Pleural empyema

Efficacy and safety of intrapleural streptokinase in tubercular empyema thoracis - old wine in new wineskin

Tubercular empyema thoracis continues to be one of the leading causes of morbidity in low-income countries. Despite antitubercular therapy (ATT) and thoracostomy, empyema drainage is hampered by multiple septations, loculations, debris, and blood clots leading to complications. In a comparative experimental study to estimate the efficacy and safety of intrapleural streptokinase (IPSTK) in tubercular empyema, 30 cases of chronic multiloculated tubercular empyema were compared by radiological improvement by chest radiography, duration and volume of fluid drained, and degree of dyspnoea according to the modified Borg scale, depending on whether streptokinase was used or not. The former scored on all counts; we therefore conclude that intrapleural streptokinase is a safe, efficacious intervention in tubercular empyema. It decreases morbidity and reduces the need for surgery.

Respiratory functional outcomes improvement with intervention in chronic empyema thoracis: a retrospective analysis

Introduction

Chronic pleural empyema is usually a consequence of in adequate treatment of acute pleural empyema. The incidence of tubercular and post-intervention empyema has increased in underdeveloped or developing countries adding to economic burden on the society. We have performed a retrospective analysis on role of intervention in chronic empyema to improve respiratory functional outcomes.

Methods

We retrospectively reviewed data of 115 patients of chronic tubercular and parapneumonic empyema thoracis to evaluate change in functional outcome parameters based on their treatment modalities during follow-up in department of surgery, King George's Medical University, Lucknow, India. Accordingly, four groups were made-group 1 (tube thoracostomy), group 2 (decortication by video-assisted thoracoscopic surgery (VATS)), group 3 (decortication by open thoracotomy), and group 4 (window thoracostomy followed by thoracomyoplasty).

Results

Significant improvement was noted in forced expiratory volume in one second (FEV1)% and forced vital capacity (FVC)% in all groups. In spirometry, percent change in mean FEV1 from pre-intervention to post-intervention was increase of 55.4%, 38.3%, 47.2, and 59.21% in group 1, group 2, group 3, and group 4 respectively, and percent change in mean FVC from pre-intervention to post-intervention was increase of 53.30%, 38.11%, 51.23, and 54.21% in group 1, group 2, group 3, and group 4 respectively.

Conclusion

Our study showed that a significant increase was observed in FVC and FEV1 from pre to post among all the groups. Comparable improvement of functional outcomes with non-operative intervention in properly selected patients can be achieved.

Infection of the pleural space

Parapneumonic effusions are common accompaniments of pneumonia that require proper management to prevent progression to empyema. Management decisions require thoughtful individualization of care because of the multiple factors that affect outcome; no one algorithmic approach exists for all patients. Basic principles of care, however, apply to all patients and center on the early detection of infected pleural fluid and the rapid completion of effective pleural drainage and lung re-expansion, when indicated to decrease morbidity and mortality.

Intrapleural fibrinolytic treatment of traumatic clotted hemothorax

STUDY OBJECTIVE

To evaluate the role of intrapleural fibrinolytic treatment (IPFT) in traumatic clotted hemothorax.

DESIGN AND PATIENTS

Between August 1995 and February 1997, 24 patients with traumatic clotted hemothorax were included. Streptokinase (SK), 250,000 IU, or urokinase (UK), 100,000 IU, diluted in 100 mL of saline solution was given daily. We administered 5.0+/-1.8 (range, 2 to 9) doses of SK or 6.25+/-5.97 (range, 2 to 15) doses of UK.

SETTING

Dicle University School of Medicine, Thoracic and Cardiovascular Surgery Department.

RESULTS

Complete response, which was defined as resolution of symptoms with complete drainage of fluid and no residual space radiographically, occurred in 15 (62.5%) patients. Partial response, which was defined as resolution of symptoms with a small pleural cavity, occurred in seven (29.2%) patients. Two patients (8.3%) required decortication; they were defined as nonresponders. The mean period of time between the diagnosis and fibrinolytic treatment (FT) was 11.65+/-6.38 (range, 4 to 25) days. There were no complications related to IPFT. There was no mortality during the course of IPFT.

