Management of parapneumonic effusions

Complications in community acquired pneumonia: magnitude of problem, risk factors, and management in pediatric age

Introduction: In the last decades, the large use of several effective vaccines has dramatically reduced the incidence of community acquired pneumonia (CAP) in infants and children. Moreover, the availability of new antibiotics effective against emerging resistant strains of bacteria has greatly improved the early and long-term prognosis of this disease.Areas covered: The aim of this manuscript is to evaluate the burden of complicated CAP in pediatric age and to discuss its appropriate management.Expert opinion: Complicated CAP remains a problem for children in industrialized and developing countries. A larger use of lung ultrasonography (US) as first diagnostic approach could significantly improve early identification of cases at higher risk of complications. Difficult to solve, is the problem of the use of an antibiotic therapy able to assure adequate control in all the CAP cases, including those at high risk of or with already established complications. All these findings reveal that control of the incidence of complicated CAP remains difficult and will not be significantly changed in the next few years. Any attempt to improve complicated CAP management must be made. Consensus documents on better definition of the use of corticosteroids, fibrinolytic agents, and interventional procedures (including surgery) can allow us to reach this goal.

The Use of a Novel Quantitative Marker of Echogenicity of Pleural Fluid in Parapneumonic Pleural Effusions

Background

Thoracic ultrasound is an essential tool in the daily clinical care of pleural effusions and especially parapneumonic pleural effusions (PPEs), in terms of diagnosis, management, and follow-up. Hypoechogenicity index (HI) is a quantitative marker of pleural fluid echogenicity. We aimed to examine associations of HI with pleural inflammation in patients with PPE.

Methods

All patients included underwent a thoracic ultrasound with HI determination at the first day of their admission for a PPE. Thoracentesis was performed in all patients. Demographics, laboratory measurements, and clinical data were collected prospectively and recorded in all subjects.

Results

Twenty-four patients with PPE were included in the study. HI was statistically significantly correlated with intensity of inflammation as suggested by pleural fluid LDH (p < 0.001, r = −0.831), pleural fluid glucose (p=0.022, r = 0.474), and pleural fluid pH (p < 0.001, r = 0.811). HI was correlated with ADA levels (p=0.005, r = −0.552). We observed a statistically significant correlation of HI with pleural fluid total cell number (p < 0.001, r = −0.657) and polymorphonuclears percentage (p=0.02, r = −0.590), as well as days to afebrile (p=0.046, r = −0.411), duration of chest tube placement (p < 0.001, r = −0.806), and days of hospitalization (p=0.013, r = −0.501). Discussion. HI presents a fast, easily applicable, objective, and quantitative marker of pleural inflammation that reliably reflects the intensity of pleural inflammation and could potentially guide therapeutic management of PPE.

Management of Pleural Effusions in the Emergency Department

BACKGROUND

In symptomatic patients, admitted in emergency department for acute chest pain and dyspnea, who require an urgent treatment, a rapid diagnosis and prompt management of massive pleural effusion or hemothorax can be lifesaving.

AIM

The aim of this review was to summarize the current diagnostic and therapeutic approaches for the management of the main types of pleural effusions that physicians can have in an emergency department setting.

METHODS

Current literature about the topic was reviewed and critically reported, adding the experience of the authors in the management of pleural effusions in emergency settings.

RESULTS

The paper analyzed the main types of pleural effusions that physicians can have to treat. It illustrated the diagnostic steps by the principal radiological instruments, with a particular emphasis to the role of ultrasonography, in facilitating diagnosis and guiding invasive procedures. Then, the principal procedures, like thoracentesis and insertion of small and large bore chest drains, are indicated and illustrated according to the characteristics and the amount of the effusion and patient clinical conditions.

CONCLUSION

The emergency physician must have a systematic approach that allows rapid recognition, clinical cause identification and definitive management of potential urgent pleural effusions.

Open pleural decortication for the late stage empyema thoracis in children: a retrospective observational study from a tertiary hospital of eastern Nepal

The management of late-stage empyema thoracis requires surgical intervention. We performed a retrospective descriptive analysis of open pleural decortication for late stage empyema thoracis in 55 children (age ≤ 15 years; median age = 6 years; age range = 1-15 years; 40 [72.7%] boys) over 42 months. The median time to thoracotomy from the onset of symptoms was 24 days, and the median duration of hospital stay before and after surgery was 15 and 4 days, respectively. Three (5.5%) patients had necrotising pneumonia, requiring debridement; 4 (7.3%) patients had superficial surgical site infection; 12 (21.8%) patients had perioperative pus culture positive for bacteria; and 3 (5.5%) patients had tubercular aetiology. There was no operative mortality. At median follow-up of 18 months, all patients are in good general health. Open pleural decortication leads to rapid resolution of symptoms and reduces hospital stay in paediatric late-stage empyema thoracis.

