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Chawla RK, Kumar M, Madan A, Dhar R, Gupta R, Gothi D, Desai U, Goel M, Swarankar R, Nene A, Munje R, Chaudhary D, Guleria R, Hadda V, Nangia V, Sindhwani G, Chawla R, Dutt N, Yuvarajan, Dalal S, Gaur SN, Katiyar S, Samaria JK, Gupta KB, Koul PA, Suryakant, Christopher D, Roy D, Hazarika B, Luhadia SK, Jaiswal A, Madan K, Gupta PP, Prashad B, Yusuf N, James P, Dhamija A, Tomar V, Parakh U, Khan A, Garg R, Singh S, Joshi V, Sarangdhar N, Chaudhary SR, Nayar S, Patel A, Gupta M, Dixit RK, Jain S, Gogia P, Agarwal M, Katiyar S, Chawla A, Gonuguntala HK, Dosi R, Chinnamchetty V, Jindal A, Sharma S, Chachra V, Samaria U, Nair A, Mohan S, Maitra G, Sinha A, Kochar R, Yadav A, Choudhary G, Arunachalam M, Rangarajan A, Sanjan G. NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy. Lung India 2024; 41:151-167. [PMID: 38700413 PMCID: PMC10959315 DOI: 10.4103/lungindia.lungindia_5_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 01/10/2024] [Accepted: 01/10/2024] [Indexed: 05/05/2024] Open
Abstract
ABSTRACT Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.
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Affiliation(s)
- Rakesh K. Chawla
- Department of Respiratory Medicine, Critical Care and Sleep Disorders, Jaipur Golden Hospital and Saroj Super Speciality Hospital, New Delhi, India
| | - Mahendra Kumar
- Department of Respiratory Medicine, Institute of Respiratory Diseases, SMS Medical College Jaipur, Rajasthan, India
| | - Arun Madan
- Department of Respiratory Medicine, NDMC Medical College, Delhi, India
| | - Raja Dhar
- Department of Pulmonology, C K Birla Group of Hospitals, Kolkata, West Bengal, India
| | - Richa Gupta
- Department of Respiratory Medicine, CMC Hospital, Vellore, Tamil Nadu, India
| | - Dipti Gothi
- Department of Respiratory Medicine, ESI- PGIMSR, Delhi, India
| | - Unnati Desai
- Department of Pulmonary Medicine, TNMC and BYL Nair Hospital, Mumbai, Maharashtra, India
| | - Manoj Goel
- Department of Pulmonary, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India
| | - Rajesh Swarankar
- Respiratory, Critical Care and Sleep Medicine, Get Well Hospital and Research Institute, Nagpur, Maharashtra, India
| | - Amita Nene
- Department of Respiratory Medicine, Bombay Hospital, Mumbai, Maharashtra, India
| | - Radha Munje
- Department of Respiratory Medicine, IGGMCH Nagpur, Maharashtra, India
| | - Dhruv Chaudhary
- Department of Pulmonary Medicine, PGIMS Rohtak, Haryana, India
| | - Randeep Guleria
- Chairman, Institute of Internal Medicine, Respiratory and Sleep Medicine Medanta, Gurugram, Haryana, India
- Director, Medical Education Respiratory and Sleep Medicine Medanta, Gurugram, Haryana, India
| | - Vijay Hadda
- Pulmonary, Critical Care, and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vivek Nangia
- Pulmonary, Critical Care, and Sleep Medicine, MAX Super Speciality Hospital Saket, New Delhi, India
| | | | - Rajesh Chawla
- Respiratory Medicine, Indraprastha Apollo Hospitals, Delhi, India
| | - Naveen Dutt
- Department of Pulmonary Medicine, AIIMS Jodhpur, Rajasthan, India
| | - Yuvarajan
- Department of Respiratory Medicine, SMVMCH, Pondicherry, India
| | - Sonia Dalal
- Pulmonologist and Director, Dalal Sleep and Chest Medical Institute Pvt Ltd Vadodara, Gujarat, India
| | - Shailendra Nath Gaur
- Department of Respiratory Medicine, Sharda Medical College, Noida, Uttar Pradesh, India
| | - Subodh Katiyar
- Department of Tuberculosis and Respiratory Diseases, G. S. V. M. Medical College, Kanpur, Uttar Pradseh, India
| | - Jai Kumar Samaria
- Department of Chest Diseases, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
- Director and Chief Consultant, Centre for Research and Treatment of Allergy, Asthma and Bronchitis and Dr. Samaria Multispeciality Centre Varanasi, Uttar Pradesh, India
| | - K. B Gupta
- Department of Pulmonary Medicine PGIMS Rohtak, Haryana, India
| | - Parvaiz A Koul
- Pulmonary Medicine and Director, SKIMS, Srinagar, Jammu and Kashmir, India
| | - Suryakant
- Department of Respiratory Medicine, King George’s Medical University UP Lucknow, Uttar Pradesh, India
| | - D.J. Christopher
- Department of Pulmonary Medicine, CMC, Vellore, Tamil Nadu, India
| | - Dhrubajyoti Roy
- Pulmonary and Respiratory Medicine in Columbia Asia Hospital, Salt Lake Kolkata, West Bengal, India
| | - Basant Hazarika
