Optimizing the management of complicated pleural effusion: From intrapleural agents to surgery

Ultrasound and Intrapleural Enzymatic Therapy for Complicated Pleural Effusion: A Case Series with a Literature Review

Pleural effusion is the most common manifestation of pleural disease, and chest ultrasound is crucial for diagnostic workup and post-treatment monitoring. Ultrasound helps distinguish the various types of pleural effusion and enables the detection of typical manifestations of empyema, which presents as a complicated, septated effusion. This may benefit from drainage and the use of intrapleural enzyme therapy or may require more invasive approaches, such as medical or surgical thoracoscopy. The mechanism of action of intrapleural enzymatic therapy (IPET) is the activation of plasminogen to plasmin, which breaks down fibrin clots that form septa or the loculation of effusions and promotes their removal. In addition, IPET has anti-inflammatory properties and can modulate the immune response in the pleural space, resulting in reduced pleural inflammation and improved fluid reabsorption. In this article, we briefly review the literature on the efficacy of IPET and describe a case series in which most practical applications of IPET are demonstrated, i.e., as a curative treatment but also as an alternative, propaedeutic, or subsequent treatment to surgery.

Reduction in the need for surgery and mortality after early administration of fibrinolytics following empyema drainage

OBJECTIVES

Although intrapleural administration of fibrinolytics is an important treatment option for the management of empyema, the addition of fibrinolytics failed to reduce the need for surgery and mortality in previous randomized controlled trials. This study aimed to investigate the effects of administrating fibrinolytics in the early phase (within 3 days of chest tube insertion) of empyema compared with late administration or no administration.

METHODS

We used the Japanese Diagnosis Procedure Combination Inpatient Database to identify patients aged ≥16 years who were hospitalized and underwent chest tube drainage for empyema. A 1:2 propensity score matching and stabilized inverse probability of treatment weighting were conducted.

RESULTS

Among the 16 265 eligible patients, 3082 and 13 183 patients were categorized into the early and control group, respectively. The proportion of patients who underwent surgery was significantly lower in the early fibrinolytics group than in the control group; the odds ratio (95% confidence interval) was 0.69 (0.54-0.88) in the propensity score matching (P = 0.003) and 0.64 (0.50-0.80) in the stabilized inverse probability of treatment weighting analysis (P < 0.001). All-cause 30-day in-hospital mortality, length of hospital stay, duration of chest tube drainage, and total hospitalization costs were also more favourable in the early fibrinolytics group.

CONCLUSIONS

The early administration of fibrinolytics may reduce the need for surgery and death in adult patients with empyema.

Chest ultrasound is better than CT in identifying septated effusion of patients with pleural disease

Septated pleural effusion is very common. The presence of septations in pleural effusion determines the local treatment strategy for such patients. Therefore, there is a pressing need for imaging techniques to assess the presence of septations. The objective of this research was to assess the diagnostic efficacy of computed tomography (CT) and chest ultrasound in identifying septated pleural effusion. We delineated the ultrasound and enhanced chest CT manifestations for diagnosing septated pleural effusions, and subsequently, we conducted a comparative analysis to assess the diagnostic efficacy of enhanced chest CT and ultrasound in identifying septated pleural effusions. Medical thoracoscopy served as the gold standard for confirming the diagnosis of septated pleural effusions. Ultrasound demonstrated a sensitivity of 82.6% (95% CI 73.3-89.7%) and a specificity of 100.0% (95% CI 98.1-NaN) for diagnosing septated pleural effusion. In comparison, enhanced chest CT exhibited a sensitivity of 59.8% (95% CI 49.0-69.9%) and a specificity of 87.0% (95% CI 81.5-91.4%). The positive predictive value for ultrasound was 100.0% (95% CI 95.3-100.0%), while for enhanced chest CT, it was 68.8% (95% CI 59.0-77.4%). Ultrasound yielded a negative predictive value of 92.3% (95% CI 87.5-NaN), and enhanced chest CT had a negative predictive value of 82.0% (95% CI 74.6-87.8%) in diagnosing septated pleural effusion. Thoracic ultrasound exhibits superior sensitivity and specificity compared to enhanced chest CT in diagnosing septated pleural effusions. Therefore, chest ultrasound is highly recommended as an adjunct for determining septated pleural effusion.