Features of Parapneumonic Effusions

Introduction: Parapneumonic effusions, as a complication of community-acquired pneumonia (CAP), usually have a good course, but they sometimes progress into complicated parapneumonic effusion (CPPE) and empyema, thus becoming a significant clinical problem.

Aim: To review clinical and radiological features, as well as diagnostic and therapeutic options in parapneumonic effusions.

Material and methods: The analysis included 94 patients with parapneumonic effusion hospitalized at the University Infectious Diseases Clinic in Skopje during a 4 year period. Out of 755 patients with CAP, 175 (23.18%), had parapneumonic effusion. Thoracentesis was performed in 94 (53.71%) patients, 50 patients were with uncomplicated parapneumonic effusions (UCPPE) and 44 with complicated parapneumonic effusions (CPPE).

Results: More patients (59.57%) were male; the average age was 53.82±17.5 years. The most common symptoms included: fever (91; 96.81%), cough (80; 85.11%), pleuritic chest pain (68; 72.34%), dyspnea (65; 69.15%). Alcoholism was the most common comorbidity registered in 12 (12.77%) patients. Macroscopically, effusion was yellow and clear in most cases (36; 38.29%). Localization of pleural effusion was often in the left costophrenic angle (53; 56.38%) and ultrasonographic non-septated complex. Between the two groups of effusions there was a significant difference between the ERS, WBC and CRP in serum and CRP in pleural fluid. Statistical difference existed in terms of days of hospitalization with a longer hospital stay for patients with CPPE (p <0.0001).

Conclusion: Patients with parapneumonic effusion have the symptoms of acute respiratory infection and frequent accompanying diseases. Future diagnostic and therapeutic treatment depends on pleural fluid features and imaging lung findings.

Trends in the Incidence, Etiology, Treatment, and Outcomes of Pleural Infections in Adults Over a Decade in a Finnish University Hospital

BACKGROUND AND AIMS

The aim of the study was to ascertain changes in the incidence, etiology, treatment, and outcomes of pleural infections over a decade in a Finnish University Hospital.

MATERIALS AND METHODS

All patients treated for pleural infections in Tampere University Hospital during 2000-2008 and 2012-2016 were included. The incidence rates and the epidemiologic data and medical history of patients, etiology of infection, and treatment trends and outcomes were compared between the cohorts.

RESULTS

The incidence of pleural infections increased from 4.4 during 2000-2008 to 9.9 during 2012-2016 per 100.000 patient-years, p < 0.001. The patients in the latter group were older, 63 versus 57 years, p = 0.001, and the prevalence of chronic lung disease, hypertension, heart failure, dyslipidemia, and immunosuppressive medication were higher. The causes of infection remained similar and pneumonia accounted for 70% of all cases. The identification rate of the microbe pathogens increased from 49% to 64%, p = 0.002, while the distribution of identified pathogens was unchanged. More patients in the latter cohort were treated operatively, 88.3% versus 80.9%, p = 0.005, and, in these, the proportion of thoracoscopic surgery was higher, 57.4% versus 8.0%, p < 0.001, and the delay to surgery shorter, 5 versus 7 days, p < 0.001. Radiologic outcomes were similar. The 30-day mortality rate was 3.1% during 2000-2008 and 5.1% during 2012-2016, p = 0.293.

CONCLUSION

The overall incidence of pleural infections has increased significantly while the causes of pleural infections and the distribution of pathogens remain unchanged. Contemporary patients are older with higher prevalence of comorbidities and more frequently undergo thoracoscopic surgery.

When should parapneumonic pleural effusions be drained in children?

Pneumonia is an important health problem in children, and parapneumonic pleural effusion (PPE) is a frequent complication. There is no standard strategy for treating PPE, reflected in the few international guidelines that have been published on the issue. Compared to adults, there is no consensus on the utility of pleural fluid analysis in paediatric PPE. This is because of the lack of good evidence either in favour or against it and the risks of procedural sedation for acquiring pleural fluid for analysis to guide management. In this paper we provide a succinct review of the different approaches to the management of PPE, including diagnosis, pleural fluid analysis (Light's criteria) and treatment, both medical and surgical.