- Department of Pulmonary Medicine Guwahati Medical College, Guwahati, Assam, India
| | - Shanti Kumar Luhadia
- Department of Respiratory Medicine, Geetanjali Medical College and Hospital Udaipur, Rajasthan, India
| | - Anand Jaiswal
- Director, Respiratory and Sleep Medicine Medanta, The Medicity Gurugram, Haryana, India
| | - Karan Madan
- Pulmonary Medicine and Sleep Disorders Department, AIIMS, Delhi, India
| | | | - B.N.B.M. Prashad
- Department of Respiratory Medicine, KGMC, Lucknow, Uttar Pradesh, India
| | - Nasser Yusuf
- Department of Minimally Invasive Thoracic Surgery, Sunrise Group of Hospitals Kochi, Calicut, Kerala, India
| | - Prince James
- Interventional Pulmonology and Respiratory Medicine Naruvi Hospitals, Vellore, Tamil Nadu, India
| | - Amit Dhamija
- Chest Medicine, Sir Ganga Ram Hospital New Delhi, India
| | - Veerotam Tomar
- Director and Consultant Pulmonologist, Dr Shivraj Memorial Chest and Maternity Centre Meerut, Uttar Pradesh, India
| | - Ujjwal Parakh
- Department of Respiratory Medicine, Sir Ganga Ram Hospital New Delhi, India
| | - Ajmal Khan
- Department of Pulmonary and Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine AIIMS, New Delhi, India
| | - Sheetu Singh
- Director, Asthma Bhawan, Rajasthan Hospital, Rajasthan, India
| | - Vinod Joshi
- Principal and Controller, RUHS College of Medical Sciences, Jaipur, Rajasthan, India
| | - Nikhil Sarangdhar
- Department of Pulmonary Medicine, D. Y. Patil University School of Medicine, Navi Mumbai, Maharashtra, India
| | | | - Sandeep Nayar
- Senior Director and Head Centre for Chest and Respiratory Diseases BLK-Max Super Speciality Hospital, New Delhi, India
| | - Anand Patel
- Department of Pulmonary Medicine GMERS Medical College and Hospital, Gujarat, India
| | - Mansi Gupta
- Department of Pulmonary, Critical Care and Sleep Medicine, SGPGI Lucknow, Uttar Pradesh, India
| | - Rama Kant Dixit
- Department of Respiratory Medicine, J L N Medical College, Ajmer, Rajasthan, India
| | - Sushil Jain
- Department of Respiratory Medicine, APOLLO, Raipur, Chhattisgarh, India
| | - Pratibha Gogia
- Respiratory Medicine, Allergy and Sleep Disorders Department, Venkateshwar Hospital, Dwarka, New Delhi, India
| | - Manish Agarwal
- Pulmonary Medicine and Sleep Disorders Department, Jaipur Golden Hospital, Delhi, India
| | | | - Aditya Chawla
- Department of Respiratory Medicine, Sleep and Critical Care, Saroj Super Speciality Hospital and Jaipur Golden Hospital, New Delhi, India
| | | | - Ravi Dosi
- Consultant Chest Physician, Kokilaben Dhirubhai Ambani Hospital, Indore, Madhya Pradesh, India
| | - Vijya Chinnamchetty
- Lead Interventional Pulmonologist Apollo Health City, Hyderabad, Telangana, India
| | - Apar Jindal
- Lung Transplant Interventional Pulmonology and Respiratory Medicine MGM Healthcare, Chennai, Tamil Nadu, India
| | - Shubham Sharma
- Consultant Advanced Lung Failure and Transplant Pulmonologist, Yashoda Hospitals, Ghaziabad, UP, India
| | | | - Utsav Samaria
- Pulmonologist, Apollo Spectra Kanpur, Uttar Pradesh, India
| | - Avinash Nair
- Department of Respiratory Medicine Christian Medical College, Vellore, Tamil Nadu, India
| | - Shruti Mohan
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - Gargi Maitra
- Pulmonologist, Fortis Memorial Research Institute, Gurgaon, Haryana, India
| | - Ashish Sinha
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - Rishabh Kochar
- Department of Pulmonary, Critical Care and Sleep Medicine, AIIMS Jodhpur, Rajasthan, India
| | - Ajit Yadav
- Department Respiratory Medicine MMIMSR, Ambala, Haryana, India
| | - Gaurav Choudhary
- Department of Respiratory Medicine, Jaipur Golden Hospital New Delhi, India
| | - M Arunachalam
- Pulmonary and Sleep Medicine Yatharth Wellness Super Speciality Hospital, Noida, Uttar Pradesh, India
| | | | - Ganesh Sanjan
- SR Pulmonary Medicine AIIMS, Rishikesh, Uttarakhand, India