Infective Pleural Effusions-A Comprehensive Narrative Review Article

Infective pleural effusions are mainly represented by parapneumonic effusions and empyema. These conditions are a spectrum of pleural diseases that are commonly encountered and carry significant mortality and morbidity rates reaching upwards of 50%. The causative etiology is usually an underlying bacterial pneumonia with the subsequent seeding of the infectious culprit and inflammatory agents to the pleural space leading to an inflammatory response and fibrin deposition. Radiographical evaluation through a CT scan or ultrasound yields high specificity and sensitivity, with features such as septations or pleural thickening indicating worse outcomes. Although microbiological yields from pleural studies are around 56% only, fluid analysis assists in both diagnosis and prognosis by evaluating pH, glucose, and other biomarkers such as lactate dehydrogenase. Management centers around antibiotic therapy for 2-6 weeks and the drainage of the infected pleural space when the effusion is complicated through tube thoracostomies or surgical intervention. Intrapleural enzymatic therapy, used to increase drainage, significantly decreases treatment failure rates, length of hospital stay, and surgical referrals but carries a risk of pleural hemorrhage. This comprehensive review article aims to define and delineate the progression of parapneumonic effusions and empyema as well as discuss pathophysiology, diagnostic, and treatment modalities with aims of broadening the generalist's understanding of such complex disease by reviewing the most recent and relevant high-quality evidence.

Effects of inhaled beclomethasone dipropionate/formoterol fumarate/glycopyrronium on diaphragmatic workload and lung function in uncontrolled asthma: a case report

Beclomethasone dipropionate/formoterol fumarate/glycopyrronium (BDP/FF/G) single inhaler extrafine triple therapy is effective for the treatment of uncontrolled asthma. Nevertheless, there is a lack of data about the use of diaphragmatic ultrasonography to monitor adult asthmatics while they are receiving inhaled treatment. We took into consideration a 78-year-old woman complaining of asthma, treated with inhaled corticosteroid/long-acting β2-adrenergic agonist (ICS/LABA), characterized by an asthma control questionnaire-5 (ACQ-5) score and a lung function test suggestive of uncontrolled asthma. Moreover, a diaphragmatic ultrasound showed signs of high diaphragm workload. Because of these findings, we proposed to our patient a shift toward triple inhaled therapy with BDP/FF/G, and she underwent a second evaluation after 7 days of treatment. Improvements in the diaphragmatic ultrasound parameters, lung function test, and ACQ-5 score were found. In particular, we detected a reduction of thickening fraction (TF), and a normalization of the other diaphragmatic measures, indicative of a decrease in diaphragmatic workload. To our knowledge, this is the first literature report showing concomitant improvements of both lung function tests and diaphragmatic ultrasonography parameters, observed in an adult patient with uncontrolled asthma after short-term treatment with the single inhaler triple therapy BDP/FF/G.

Novel Insights from Clinical Practice Autologous Blood Patch Pleurodesis and Endobronchial Valves for Management of Persistent Air Leaks in Two Cases of Tuberculosis

INTRODUCTION

Pulmonary infections, such as tuberculosis, can result in numerous pleural complications including empyemas, pneumothoraces with broncho-pleural fistulas, and persistent air leak (PAL). While definitive surgical interventions are often initially considered, management of these complications can be particularly challenging if a patient has an active infection and is not a surgical candidate.

CASE PRESENTATION

Autologous blood patch pleurodesis and endobronchial valve placement have both been described in remedying PALs effectively and safely. PALs due to broncho-pleural fistulas in active pulmonary disease are rare, and we present two such cases that were managed with autologous blood patch pleurodesis and endobronchial valves.

CONCLUSION

The two cases presented illustrate the complexities of PAL management and discuss the treatment options that can be applied to individual patients.

Successful Interventional Treatment of Pyopneumothorax Caused by Streptococcus constellatus Associated with Hashimoto's Thyroiditis: A Case Report and Literature Review

Background

Streptococcus constellatus rarely causes pyopneumothorax, which is a serious state and requires a surgery. However, not every patient can tolerate surgery and individualized solutions are needed. Furthermore, many known situations are risk factors of S. constellatus infection, but S. constellatus pyopneumothorax associated with Hashimoto's thyroiditis has not been reported.

Case Presentation

We present the case of a 74-year-old male with multiple encapsulated pyopneumothorax caused by S. constellatus. Given his respiratory failure, we provided two-stage percutaneous right empyema radiography for catheter drainage in the radiology interventional department instead of surgery. Moreover, an occult Hashimoto's thyroiditis was discovered in the patient, which was possibly associated with S. constellatus pyopneumothorax. Levothyroxine was administered to improve his situation.

