hypothesized that LTI-01 (scuPA), which is relatively resistant to PA inhibitor-1 (PAI-1), would be well-tolerated. METHODS This was an open-label, dose-escalation trial of LTI-01 IPFT at 50,000-800,000 IU daily for up to 3 days in adults with loculated CPE/empyema and failed pleural drainage. The primary objective was to evaluate safety and tolerability, and secondary objectives included assessments of processing and bioactivity of scuPA in blood and pleural fluid (PF), and early efficacy. RESULTS LTI-01 was well tolerated with no bleeding, treatment-emergent adverse events or surgical referrals (n=14 subjects). uPA antigen increased in PFs at 3 hours after LTI-01 (p<0.01) but not in plasma. PF saturated active PAI-1, generated PAI-1-resistant bioactive complexes, increased PA and fibrinolytic activities and D-dimers. There was no systemic fibrinogenolysis, nor increments in plasma D-dimer. Decreased pleural opacities occurred in all but one subject. Both subjects receiving 800,000 IU required two doses to relieve pleural sepsis, with two other subjects similarly responding at lower doses. CONCLUSION LTI-01 IPFT was well-tolerated at these doses with no safety concerns. Bioactivity of LTI-01 IPFT was confirmed, limited to PFs where its processing simulated that previously reported in preclinical studies. Preliminary efficacy signals including reduction of pleural opacity were observed.
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Affiliation(s)
| | - Ben Brockway
- University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | | | - Y.C. Gary Lee
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Najib Rahman
- Nuffield Department of Medicine, University of Oxford, and Oxford NIHR Biomedical Research Centre, Oxford, United Kingdom
| | - Richard W. Light
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - John Gillies
- Clinical Network Services (CNS), Auckland, New Zealand
| | | | | | | | | | - Harrison Ndetan
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Community and Rural Health, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas, USA
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Abstract
PURPOSE OF REVIEW Pleural infection remains an important pulmonary disease, causing significant morbidity and mortality. There is a resurgence of disease burden despite introduction of antibiotics and pneumococcal vaccines. A revisit of the pathogenesis and update on intervention may improve the care of pleural infection. RECENT FINDINGS Recent studies have uncovered the prognostic implication of the presence of a pleural effusion in patients with pneumonia. Identifying where the bacteria lives may have diagnostic and therapeutic implications. Over-exaggerated pleural inflammation may underlie development of parapneumonic effusion as indirect evidence and a randomized study in children raised a role of corticosteroids in parapneumonic pleural effusions, but data are lacking for adults. Optimization of the delivery regimen of intrapleural fibrinolytic and deoxyribonuclease therapy is ongoing. SUMMARY The review aims to review the current practice and explore new directions of treatment on pleural infection.
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Bedawi EO, Hassan M, McCracken D, Rahman NM. Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics. Expert Rev Respir Med 2019; 13:337-347. [PMID: 30707629 DOI: 10.1080/17476348.2019.1578212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms 'pleural infection', 'empyema' and 'parapneumonic'. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.
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Affiliation(s)
- Eihab O Bedawi
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK
| | - Maged Hassan
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK.,c Chest Diseases Department, Faculty of Medicine , Alexandria University , Alexandria , Egypt
| | - David McCracken
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK
| | - Najib M Rahman
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK.,d Oxford NIHR Biomedical Research Centre , Oxford , UK
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10
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Conway FM, Garner JL, Orton CM, Srikanthan K, Kemp SV, Shah PL. Contemporary Concise Review 2018: Lung cancer and pleural disease. Respirology 2019; 24:475-483. [PMID: 30772946 DOI: 10.1111/resp.13499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 01/23/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Francesca M Conway
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Justin L Garner
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Christopher M Orton
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Karthi Srikanthan
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Samuel V Kemp
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Pallav L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
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Bedawi EO, Hassan M, Rahman NM. Recent developments in the management of pleural infection: A comprehensive review. CLINICAL RESPIRATORY JOURNAL 2018; 12:2309-2320. [PMID: 30005142 DOI: 10.1111/crj.12941] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. DATA SOURCE Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included. RESULTS A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. CONCLUSION Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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12
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Simpson G. Letter from Australia. Respirology 2018; 23:788-789. [DOI: 10.1111/resp.13321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Graham Simpson
- Department of Thoracic Medicine, The Cairns Hospital; Cairns QLD Australia
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13
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Porcel JM. Minimally invasive treatment of complicated parapneumonic effusions and empyemas in adults. THE CLINICAL RESPIRATORY JOURNAL 2018; 12:1361-1366. [DOI: 10.1111/crj.12730] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- José M. Porcel
- Pleural Medicine Unit, Department of Internal MedicineArnau de Vilanova University Hospital, IRBLleidaLleidaSpain
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14
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Komissarov AA, Rahman N, Lee YCG, Florova G, Shetty S, Idell R, Ikebe M, Das K, Tucker TA, Idell S. Fibrin turnover and pleural organization: bench to bedside. Am J Physiol Lung Cell Mol Physiol 2018; 314:L757-L768. [PMID: 29345198 DOI: 10.1152/ajplung.00501.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.