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Das NN, Lakhotia S, Verma A. Surgical outcome of empyema thoracis patients with special correlation to pre-operative contrast-enhanced computerized tomography (CECT) thorax morphometry. Indian J Thorac Cardiovasc Surg 2020; 37:164-174. [PMID: 33642714 DOI: 10.1007/s12055-020-01053-5] [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: 05/11/2020] [Revised: 09/03/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose Empyema thoracis is a very common disease. The surgical outcome of empyema patients depends upon various factors. To the best of our knowledge, there is no study in literature describing the surgical outcome of patients in relation to the contrast-enhanced computerized tomography (CECT) thorax morphometric findings. In this study, we examined the surgical outcome of empyema thoracis patients in relation to both clinical and radiological findings. Materials and methods It is a prospective hospital-based study conducted between October 2016 and August 2018. A total of 30 patients, who underwent decortication during the study period, were included. They were divided into three performance groups (excellent performance, average performance and poor performance groups) according to the outcome. The surgical outcome was correlated with the pre-operative clinical, radiological, intra-operative and post-operative parameters. Results Intra-operative ability to complete decortication, intra-operative expansion of the lungs and presence of broncho-pleural fistula were significantly different between the three performance groups. Duration of the disease, pre-operative duration of antitubercular therapy (ATT) intake and duration of pre-operative intercostal drain (ICD) were statistically insignificant between groups. In computed tomography (CT) morphometry, residual lung volume of the involved lung and volume of empyema were found to be significantly different between the performance groups. The residual volume of the involved lung (expressed in terms of the percentage of lung volume of the normal opposite lung) can predict the complete expansion of the lung with sensitivity of 71% and specificity of 70%. Conclusion The pre-operative residual lung volume of the involved lung, empyema volume, completeness of decortication, intra-operative expansion of the lung and presence or absence of broncho-pleural fistula can determine the surgical outcome in empyema thoracis patients.
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Affiliation(s)
- Narendra Nath Das
- Department of CTVS, Institute of Medical Sciences, BHU, Varanasi, India
| | | | - Ashish Verma
- Department of Radio Diagnosis and Imaging, Institute of Medical Sciences, BHU, Varanasi, India
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van Middendorp LB, Franssen S, Gillissen S, Maessen JG, Hulsewé KWE, Vissers YLJ, de Loos ER. Uniportal video-assisted thoracoscopy is a safe approach in patients with empyema requiring surgery. J Thorac Dis 2020; 12:1460-1466. [PMID: 32395283 PMCID: PMC7212173 DOI: 10.21037/jtd.2020.02.29] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Empyema is a well-known complication of pneumonia, with high morbidity and mortality rates. This warrants direct treatment either with antibiotics and chest tube drainage or surgery. With less invasive surgical approaches such as uniportal video-assisted thoracoscopic surgery (uVATS), surgical intervention gets a more prominent role early on in the treatment of empyema. The aim of this study was to compare uVATS with the complete VATS (cVATS) approach in empyema, with respect to postoperative complications, hospital length of stay and mortality. Methods All cases of empyema that were treated surgically in our hospital between 2006 and 2019 were included in a retrospective database. The preferential surgical approach changed from cVATS from 2006 to 2015, towards uVATS from 2016 and on, based on the experience of the surgical team. The database included pre- and postoperative data, as well as peropartive characteristics. Results One hundred and thirty-seven patients were treated with cVATS and 49 with uVATS. Apart from a slightly reduced kidney function in the uVATS group (57.3±6.3 vs. 71.4±17.2 mL/min/1.73 m2, P≤0.001), there were no significant baseline differences in patient characteristics. The duration of uVATS was comparable to cVATS (70±17 vs. 56±23 min, P=0.240), and with low per- and postoperative complications. The postoperative hospital stay was equal in both groups (19±13 vs. 20±15 days, P=0.320). There were no statistically significant differences in postoperative complications or death. Conclusions Uniportal VATS is a feasible and safe technique for the use in patients with empyema requiring surgery. Even if decortication in stage III empyema is required this can be performed by uniportal VATS.