A review of the management of complex para-pneumonic effusion in adults

A complex para-pneumonic effusion is a descriptive term for exudative effusions, which complicate or are likely to complicate the anatomy of the pleural space after pneumonia. We performed an online search was performed using the resources PubMed and Google Scholar to provide an update on the management of such effusions based on review of published literature. Search terms including pleural effusion (PE), parapneumonic effusion, and empyema were used. Relevant studies were identified and original articles were studied, compared and summarized. References in these articles were examined for relevance and included where appropriate. Studies involving pediatric patients were excluded. Management of para-pneumonic PE has changed tremendously over the last decade. As we accumulate more evidence in this area, approach to pleural fluid drainage is becoming more specific and guideline based. An example of a practice changing study in this aspect is the Multi-center Intrapleural Streptokinase Trial (MIST) 2 trial which demonstrated that a combination of intra-pleural tPA and DNAse improved outcomes in pleural infections compared to DNase or t-PA alone. More randomized control trials are needed to describe the role of surgical techniques like VATS (video-assisted thoracoscopic surgery) when MIST 2 protocol fails; this combination has revolutionized the management of empyema in recently.

Repeated therapeutic thoracentesis to manage complicated parapneumonic effusions

PURPOSE OF REVIEW

In complicated parapneumonic effusion (CPPE), antibiotics and evacuation of the infected pleural fluid are mandatory. The first-line evacuation treatment is still controversial. The aim of this article is to highlight the usefulness of repeated therapeutic thoracentesis (RTT) as a first-line treatment.

RECENT FINDINGS

In the most recent study on RTT in CPPE, disposable pleural needles were used and the median number of thoracentesis was 3. The success rate was 81%, and only 4% of the patients were referred for thoracic surgery. The 1-year survival rate was 88%. On multivariate analysis, the observation of microorganisms in the pleural fluid after Gram staining and first thoracentesis volume at least 450 ml was associated with a higher risk of RTT failure. RTT is less invasive and can target different loculated pleural collections. Patients are less confined to beds between each procedure, and could even be ambulatory managed. The use of intrapleural fibrinolytics in association with DNase could most likely enhance the efficacy of RTT.

SUMMARY

RTT is efficient and well tolerated in the management of CPPE, including pleural empyema, and could be proposed as a first-line therapy for CPPE. This technique could be used in association with intrapleural fibrinolytics and DNase.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.

Management of pleural effusion, empyema, and lung abscess

Pleural effusion is an accumulation of fluid in the pleural space that is classified as transudate or exudate according to its composition and underlying pathophysiology. Empyema is defined by purulent fluid collection in the pleural space, which is most commonly caused by pneumonia. A lung abscess, on the other hand, is a parenchymal necrosis with confined cavitation that results from a pulmonary infection. Pleural effusion, empyema, and lung abscess are commonly encountered clinical problems that increase mortality. These conditions have traditionally been managed by antibiotics or surgical placement of a large drainage tube. However, as the efficacy of minimally invasive interventional procedures has been well established, image-guided small percutaneous drainage tubes have been considered as the mainstay of treatment for patients with pleural fluid collections or a lung abscess. In this article, the technical aspects of image-guided interventions, indications, expected benefits, and complications are discussed and the published literature is reviewed.

Pleural disease in the emergency department

Emergency department presentations of pleural-based diseases are common, with severity ranging from mild to life threatening. The acute assessment, diagnosis, and treatment of pleural disease are critical as urgent invasive maneuvers such as thoracocentesis and thoracostomy may be indicated. The emergency physician must have a systematic approach to these conditions that allows for rapid recognition, diagnosis, and definitive management. This article focuses on nontraumatic pleural disease, including diagnostic and treatment considerations of pleural effusion, empyema, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pediatric pneumothorax, spontaneous hemothorax, and spontaneous tension pneumothorax.

Thoracoscopic management of empyema thoracis

Appropriate management of empyema thoracis is dependent upon a secure diagnosis of the etiology of empyema and the phase of development. Minimal access surgery using video-assisted thoracoscopy (VATS) is one of many useful techniques in treating empyema. Complex empyema requires adjunctive treatment in addition to VATS.