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Affiliation(s)
- Andrey A Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Najib Rahman
- Oxford Pleural Unit and Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital; and National Institute of Health Research Biomedical Research Centre , Oxford , United Kingdom
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital; Pleural Medicine Unit, Institute for Respiratory Health , Perth ; School of Medicine and Pharmacology, University of Western Australia , Perth , Australia
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Sreerama Shetty
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Richard Idell
- Department of Behavioral Health, Child and Adolescent Psychiatry, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Mitsuo Ikebe
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Kumuda Das
- Department of Translational and Vascular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Torry A Tucker
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler , Tyler, Texas
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Popowicz N, Idell S, Lee YG. Pathogenesis of pleural infection: A complex warfare. Respirology 2017; 23:8-9. [DOI: 10.1111/resp.13171] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 08/22/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Natalia Popowicz
- Department of Respiratory Medicine; Sir Charles Gairdner Hospital; Perth WA Australia
- Pleural Medicine Unit; Institute for Respiratory Health; Perth WA Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth WA Australia
| | - Steven Idell
- Department of Cellular and Molecular Biology and Texas Lung Injury Institute; The University of Texas Health Science Center at Tyler; Tyler TX USA
| | - Y.C. Gary Lee
- Department of Respiratory Medicine; Sir Charles Gairdner Hospital; Perth WA Australia
- Pleural Medicine Unit; Institute for Respiratory Health; Perth WA Australia
- School of Medicine and Pharmacology; University of Western Australia; Perth WA Australia
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Precision-guided, Personalized Intrapleural Fibrinolytic Therapy for Empyema and Complicated Parapneumonic Pleural Effusions: The Case for the Fibrinolytic Potential. ACTA ACUST UNITED AC 2017; 24:163-169. [PMID: 29081644 DOI: 10.1097/cpm.0000000000000216] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Complicated pleural effusions and empyema with loculation and failed drainage are common clinical problems. In adults, intrapleural fibrinolytic therapy is commonly used with variable results and therapy remains empiric. Despite the intrapleural use of various plasminogen activators; fibrinolysins, for about sixty years, there is no clear consensus about which agent is most effective. Emerging evidence demonstrates that intrapleural administration of plasminogen activators is subject to rapid inhibition by plasminogen activator inhibitor-1 and that processing of fibrinolysins is importantly influenced by other factors including the levels and quality of pleural fluid DNA. Current therapy for loculation that accompanies pleural infections also includes surgery, which is invasive and for which patient selection can be problematic. Most of the clinical literature published to date has used flat dosing of intrapleural fibrinolytic therapy in all subjects but little is known about how that strategy influences the processing of the administered fibrinolysin or how this influences outcomes. We developed a new test of pleural fluids ex vivo, which is called the Fibrinolytic Potential or FP, in which a dose of a fibrinolysin is added to pleural fluids ex vivo after which the fibrinolytic activity is measured and normalized to baseline levels. Testing in preclinical and clinical empyema fluids reveals a wide range of responses, indicating that individual patients will likely respond differently to flat dosing of fibrinolysins. The test remains under development but is envisioned as a guide for dosing of these agents, representing a novel candidate approach to personalization of intrapleural fibrinolytic therapy.
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