Conclusion

To our knowledge, it is the first case described in this context. We provided an alternative treatment for S. constellatus encapsulated pyopneumothorax in patient who might not tolerate surgery. We also revealed the possible relationship between S. constellatus pyopneumothorax and Hashimoto's thyroiditis.

Comparative analysis of five etiological detecting techniques for the positive rates in the diagnosis of tuberculous granuloma

Purpose

To examine the relationship between the positive rate and types of necrosis in pathological examinations of tuberculosis granulomas with necrosis, to improve the detection rate of positive cases.

Methods

Specimens from 381 patients were collected in Wuhan Pulmonary Hospital from Jan 2022 to Feb 2023. The samples were examined using various methods such as AFB smear microscopy, mycobacterial culture, PCR, SAT-TB, and X-pert MTB/RIF rapid molecular detection.

Result

There were 3 types of necrosis. Including 270 cases of caseous necrosis, 30 cases of coagulation necrosis, and 76 cases of an abscess. Five cases were non-necrotizing granulomas.In the pathological specimen testing for tuberculosis, five detection techniques were used and their positive rates detected in descending order were X-pert, TBDNA, SAT-TB, tuberculosis culture, AFB. Comparison between different examinations in the group: X-pert had the highest positive rate in each group, and it was significantly higher than TBDNA (P < 0.01) in caseous necrosis specimens. Compared with the same examination between the groups, the detection rates of X-pert and TBDNA in abscess and caseous necrosis specimens were significantly higher than in coagulation necrosis specimens (P < 0.01).

Conclusion

The positive rates of the five etiological detection techniques in tuberculous granuloma with different types of necrosis were quite different. The specimens of caseous necrosis or abscess could be selected for detection, and X-pert had the highest positive rate.

Management of hemorrhagic pleural effusion with intrapleural streptokinase in a patient on peritoneal dialysis and dual antiplatelet therapy

Key Clinical Message

Intrapleural streptokinase can be an option for loculated hemorrhagic pleural effusion among patients receiving CAPD and under DAPT. Its use can be individualized based on risk benefit analysis by the treating clinician.

Abstract

Pleural effusion is seen in up to 10 percent of patients on peritoneal dialysis (PD). A hemorrhagic pleural effusion is a diagnostic dilemma and a therapeutic challenge. We report a complicated case of 67 years old man with end stage renal disease, with coronary artery disease and stent in situ under dual antiplatelet therapy and continuous ambulatory peritoneal dialysis. The patient presented with left-sided loculated hemorrhagic pleural effusion. He was managed with intrapleural streptokinase therapy. His loculated effusion resolved without any local and systemic bleeding manifestations. Therefore, in poor resource settings, Intrapleural streptokinase can be an option for loculated hemorrhagic pleural effusion among patients receiving CAPD and under DAPT. Its use can be individualized based on risk benefit analysis by the treating clinician.

Interventional pulmonology techniques in lung transplantation

Lung transplantation is a key therapeutic option for several end-stage lung diseases. Interventional pulmonology techniques, mostly bronchoscopy, play a key role throughout the whole path of lung transplantation, from donor evaluation to diagnosis and management of post-transplant complications. We carried out a non-systematic, narrative literature review aimed at describing the main indications, contraindications, performance characteristics and safety profile of interventional pulmonology techniques in the context of lung transplantation. We highlighted the role of bronchoscopy during donor evaluation and described the debated role of surveillance bronchoscopy (with bronchoalveolar lavage and transbronchial biopsy) to detect early rejection, infections and airways complications. The conventional (transbronchial forceps biopsy) and the new techniques (i.e. cryobiopsy, biopsy molecular assessment, probe-based confocal laser endomicroscopy) can detect and grade rejection. Several endoscopic techniques (e.g. balloon dilations, stent placement, ablative techniques) are employed in the management of airways complications (ischemia and necrosis, dehiscence, stenosis and malacia). First line pleural interventions (i.e. thoracentesis, chest tube insertion, indwelling pleural catheters) may be useful in the context of early and late pleural complications occurring after lung transplantation. High quality studies are advocated to define endoscopic standard protocols and thus help improving long-term prognostic outcomes of lung transplant recipients.