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Affiliation(s)
- Lars B van Middendorp
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands.,Department of Cardiothoracic Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Stijn Franssen
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Sanne Gillissen
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht UMC+, Maastricht, The Netherlands
| | - Karel W E Hulsewé
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Yvonne L J Vissers
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
| | - Erik R de Loos
- Department of Surgery, Division of Thoracic Surgery, Zuyderland Medical Center, Heerlen, The Netherlands
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Khan J, Ala-Seppälä H, Lehtomäki A, Toikkanen V, Pohja E, Laurikka J, Ukkonen M. The Occurrence of Lung Cancer and Non-Pulmonary Malignancies After Pleural Infections. Scand J Surg 2020; 110:99-104. [PMID: 31959068 DOI: 10.1177/1457496919900406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Patients who develop infections of the pleura have several risk factors for malignancies, particularly lung cancer, and the infections might even be caused by undiagnosed intra-thoracic neoplasms. The aim of the study was to compare the occurrence of lung cancer and other malignancies between patients treated for pleural infections and controls during long-term follow-up. MATERIALS AND METHODS All consecutive patients treated for pleural infections between January 2000 and June 2016 at the Tampere University Hospital were included. Ten matched controls and data regarding later cancer diagnoses were requested from national registries. The cancer types and rates, the diagnostic delays, as well as survival were compared between patients and controls. RESULTS The material comprised 506 patients and 5022 controls (78% was male and median age was 60 years in both groups) with a median follow-up time of 69 months. In total, 74% of pleural infections were related to pneumonia. The occurrence of lung cancer during follow-up was 3.0% in all patients, 2.2% in pneumonia-related cases, and 0.6% in controls, p < 0.001 when compared with controls. The overall rate of non-pulmonary malignancies did not differ. Lung cancer was diagnosed within 3 months in 73% of patients versus in 6.9% of controls, p < 0.001. The survival in patients with later lung cancers or other malignancies was inferior to that of controls with similar neoplasms. CONCLUSION The rate of lung cancer diagnoses was significantly increased in patients treated for pleural infections when compared with matched controls and the prognosis of patients with subsequent malignancies was impacted.
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Affiliation(s)
- J Khan
- Department of Cardio-Thoracic Surgery, Heart Center, Tampere University Hospital, Tampere, Finland
| | - H Ala-Seppälä
- Department of Cardio-Thoracic Surgery, Heart Center, Tampere University Hospital, Tampere, Finland
| | - A Lehtomäki
- Department of Cardio-Thoracic Surgery, Heart Center, Tampere University Hospital, Tampere, Finland
| | - V Toikkanen
- Department of Cardio-Thoracic Surgery, Heart Center, Tampere University Hospital, Tampere, Finland
| | - E Pohja
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - J Laurikka
- Department of Cardio-Thoracic Surgery, Heart Center, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - M Ukkonen
- Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
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Khan JA, Lehtomäki AI, Toikkanen VJ, Ukkonen MT, Nevalainen RM, Laurikka JO. Long-Term Prognosis and Causes of Death After Pleural Infections. Scand J Surg 2017; 107:145-151. [PMID: 29121816 DOI: 10.1177/1457496917738868] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS The development of pleural infection may imply a worse state of health and prognosis. The objective of this study was to ascertain the long-term survival and causes of death after pleural infections and to compare them to those of matched controls. MATERIAL AND METHODS Altogether 191 patients treated for pleural infections at a single University Hospital between January 2000 and December 2008 and 1910 age- and gender-matched controls were included. Survival data and the causes of death for non-survivors were obtained from national databases and compared between the groups. RESULTS The etiology of pleural infection was pulmonary infection in 70%, procedural complication in 9%, trauma in 5%, malignancy in 4%, other in 7%, and unknown in 5% of patients. The course of treatment was surgical in 82%, drainage only in 12%, and conservative in 5% of included patients. The median follow-up time was 11 years. Mortality rates were 8.4% versus 0.8% during the first 90 days, p < 0.001, and 46.6% versus 24.5% overall, p < 0.001, in patients and controls, respectively. Mortality was significantly higher in patients with pulmonary infection, procedural complication, or malignancy as the etiology of pleural infection. In multivariable analysis, advanced age, previous malignancies, institutional care, alcoholism, and malignant etiology for the infection were associated with inferior survival. Deaths caused by malignancies, respiratory diseases, and digestive diseases were significantly more common in patients than in controls. CONCLUSION Long-term survival in patients with pleural infections is significantly inferior to that of age and gender-matched controls.
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Affiliation(s)
- J A Khan
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - A I Lehtomäki
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - V J Toikkanen
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - M T Ukkonen
- 2 Department of Gastroenterology and Alimentary Tract Surgery, Tampere University Hospital, Tampere, Finland
| | - R M Nevalainen
- 3 Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - J O Laurikka
- 1 Department of Cardio-Thoracic Surgery, Tays Heart Hospital, Tampere University Hospital, Tampere, Finland.,4 Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Abstract
PURPOSE OF REVIEW Medical thoracoscopy provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it achieves therapeutic goals of fluid drainage, guided chest tube placement, and pleurodesis. RECENT FINDINGS Comparable diagnostic yield is achieved with the flexi-rigid pleuroscope even though pleural biopsies are smaller using the flexible forceps as compared to rigid thoracoscopy. Flexi-rigid pleuroscopy is extremely well tolerated and can be performed safely as an outpatient procedure. Biopsy quality can be further enhanced with accessories that are compatible with the flex-rigid pleuroscope such as the insulated tip knife and cryoprobe. SUMMARY With more sensitive tools to image the pleura such as contrast-enhanced computed tomography, MRI, ultrasonography, PET, increased yield with image-guided biopsy as well as advances in cytopathology, what lies in the future for medical thoracoscopy remains to be seen. However, it is the authors' opinion that medical thoracoscopy will evolve with time, complement novel techniques, and continue to play a pivotal role in the evaluation of pleuropulmonary diseases.