Diagnostic accuracy of biomarkers of oxidative stress in parapneumonic pleural effusions

BACKGROUND

The imbalance between oxidants and antioxidants is referred to as oxidative stress and has been associated with various respiratory disorders. The aim of this study was the assessment of 8-isoprostane (8-iso-PGF(2α)) and Cu/Zn superoxide dismutase (Cu/Zn SOD) in exudative pleural effusions in order to examine the diagnostic accuracy of these markers in the differentiation between complicated and uncomplicated parapneumonic effusions.

METHODS

The study included 214 consecutive patients with pleural effusions [68 parapneumonic (31 uncomplicated parapneumonic, 20 complicated parapneumonic, 17 empyemas), 24 tuberculous, 88 malignant and 34 transudates]. 8-Isoprostane and Cu/Zn SOD were determined by ELISA in pleural fluid and serum.

RESULTS

Parapneumonic effusions were characterized by higher pleural fluid 8-isoprostane levels compared to transudative, malignant and tuberculous effusions. Pleural fluid Cu/Zn SOD levels were lower in transudates, while serum levels were higher in transudative compared to all exudative pleural effusions. Both pleural fluid 8-isoprostane and Cu/Zn SOD were higher in complicated parapneumonic effusions and empyemas compared to uncomplicated parapneumonic effusions. Pleural fluid 8-isoprostane was the most accurate test to differentiate between complicated and uncomplicated parapneumonic pleural effusions with a sensitivity of 100% and a specificity of 58·1% at a cut-off point of 35·1 (AUC = 0·848).

CONCLUSIONS

Pleural fluid 8-isoprostane and Cu/Zn SOD may provide useful information for the differentiation between uncomplicated and complicated parapneumonic effusions and empyemas.

Empyema thoracis: a clinical study

BACKGROUND:

Empyema thoracis is a disease that, despite centuries of study, still causes significant morbidity and mortality.

AIM:

The present study was undertaken to study the age-sex profile, symptomatology, microbiologic findings, etiology and the management and treatment outcome in a tertiary care hospital.

SETTINGS AND DESIGN:

A prospective study of empyema thoracis was conducted on 40 consecutive patients with empyema thoracis admitted to the tuberculosis and chest diseases ward of a teaching hospital.

MATERIALS AND METHODS:

The demographic data, clinical presentation, microbiological findings, etiology, the clinical course and management were recorded as per a planned pro forma and analyzed.

RESULTS:

The peak age was in the range of 21-40 years, the male-to-female ratio was 3.4:1.0 and the left pleura was more commonly affected than the right pleura. Risk factors include pulmonary tuberculosis, chronic obstructive pulmonary diseases, smoking, diabetes mellitus and pneumonia. Etiology of empyema was tubercular in 65% cases and nontubercular in 35% cases. Gram-negative organisms were cultured in 11 cases (27.5%). Two patients received antibiotics with repeated thoracentesis only, intercostal chest tube drainage was required in 38 cases (95%) and more aggressive surgery was performed on 2 patients. The average duration for which the chest tube was kept in the complete expansion cases was 22.3 days.

CONCLUSION:

It was concluded that all cases of simple empyema with thin pus and only those cases of simple empyema with thick pus where size of empyema is small should be managed by aspiration/s. Cases failed by the above method, all cases of simple empyema with thick pus and with moderate to large size of empyema and all cases of empyema with bronchopleural fistula should be managed by intercostal drainage tube connected to water seal. It was also observed that all cases of empyema complicated by bronchopleural fistula were difficult to manage and needed major surgery.

Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema

BACKGROUND

Pleural effusions and empyema may complicate lower respiratory tract infections. Treatment of these collections of pus includes surgical drainage and the use of intra-pleural fibrinolysis to break down fibrin bands that may cause loculation.

OBJECTIVES

To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated para pneumonic effusions and empyema to reduce mortality or the need for subsequent surgical debridement of the pleural space.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in November 2006.

SELECTION CRITERIA

All studies in the review were Randomised Controlled Trials in adult patients with post-pneumonic empyema or complicated parapneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) via an intercostal chest drain (ICD) versus control, or a comparison of the two agents.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data . Study authors were contacted for further information.

MAIN RESULTS

Seven studies met the eligibility criteria of the review, recruiting 761 participants. The only consistent end points in all trials were treatment failure, as gauged by the requirement for additional intervention including surgery or death. In studies where patients had either loculation and empyema, there was no significant difference in the risk of death with fibrinolytics (RR 1.08; 95% CI 0.69 to 1.68). When treatment failure was considered as surgical intervention, fibrinolytics reduced the risk of this outcome (RR 0.63; 95% CI 0.46 to 0.85), but there is discordance between earlier positive studies and the more recent negative study by Maskell.