CONCLUSION

The use of intrapleural fibrinolytic agents has resulted in resolution of clotted hemothorax with an overall success rate of 91.7%. We recommend that IPFT should be added to the algorithm for management of clotted hemothorax before proceeding with minithoracotomy or pleural decortication.

Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas

Acute multiloculated thoracic empyemas incompletely drained by tube thoracostomy alone usually require operation. To avoid a thoracotomy yet treat this difficult problem, intrapleural fibrinolytic agents were employed. Between April 1, 1990, and April 1, 1993, 13 consecutive patients presenting with a fibrinopurulent empyema were demonstrated to have incomplete drainage. To facilitate drainage, streptokinase, 250,000 units in 100 mL 0.9% saline solution (3 patients), or urokinase, 100,000 units in 100 mL 0.9% saline solution (10 patients), was instilled daily into the chest tube, and the tube was clamped for 6 to 12 hours followed by suction. This routine was continued daily for a mean of 6.8 +/- 3.7 days (range, 1 to 14 days) until resolution of the pleural fluid collection was demonstrated by computed chest tomography and clinical indications. This regimen was completely successful in 10 of 13 patients (77%), who had resolution of the empyema, eventual withdrawal of chest tubes, and no recurrence. Two patients, both pediatric liver transplant patients, had an initial good response but eventually required decortication. One patient with a good radiographic response became increasingly febrile during streptokinase therapy and underwent a thoracotomy, but no significant undrained fluid was found. This patient's continued fever was believed to be a streptokinase reaction. Urokinase was used subsequently. No treatment-related mortalities or complications occurred. Intrapleural fibrinolytic agents, especially urokinase, are safe, cost-effective means of facilitating complete chest tube drainage, thereby avoiding the morbidity of a major thoracotomy for 77% of a group of multiloculated empyema patients who traditionally would have required open surgical therapy.

Paediatric empyema thoracis in Zaria, Nigeria

From 1977 to 1986 at the Ahmadu Bello University Hospital in Zaria, the diagnosis of empyema thoracis was made in 150 children representing 0.35% of all paediatric admissions. Empyema was a complication of pneumonia in 98 of 100 cases reviewed, of whom 70 were 3 years old or younger. There was no sex or side preference. Fifty-nine patients were severely ill on admission, with a mean symptom duration of 21 days. In many of them, anaemia, protein-energy malnutrition, measles and gastro-enteritis were present as associated illnesses. Staphylococcus aureus was the most frequent bacterial isolate (39%), of which 83% of the cultures were sensitive to cloxacillin. Adequate rehydration, systemic antibiotics and tube thoracostomy drainage performed in 80 patients were more successful than repeated needle aspiration. Fourteen of the children died, six absconded and 80 were discharged home.

Use of intrapleural streptokinase in the treatment of thoracic empyema

The incidence of pleural effusions in bacterial pneumonia may exceed 40%, a factor that may be related to increased morbidity and mortality. Options in the treatment of complicated pleural effusions or empyema, when unresponsive to closed tube drainage, include repositioning of the indwelling tube thoracostomy or insertion of additional chest tubes, instillation of intrapleural streptokinase, and surgical intervention. The authors describe the course of three patients wherein the use of intrapleural streptokinase was efficacious in effecting prompt drainage of previously inadequately evacuated empyema, thus eliminating the necessity for further invasive intervention.

Successful treatment of empyema thoracis with polymethylmethacrylate antibiotic-impregnated beads in the guinea pig

Two hundred nine Duncan-Harley guinea pigs had intrathoracic inoculation with 10(8) Staphylococcus aureus, accompanied by blood and umbilical tape. One hundred fifty-two animals were excluded because of clinical recovery, early death, or complications related to intrathoracic polymethylmethacrylate (PMMA) bead placement. The remaining 57 animals had clinical signs of empyema thoracis and were the subjects of this study. Group I animals (N = 24) served as the controls and had no therapy. Group II animals (N = 14) were treated by intrathoracic placement of placebo PMMA beads. Group III animals (N = 19) were treated by intrathoracic placement of tobramycin sulfate-impregnated PMMA beads. There were no differences between the groups in pleural reaction or pneumonia scores. These findings demonstrate a similar host response to the established infection. Group III, however, had a higher sterilization rate than Groups I and II (p less than 0.05), a finding underlining the therapeutic effect of tobramycin-treated PMMA beads. We conclude that intrathoracic local antimicrobial therapy with slow-release tobramycin-impregnated PMMA beads may enhance empyema treatment by increasing the rate of local sterilization. More experiments are necessary to assess the efficacy of this potentially important therapeutic arm for the treatment of thoracic empyema.