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Hajjar WM, Ahmed I, Al-Nassar SA, Alsultan RK, Alwgait WA, Alkhalaf HH, Bisht SC. Video-assisted thoracoscopic decortication for the management of late stage pleural empyema, is it feasible? Ann Thorac Med 2016; 11:71-8. [PMID: 26933461 PMCID: PMC4748619 DOI: 10.4103/1817-1737.165293] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND: Video-assisted thoracoscopic surgical decortication (VATSD) is widely applicable in fibrinopurulent Stage II empyema. While, more chronic thick walled Stage III empyema (organizing stage) needs conversion to open thoracotomy, and existing reports reveal a lacuna in the realm of late stage empyema patient's management through VATS utilization, particularly Stage III empyema. We prospectively evaluated the application of VATSD regardless of the stage of pleural empyema for the effective management of late stage empyema in comparison to open decortications (ODs) to minimize the adverse effects of the disease. METHODS: All patients with pyogenic pleural empyema (Stage II and Stage III) in King Khalid University Hospital (KKUH) (admitted from January 2009 to December 2013) who did not respond to chest tube/pigtail drainage and/or antibiotic therapy were treated with VATSD and/or open thoracotomy. Prospective evaluation was carried out, and the effect of this technique on perioperative outcomes was appraised to evaluate our technical learning with the passage of time and experience with VATS for late stage empyema management. RESULTS: Out of total 63 patients, 26 had Stage II empyema and 37 had Stage III empyema. VATSD was employed on all empyema patients admitted in the KKUH. VATSD was successful in all patients with Stage II empyema. Twenty-five patients (67.6%) with Stage III empyema completed VATSD successfully. However, only 12 cases (32.4%) required conversions to open (thoracotomy) drainage (OD). The median hospital stay for Stage III VATSD required 9.65 ± 4.1 days. Whereas, patients who underwent open thoracotomy took longer time (21.82 ± 16.35 days). Similarly, Stage III VATSD and Stage III open surgery cases showed significance difference among chest tube duration (7.84 ± 3.33 days for VATS and 15.92 ± 8.2 days for open thoracotomy). Significantly, lower postoperative complications were detected in patients treated with VATSD in terms of atelectasis, prolonged air leak, wound infection, etc. CONCLUSION: VATSD facilitates the management of fibrinopurulent, organized pyogenic pleural empyema with less postoperative discomfort, reduced hospitalization, and have fewer postoperative complications. VATSD can be an effective, safe first option for patients with Stage II pleural empyema, and feasible in most patients with Stage III pleural empyema.
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Affiliation(s)
- Waseem M Hajjar
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Iftikhar Ahmed
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Sami A Al-Nassar
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Rawan K Alsultan
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Waad A Alwgait
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Hanoof H Alkhalaf
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Shekhar C Bisht
- Department of Surgery, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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8
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Abstract
Pleuroscopy provides a window to the pleural space while enabling biopsy of the parietal pleura under direct visual guidance for effusions of unknown etiology, guided chest tube placement, and pleurodesis for recurrent pleural effusions or pneumothoraces in selected patients. The procedure enjoyed resurgence when thoracic surgeons introduced the technique for video-assisted thoracic surgery (VATS). VATS is performed under general anesthesia with single-lung ventilation; pleuroscopy is performed in an endoscopy suite using nondisposable rigid or flex-rigid instruments, local anesthesia, and conscious sedation. Pleuroscopy is less invasive; in this review, we discuss the indications, complications, techniques, and recent advances in the procedure.
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Affiliation(s)
- Pyng Lee
- Division of Respiratory & Critical Care Medicine, Department of Medicine, Yong Loo Lin Medical School, National University Hospital, National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 10, Singapore 119228.
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Paraskakis E, Vergadi E, Chatzimichael A, Bouros D. Current evidence for the management of paediatric parapneumonic effusions. Curr Med Res Opin 2012; 28:1179-92. [PMID: 22502916 DOI: 10.1185/03007995.2012.684674] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment. SCOPE In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children. FINDINGS A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed. CONCLUSION The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.
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Affiliation(s)
- Emmanouil Paraskakis
- Department of Paediatrics, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece.