AUTHORS' CONCLUSIONS

Intrapleural fibrinolytic therapy confers significant benefit in reducing the requirement for surgical intervention for patients in the early studies included in this review but not in the more recently published Maskell study. The reasons for this difference are uncertain. Separate subgroup analysis of proven loculated/septated effusions from the available data in our meta-analysis suggests a potential overall treatment benefit with fibrinolytics, but these results should be treated with caution as the data are incomplete and the benefit is not significant in the subgroup of high quality trials (Cochrane Grade A). Intrapleural fibrinolytics have not been shown to significantly increase adverse events, but the confidence interval is too wide to firmly exclude this possibility.

Sonographic diagnosis and follow-up of pneumonia: a prospective study

BACKGROUND

Although transthoracic ultrasound offers several important advantages as diagnostic imaging technique in pleural and pulmonary conditions, its significance for the diagnosis and monitoring of pneumonia has yet to be established.

OBJECTIVES

To identify sonographic features associated with pneumonia at admission and during the course of the disease under treatment.

METHODS

Thirty patients (12 females, 18 males; median age 65.5 years) with X-ray-proven pneumonia underwent transthoracic sonography (TS) on day 0, between days 1 and 3, 4 and 7, 8 and 14, 15 and 21, and after day 21. TS was assessed according to: number, location, shape, echogenicity, echotexture, echostructure, breath-depending movement, size of pneumonic lesions, bronchoaerogram, fluid bronchogram, superficial fluid alveologram, necrotic areas, vascularity and incidence of local and/or basal pleural effusion.

RESULTS

Thirty-three pneumonic infiltrates were eligible for analysis in 30 patients. In 57% (17/30), the likely pathogenic microorganism was identified. Pneumonia was recognized as a hypoechoic area of varying size (mean size between 33.7 x 9.38 and 91.2 x 45.3 mm) and shape, with irregular and blurred margins along with a nonhomogeneous echotexture. The most characteristic feature was a positive bronchoaerogram (32/33). Sixty-one percent (20/33) revealed basal and 9% (3/33) local effusion. During follow-up, lesions decreased in size or disappeared (30/33) or decreased in number (4/9). The bronchoaerogram became less pronounced (13/32), basal pleural effusion either diminished (7/20) or dissipated (7/20), as did localized effusion (3/3). In 30 cases, the course of pneumonia was comparable using X-ray and TS.

CONCLUSIONS

TS is a noninvasive technique for the diagnosis and follow-up of patients with pneumonia.

Identification with MRI of the pleura as a major site of the acute inflammatory effects induced by ovalbumin and endotoxin challenge in the airways of the rat

Inflammatory effects in the rat lung have been investigated, non-invasively by MRI, at early time points (3 and 6 h) after ovalbumin (OA) or endotoxin (LPS) challenges. Six hours after challenge with OA, a strong, even inflammatory signal was present around the periphery of the lung in a region corresponding to the pleura. Histological analysis confirmed the presence of marked edema associated with the pleural cavity of OA-treated animals. Lower levels of pleural edema were observed in MRI and histological evaluation of LPS-treated animals and no abnormality was observed in actively sensitized and naïve, saline-treated groups. Diffuse edematous signals were detected in the lung 3 and 6 h after challenge with OA or LPS; the signal volumes were larger at both time points following OA instillation. Bronchoalveolar lavage (BAL) fluid analysis performed 6 h after challenge revealed increased levels of protein and greater cellular activation in OA- than in LPS-treated animals. Furthermore, increased levels of peribronchial edema were found by histology 6 h after OA. BAL fluid and histological assessments demonstrated that the inflammatory signals were due to edema and not mucus as no significant changes in BAL mucin concentrations or differences in goblet cells were identified between OA or LPS challenge and their respective vehicle groups. Our data show that MRI is able to detect, non-invasively, inflammatory signals in both the lung and the pleura in spontaneously breathing animals, highlighting its potential to study the consequences of pulmonary insults on both sites.

Childhood Parapneumonic Effusions

STUDY OBJECTIVES

Biochemical and inflammatory markers in pleural inflammation were evaluated in pediatric cases of parapneumonic effusions, and interleukin (IL)-8 and tumor necrosis factor (TNF)-alpha concentrations were tested for possible differentiation of the complicated nature of effusions.