Streptokinase in a loculated pleural effusion. Effectiveness determined by site of instillation

A patient with a large loculated pleural effusion had streptokinase instilled into the loculation, and this was ineffective; however, when the same amount of streptokinase was instilled into the space around the loculation, there was rapid lysis of the loculation, resulting in the drainage of purulent fluid through the chest tube.

Experimental aerobic-anaerobic thoracic empyema in the guinea pig

The clinical and pathological features of experimental aerobic-anaerobic thoracic empyema in the Duncan-Harley guinea pig are described. Thoracic empyema development and early death (less than 14 days after bacterial inoculation) were noted after various concentrations and species were inoculated into the pleural space with a piece of umbilical tape, which was used as a cofactor. The effect of concomitant hemothorax was also tested. Gram-negative infection was found to have a more virulent course than Gram-positive infection in the thoracic cavity. Moreover, these findings support the thesis that intrathoracic inoculation of anaerobic bacteria, even in combination with other anaerobic species, fails to produce clinical empyemas. However, anaerobic bacteria appear to enhance synergistically the virulence of sublethal and subempyema-forming concentrations of aerobic bacteria such as Staphylococcus aureus and Escherichia coli.

Open window thoracostomy and plastic surgery with muscle flaps in the treatment of chronic empyema

Open window thoracostomy (OWT) and plastic surgery using myocutaneous flaps of extrathoracic muscles, was done in nine patients with chronic empyema, after conventional therapy had failed. In all these patients, the pleural cavity and bronchopleural fistulas, when present, closed within eight to 61 days (mean 30), after the second stage of surgery comprising the myoplasty; this in turn was performed between three to seven (mean 3.0) months after the OWT. All patients were considered cured with a minimal deformity of the chest wall. The final scar had an acceptable cosmetic appearance.

The management of empyema thoracis by thoracoscopy and irrigation

A technique of irrigation for the management of empyema is described. Initial thoracoscopy under general anesthesia enabled full debridement and division of loculi within the empyema cavity under direct vision. Irrigation with two tubes was instituted until three consecutive cultures of irrigation fluid became sterile; then the chest drains were removed. The results in 12 patients are presented. Using this method, irrigation was required for an average of 14 days and chest drains were removed after an average of 20 days. Patients remained in the hospital for an average of 4.8 weeks. Tuberculous empyema was not found to be a contraindication to the irrigation technique.

Major hemorrhage following administration of intrapleural streptokinase

Severe spontaneous bleeding has not been reported to complicate therapy with intrapleural streptokinase (SK). Recent data have demonstrated intrapleural SK to be devoid of systemic fibrinolytic effect. This report presents a patient who suffered major hemorrhage following the administration of 500,000 units of SK intrapleurally.

Serious infections caused by Streptococcus milleri

Viridans streptococci continue to be the most common etiologic agents in bacterial endocarditis. The spectrum of diseases other than endocarditis caused by these organisms, however, has received sparse attention. Moreover, little clinical information is available concerning the individual viridans streptococcal species. During the 16 months of this study, one species of viridans streptococci, Streptococcus milleri, caused a surprising number of clinically significant suppurative infections. Clinical syndromes included the following: abscesses, 10 cases; peritonitis, four cases; endocarditis, three cases; cholangitis, empyema and cellulitis, one case each. A gastrointestinal source was apparent in eight of these 20 cases. Review of 58 cases of viridans streptococcal endocarditis demonstrated that although Strep. milleri was an infrequent cause of endocarditis, this species was associated with an unusual frequency of suppurative complications. Our experience suggests that Strep. milleri may be more commonly associated with serious suppurative infections than other viridans streptococci and that species identification may be a clinically useful procedure.

Pleural empyema in a newborn infant. An unusual cause of respiratory distress

In a 2-day-old baby with symptoms of respiratory distress a right-sided pleural empyema caused by haemolytic streptococci was found. Possible sources of infection are discussed. The mother had purulent discharge from a tooth a few weeks before delivery, and this may have been the focus. The baby was treated with pleural drainage and ampicillin with good result.