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10
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Medford ARL, Bennett JA, Free CM, Agrawal S. Current status of medical pleuroscopy. Clin Chest Med 2010; 31:165-72, Table of Contents. [PMID: 20172442 DOI: 10.1016/j.ccm.2009.10.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Medical pleuroscopy (MP) offers a safe and minimally invasive tool for interventional pulmonologists. It allows diagnosis of unexplained effusion, while at the same time allowing drainage and pleurodesis. It can also help in the diagnosis of diffuse interstitial disease or associated peripheral lung abnormality in the presence of effusion. It can have a therapeutic role in pneumothorax and hyperhidrosis or chronic pancreatic pain. This article reviews the technical aspects and range of applications of MP.
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Affiliation(s)
- Andrew R L Medford
- Department of Respiratory Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester LE3 9QP, Leicestershire, UK.
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11
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PETRAKIS IE, HEFFNER JE, KLEIN JS. Surgery should be the first line of treatment for empyema. Respirology 2010; 15:202-7. [DOI: 10.1111/j.1440-1843.2009.01677.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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12
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Abstract
Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.
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Affiliation(s)
- M Klopp
- Chirurgische Abteilung, Thoraxklinik am Universitätsklinikum, Amalienstrasse 5, 69126, Heidelberg, Germany.
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13
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Abstract
The terms pleuroscopy, thoracoscopy, medical thoracoscopy, and video-assisted thoracic surgery are often used interchangeably to describe a minimally invasive procedure that provides access to the pleural space, parietal pleura, lung, and other structures within the thoracic cavity. Pleuroscopy is a more exact term for describing visualization of the pleura and contents of the pleural cavity using an endoscope. This procedure provides physicians a window into the pleural space, to perform biopsy of the parietal pleura under direct visual guidance, particularly for biopsies in cases of exudative effusions with unclear origin, chest tube placement, and pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. In this state-of-the-art review, we discuss the indications, contraindications, and complications of pleuroscopy, and its role in thoracic oncology.
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Affiliation(s)
- Pyng Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
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14
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Abstract
Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.
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Affiliation(s)
- Scott A Engum
- Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202, USA.
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15
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Kuboi S, Nomura H. Clinical background of cases showing a positive culture of pleural effusion at Shin-Kokura Hospital over a period of 5 years. J Infect Chemother 2006; 12:264-8. [PMID: 17109089 DOI: 10.1007/s10156-006-0459-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Accepted: 06/27/2006] [Indexed: 10/23/2022]
Abstract
We investigated the clinical background of patients at Shin-Kokura Hospital who showed a positive culture of pleural effusion during the period from January 1998 through December 2002. Microorganism cultures of the pleural effusions of 127 patients were performed in this 5-year period. Seventeen patients showed a positive microorganism culture from a pleural effusion, and 12 of these patients (70.6%) were 60 years old or more. Ten patients were diagnosed with thoracic empyema. Thirteen patients had an underlying disease such as malignancy (5 cases), diabetes mellitus (4 cases), etc. A purulent effusion and a high concentration of lactic dehydrogenase (LDH) in the pleural fluid were more frequently recognized in the positive-culture group. A total of 21 strains of microorganism were isolated from the 17 patients, including 10 strains of Gram-positive cocci, 6 strains of Gram-negative bacilli, 3 strains of anaerobes, 1 strain of mycobacterium (Mycobacterium tuberculosis), and 1 strain of fungus. Susceptibility to antimicrobial agents was generally good for most of the microorganisms isolated. Of the 17 patients, chest-tube drainage was performed in 13, and 6 needed a surgical operation. Twelve patients improved, but 5 died. In this study, thoracic empyema accounted for 58.8% of the 17 cases with a positive culture of pleural effusion. Of the 10 thoracic empyema patients, 5 patients needed surgical treatment in spite of adequate antimicrobial treatment and chest-tube drainage. Our data indicate that thoracic empyema is still difficult to treat, and thus adequate and rapid treatment is needed for any pleural infection.
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Affiliation(s)
- Satoshi Kuboi
- Department of Internal Medicine, Shin-Kokura Hospital, 1-3-1 Kanada, Kokurakita-ku, Kitakyushu, 803-8505, Japan.
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Bouros D, Tzouvelekis A, Antoniou KM, Heffner JE. Intrapleural fibrinolytic therapy for pleural infection. Pulm Pharmacol Ther 2006; 20:616-26. [PMID: 17049447 DOI: 10.1016/j.pupt.2006.08.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Accepted: 08/08/2006] [Indexed: 11/26/2022]
Abstract
Pneumonia with secondary pleural infection causes considerable morbidity and mortality. Intrapleural instillation of fibrinolytic agents to dissolve fibrinous adhesions is intended to improve pleural fluid drainage and prevent pleural loculations. In the last 20 years their application in the every day clinical practice has dragged much of attention and several studies have supported their use in the management of parapneumonic pleural effusions (PPE) and pleural empyema (PE). However, recent published data cast doubt on the effectiveness of intrapleural fibrinolytic agents in promoting drainage of infected pleural effusions. Pending future clinical trials, fibrinolytic therapy may be used selectively in patients who fail drainage with appropriately sized, image-guided chest tubes if reasons exist to delay or avoid definitive surgical drainage. The scope of this article is to systematically review evidence for the efficacy of intrapleural fibrinolytic therapy in the treatment of PPE and PE with emphasis on controlled trials and present some of the future perspectives.