PATIENTS

Twenty-eight patients (12 female) who were admitted to Hacettepe University Childrens' Hospital over a 2-year period were included in the study.

MEASUREMENTS

Patients were grouped according to the stage of effusion. Pleural fluid leukocyte count, neutrophil ratio, pH, protein, glucose levels, lactate dehydrogenase (LDH) levels, TNF-alpha levels, IL-8 levels, and nitrite levels were obtained.

RESULTS

Of these patients, 13 had empyema, 10 had complicated parapneumonic effusions (CPEs), and 5 had uncomplicated parapneumonic effusions (UPEs). Protein and glucose levels decreased, leukocyte count, neutrophil ratio, TNF-alpha levels, nitrite levels, and IL-8 levels increased progressively as the stage of the disease progressed. IL-8 levels, but not TNF-alpha and nitrite levels, were statistically different among the groups. IL-8, TNF-alpha, and nitrite levels all correlated positively with each other (all p < or = 0.001), and pH correlated negatively with these markers (all p < or = 0.001). At a cutoff value of 76.6 pg/mL, TNF-alpha discriminated between CPEs and UPEs with a sensitivity of 50%, a specificity of 100%, and an accuracy of 78%. At a cutoff value of 701.6 pg/mL, IL-8 differentiated CPE and UPE with a sensitivity of 80%, a specificity of 80%, and an accuracy of 86%.

CONCLUSIONS

Progressive changes in common biochemical markers (ie, pH, and protein, glucose, and LDH levels) are interrelated during stages of pleural inflammation. IL-8 may be used as an alternative marker for discriminating between CPEs and UPEs in pediatric parapneumonic effusions.

Toracocentese esvaziadora com irrigação e uso de antimicrobiano intrapleural no tratamento do empiema

INTRODUÇÃO: O empiema é uma doença grave caracterizada classicamente pela presença de pus na cavidade pleural. Seu reconhecimento precoce exige tratamento imediato, porém ainda existe grande controvérsia em relação à melhor terapêutica. OBJETIVO: Analisar o tratamento do empiema através de toracocentese, irrigação do espaço pleural, e uso de antimicrobiano intrapleural. MÉTODO: Foram avaliados dezessete pacientes com diagnóstico de empiema pleural livre ou septado, no período de janeiro de 1999 a maio de 2000, nos quais foi realizada toracocentese esvaziadora, seguida de lavagem exaustiva da cavidade pleural com solução isotônica e administração intrapleural de agente antimicrobiano não irritante à pleura. RESULTADOS: Foram analisados 15 homens e 2 mulheres com idade média de 44 anos. Os sinais clínicos mais freqüentes foram febre, tosse produtiva, dor torácica e dispnéia. A causa mais comum foi pneumonia. Macroscopicamente, 12 pacientes apresentavam líquido pleural francamente purulento. O agente etiológico foi identificado em quatro casos (26,67%), sendo o mais frequente o Staphylococcus sp. Dois pacientes foram encaminhados para decorticação pulmonar e foram excluídos do estudo. O tempo médio de internação foi de 15,1 dias, sendo que três pacientes realizaram o protocolo ambulatorialmente. Não observamos recidiva com o método e todos os pacientes sobreviveram. CONCLUSÃO: Essa abordagem diminuiu a necessidade de outros procedimentos invasivos. Mostrou-se eficaz, segura e com baixa morbi-mortalidade em comparação com as demais modalidades terapêuticas.

Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema

BACKGROUND

Effusions and empyema may complicate lower respiratory tract infections. Loculation of fluid is a major problem with this condition and treatments have included surgical drainage and the use of intra-pleural fibrinolysis to break down fibrin bands that may cause loculation.

OBJECTIVES

To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated para pneumonic effusions and empyema.

SEARCH STRATEGY

The Cochrane Controlled Trials Register was initially searched for relevant RCT's. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in July 2003.

SELECTION CRITERIA

All studies in the review were Randomised Controlled Trials in adult patients with empyema or complicated para pneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) versus control or a comparison of the two.

DATA COLLECTION AND ANALYSIS

All identified studies were reviewed independently by two reviewer and all data collected. Reviews were scored according to the Cochrane assessment of allocation concealment and the Jadad scale of methodological quality. Disagreements between reviewers were referred to a third reviewer. Where further information was required, authors of trial papers were contacted for further details.