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Affiliation(s)
- Demosthenes Bouros
- Department of Pneumonology, Medical School University of Thrace, Alexandroupolis 68100, Greece.
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17
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Lardinois D, Gock M, Pezzetta E, Buchli C, Rousson V, Furrer M, Ris HB. Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema. Ann Thorac Surg 2006; 79:1851-6. [PMID: 15919270 DOI: 10.1016/j.athoracsur.2004.12.031] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2004] [Revised: 12/14/2004] [Accepted: 12/21/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema was assessed in a consecutive series of 328 patients between 1992 and 2002. An analysis of the predicting factors for conversion thoracotomy in presumed stage II empyema was performed. METHODS Empyema stage III with pleural thickening and signs of restriction on computer tomography imaging was treated by open decortication, whereas a thoracoscopic debridement was attempted in presumed stage II disease. Conversion thoracotomy was liberally used during thoracoscopy if stage III disease was found at surgery. Predictive factors for conversion thoracotomy were calculated in a multivariate analysis among several variables such as age, sex, time interval between onset of symptoms and surgery, involved microorganisms, and underlying cause of empyema. RESULTS Of the 328 patients surgically treated for stage II and III empyema, 150 underwent primary open decortication for presumed stage III disease. One hundred seventy-eight patients with presumed stage II empyema underwent a video-assisted thoracoscopic approach. Of these 178 patients, thoracoscopic debridement was successful in 99 of 178 patients (56%), and conversion thoracotomy and open decortication was judged necessary in 79 of 178 patients (44%). The conversion thoracotomy rate was higher in parapneumonic empyema (55%) as compared with posttraumatic (32%) or postoperative (29%) empyema; however, delayed referral (p < 0.0001) and gram-negative microorganisms (p < 0.01) were the only significant predictors for conversion thoracotomy in a multivariate analysis. CONCLUSIONS Video-assisted thoracoscopic debridement offers an elegant, minimally invasive approach in a number of patients with presumed stage II empyema. However, to achieve a high success rate with the video-assisted thoracoscopic approach, early referral of the patients to surgery is required. Conversion thoracotomy should be liberally used in case of chronicity, especially after delayed referral (> 2 weeks) and in the presence of gram-negative organisms.
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Affiliation(s)
- Didier Lardinois
- Division of Thoracic Surgery, University Hospital, Zurich, Switzerland.
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18
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Dzielicki J, Korlacki W. The role of thoracoscopy in the treatment of pleural empyema in children. Surg Endosc 2006; 20:1402-5. [PMID: 16823648 DOI: 10.1007/s00464-005-0750-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2005] [Accepted: 03/14/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND The treatment of empyema with pleural drainage is a widely accepted surgical procedure. Currently, thoracoscopy often is used to treat this disease in some thoracic surgery centers. This report aims to present the authors' experience with the treatment of pleural empyema and the benefits of thoracoscopy. METHODS From 1997 to 2005, 49 children with a diagnosis of pleural empyema were treated by means of thoracoscopy in the authors' department. The study group consisted of 21 girls and 28 boys, ages 1 to 17 years (mean age, 9.2 years). Thoracoscopic cleaning and drainage of the pleural cavity was performed for all the patients. RESULTS Intraoperatively, stage I empyema was recognized in 7 children (14.3%), stage II in 30 children (61.2%), and stage III in 12 children (24.5%). Very good results were obtained for all the patients. There were no intra- or postoperative major complications. The drainage time was less than 5 days for 63.3% of the children. In the remaining group of patients, drainage exceeded 8 days only for 16.3%. The postoperative time was short. Emptying of the pleural cavity and full lung decompression were achieved in all cases. In four cases, pleural biopsy showed TB, which enabled early proper treatment. CONCLUSIONS Thoracoscopy can offer good visualization and cleansing of the empyema chambers, establishing efficient drainage even for patients with advanced stages of pleural empyema. Thoracoscopy enables collection of material not only for bacteriologic, but also for histopathologic examination. The method is minimally invasive, and risk for complication is comparable with that for classical thorax drainage.