MAIN RESULTS

Four studies were included, one which directly compared the fibrinolytics streptokinase and urokinase. Three small RCTs (total 104 patients) compared streptokinase or urokinase versus normal saline control. The pooled data showed significant benefits in terms of hospital stay, time to defervescence, improvement in chest radiograph, requirement for surgery, but the results were not always consistent across studies. Complications attributable to therapy were not observed.

REVIEWERS' CONCLUSIONS

The numbers of patients in the controlled trials are small. In meta-analysis of these trials, intrapleural fibrinolytic therapy confers significant benefit when compared with normal saline control. Although lesser levels of evidence suggest that intrapleural fibrinolysis can be considered as an important adjunctive therapy to intercostal tube drainage in these conditions, on the basis of RCT evidence alone, we cannot recommend the routine use of fibrinolysis in their management as the trial numbers are too small. Both streptokinase and urokinase are equally efficacious but streptokinase has a slightly higher non-fatal complication rate. Life-threatening complications are rare and were not seen in the RCTs.

Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia

AIMS

To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades.

METHODS

A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989-98, were reviewed retrospectively.

RESULTS AND CONCLUSIONS

One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1-2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.

Single-chain urokinase alone or complexed to its receptor in tetracycline-induced pleuritis in rabbits

Intrapleural loculation can increase morbidity in hemothoraces or parapneumonic effusions. Intrapleural fibrin precedes visceral-parietal pleural adhesions. We speculated that single-chain urokinase plasminogen activator alone or bound to its receptor could prevent these adhesions by their relative resistance to local inhibition by plasminogen activator inhibitors. We found that recombinant human single-chain urokinase-bound rabbit pleural mesothelial cells or lung fibroblasts with kinetics similar to that reported for human cells (kD of approximately 5 nM). The receptor-bound fibrinolysin maintained in vitro fibrinolytic activity in the presence of pleural fluids from rabbits with tetracycline-induced pleural injury over 24 hours. In rabbits given intrapleural single-chain urokinase 24 and 48 hours after intrapleural tetracycline (n = 10 animals), adhesions were prevented, whereas the receptor-complexed form (n = 12) attenuated adhesions versus vehicle/tetracycline-treated rabbits (n = 22, p <or= 0.005 in both cases). There were more adhesions in the complex than the single-chain urokinase group (p = 0.02). Residual antigenic but not functional evidence of the interventional agents remained in pleural fluids at 72 hours after tetracycline. No local or systemic bleeding occurred because of either interventional agent. The data demonstrate that single-chain urokinase inhibits, whereas lysin-receptor complexes attenuate, adhesion formation in tetracycline-induced pleural injury in rabbits.

Management of complicated parapneumonic effusions and thoracic empyema

The optimal management of loculated parapneumonic effusions and empyema includes breakdown of adhesions to effect drainage of infected pleural fluid. The use of fibrinolytics intrapleurally appears to enhance intercostal tube drainage, reducing the requirement for subsequent surgical mechanical debridement. This article discusses the evidence for intrapleural fibrinolytics, their good safety profile and the practicalities of dose and administration. It also reviews early surgical intervention, which may be indicated for medical treatment failure and, some would argue, as a suitable alternative to other medical interventions.

Computed tomography and ultrasound in parapneumonic effusions and empyema

AIM

Imaging of pleural empyema by ultrasound (US) or computed tomography (CT) is used to confirm the diagnosis and facilitate drainage. However, the information gained from US and CT may also have prognostic significance. The aim of the present study was to determine if CT and US appearances correlated with the severity of infection as determined by established microbiological and biochemical indicators, and to establish whether either technique could predict those patients who will fail drainage and require surgery.

MATERIALS AND METHODS

Fifty patients with parapneumonic effusions were assessed. All had thoracic CT and the results of thoracic US were available in 36 patients. Imaging features were compared to the stage of the effusion and clinical outcome.

RESULTS

At US, 7/36 (19%) pleural collections were anechoic, 5/36 (14%) were hyperechoic without septae and 24/36 (67%) were hyperechoic with septae. There was no relationship between US appearances and the presence of pus, the effusion stage or the need for surgical treatment. On CT pleural enhancement was seen in all patients. There was evidence of pleural thickening in 46/50 (92%) and thickening of extrapleural fat in 38/50 (76%). There was a trend for mean pleural thickness to increase with an increasing stage of pleural infection. However, a wide range of appearances were seen and overall the thickness of pleural/extrapleural tissues was not significantly related to the stage of effusion or to the requirement for surgery.

CONCLUSIONS

Although US and CT have established roles in the investigation of parapneumonic effusions, neither technique reliably identifies the stage of pleural infection or predicts those patients who subsequently require surgical intervention after failed management by chest tube drainage and intrapleural fibrinolytics. Kearney, S. E. (2000). Clinical Radiology 55, 542-547.

Fatal haemorrhage from aortic dissection following instillation of intrapleural streptokinase

A patient is described who suffered fatal haemorrhage following intrapleural streptokinase for treatment of a presumed empyema. Autopsy revealed an unsuspected abdominal aortic dissection with extension of blood clot into the thoracic cavity. The importance of precise diagnosis of empyema and potential risks associated with intrapleural streptokinase are discussed.

Pyogenic lung infections: factors for predicting clinical outcome of lung abscess and thoracic empyema

Lung abscess and thoracic empyema continue to cause significant morbidity and mortality despite appropriate antibiotic therapy and various options for drainage of empyema. Multiple factors, including the patient's general state of health, the presence of underlying disease, the virulence of the pathogen responsible, and the promptness of drainage of empyema, appear to dictate the clinical outcome. However, the available data are derived from uncontrolled, retrospective studies and the high morbidity and mortality rates underscore the need for large prospective studies to better evaluate factors that may predict the clinical outcome of these conditions.

Pleural Disease in the Intensive Care Unit

Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.

The utility of daily therapeutic thoracentesis for the treatment of early empyema

STUDY OBJECTIVES

To determine if therapeutic thoracentesis is as effective as early chest tube placement or no drainage procedure in the treatment of early empyema in rabbits.

DESIGN AND INTERVENTIONS

An empyema, as evidenced by gross pleural pus and a decreased pleural fluid pH and glucose level, was induced in 49 rabbits. The rabbits were divided into three groups: 16 underwent daily therapeutic thoracentesis starting at 48 h, 14 underwent chest tube placement at 48 h, and 19 served as controls.

RESULTS

The mortality rate in the therapeutic thoracentesis group (0/16) did not differ significantly from that in the chest tube group (3/14) or that in the control group (6/19). At autopsy at 10 days, the gross empyema score in the therapeutic thoracentesis group (2.1 +/- 0.3) was significantly lower (p < 0.05) than that in the chest tube group (2. 8 +/- 0.3) or the control group (3.5 +/- 0.2). The mean pleural peel score of 5.8 +/- 1.1 in the therapeutic thoracentesis group was significantly less (p < 0.05) than the score for the nonintervention control group (13.4 +/- 1.6).

CONCLUSIONS

From this study, we conclude that therapeutic thoracentesis is at least as effective as early chest tube placement for the treatment of early empyema using our rabbit model of empyema.

Pyogenic lung infections

Pyogenic lung infections still occur despite the availability of effective antibiotics for the treatment of patients with acute bacterial pneumonia. Our understanding of the pathogenesis and management of these conditions has steadily improved over the past few decades, although some areas remain obscure. The effect of HIV infection on the incidence of pyogenic lung infections remains largely unknown, and large studies are required to evaluate this. Burkholderia (formerly Pseudomonas) cepacia strains are now recognized as important respiratory pathogens in patients with cystic fibrosis, and the high transmissibility of some strains, combined with their inherent multiple antibiotic resistance, are continuing causes for concern.

[Prognostic features of residual pleural thickening in metapneumonic pleural effusion]

Residual pleural thickening (RPT) develops in some patients after metapneumonic pleural effusion (MPE). Our aim was to identify factors that predict the development of RPT by retrospectively analyzing patients with MPE secondary to bacterial pneumonia in our practice from 1992 through April 1997. Patients were assigned to groups based on the presence or not of RPT (> 10 mm) three months or more after diagnosis of MPE. One hundred twenty-eight patients were included in the analysis. Seventy-nine patients (62%) developed RPT and 49 (38%) did not. Patients with RPT had significantly lower glucose levels and pH and higher LDH levels in pleural fluid. A higher percentage of patients with RPT had loculate pleural effusions and empyema, and they more often required insertion of drains. Logistic regression analysis showed that only glucose < 40 mg/dl (OR: 3.4; CI 95%: 2.3 to 4.5; p < 0.05) and the presence of pus collected from the initial thoracocentesis (OR: 3.6; CI 95%: 2.6 to 4.5; p < 0.01) were significantly associated with increased risk of developing residual pachypleuritis in subjects with MPE.