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Affiliation(s)
- J Dzielicki
- Department of Pediatric Surgery, Medical University of Silesia, 3 Maja 13-15, Zabrze, 41-800, Poland
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Schiza S, Siafakas NM. Clinical presentation and management of empyema, lung abscess and pleural effusion. Curr Opin Pulm Med 2006; 12:205-11. [PMID: 16582676 DOI: 10.1097/01.mcp.0000219270.73180.8b] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Pleural effusions, lung abscess and empyema remain a commonly encountered clinical problem and a significant source of morbidity. The aim of this review is to summarize recent developments with emphasis on controlled trials. RECENT FINDINGS There is wide variation in the management of infectious pleural effusions, partly because of the relative lack of randomized controlled trials. The recent MRC/BTS UK controlled trial of interapleural streptokinase for pleural infection assessed the efficacy of intrapleural streptokinase compared with placebo in complicated parapneumonic effusions. The study showed no difference in the primary end point, mortality, or in the need for surgery or length of the hospital stay among patients with pleural infection. The first large report published for over a decade has suggested that the bacteriological characteristics of lung abscess have changed. SUMMARY The major recent development in the management of pleural infections is the finding that we should dampen the ardor for the routine use of fibrinolytic agents in all patients with pleural infections. We strongly recommend the necessity for additional, well-designed trials to help determine optimal care for these seriously ill patients.
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Affiliation(s)
- Sophia Schiza
- Department of Thoracic Medicine, Medical School, University of Crete, Heraklion, Greece
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Schiza SE, Antoniou KM, Economidou FN, Siafakas NM. Pharmacotherapy in complicated parapneumonic pleural effusions and thoracic empyema. Pulm Pharmacol Ther 2005; 18:381-9. [PMID: 15998594 DOI: 10.1016/j.pupt.2004.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2004] [Revised: 12/01/2004] [Accepted: 12/03/2004] [Indexed: 10/25/2022]
Abstract
Parapneumonic pleural effusions (PPE) and pleural empyema (PE) present a frequently diagnostic and therapeutic challenge in clinical practice. Although pleural diseases have received increased attention during the past decade, there are still many unanswered questions concerning the diagnosis and treatment of PPE and PE. A lack of controlled studies concerning the management of PPE and PE was noted in recent guidelines. The use of fibrinolytics intrapleurally appears to enhance intercostals tube drainage, reducing the requirement for subsequent surgical mechanical debridement. Recently, there has been interest in other intrapleural agents including combination drugs consisting of streptokinase and streptodornase-alpha, Dnase. Factors to be considered in evaluating whether or not intrapleural instillation of fibrinolytics is effective include an assessment of clinical responses. This review discusses the use of fibrinolytic agents as a novel therapeutic options for treating the various stages of parapneumonic effusions and empyemas.
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Affiliation(s)
- Sophia E Schiza
- Department of Thoracic Medicine, University Hospital of Heraklion, P.O. Box 1352, 71110 Heraklion, Greece
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21
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Abstract
Pleuroscopy provides the pulmonologist with a unique opportunity to visualize the contents of the pleural space, perform biopsy of the parietal pleura under direct visual guidance, allow optimal chest tube placement and perform pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. We discuss the techniques, indications, contraindications and complications of pleuroscopy using rigid and semirigid instruments. In addition, the potential value and expanding role of pleuroscopy with semirigid instrumentation is debated.
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Affiliation(s)
- Pyng Lee
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore.
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Skeete DA, Rutherford EJ, Schlidt SA, Abrams JE, Parker LA, Rich PB. Intrapleural Tissue Plasminogen Activator for Complicated Pleural Effusions. ACTA ACUST UNITED AC 2004; 57:1178-83. [PMID: 15625447 DOI: 10.1097/01.ta.0000141879.67441.52] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study is aimed at evaluating the safety and efficacy of intrapleural tissue plasminogen activator (TPA) for complicated pleural effusions, including posttraumatic hemothorax. METHODS Data were retrospectively collected from hospitalized patients over a 4-year period (1999-2003) who were treated with intrapleural TPA after failing drainage by tube thoracostomy. Pre- and post-TPA imaging studies were reviewed and scored by a blinded radiologist. RESULTS Forty-one consecutive patients with 42 effusions were identified with the following indications: 6 traumatic hemothoraces (14%), 22 loculated pleural effusions (52%), 2 line-associated hemothoraces (5%), and 12 empyemas (29%). Nine patients (22%) required operative drainage including two with posttraumatic hemothoraces. All patients managed nonoperatively demonstrated radiographic improvement after TPA administration. One patient (2.4%) developed hematuria, requiring transfusion. No trauma patient required TPA-related blood transfusion and no deaths were attributable to TPA therapy. CONCLUSION Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.
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Affiliation(s)
- Dionne A Skeete
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Abstract
Chronic lung infections including lung abscess, bronchiectasis, and empyema remain serious medical diseases despite the availability of antimicrobial agents. Recent publications contribute to our understanding of disease pathogenesis and management of these entities. The microbial pathogen of lung abscess may be different comparing immunocompetent with immunocompromised patients, supporting a concept for aggressive diagnostic investigations and targeting of specific potential pathogens. The use of surgery in bronchiectasis may be declining, but surgical intervention remains an important strategy with favorable outcomes, especially in cases of focal bronchiectasis. For empyema, maintaining a high index of clinical suspicion may allow for diagnostic thoracentesis in patients with pleural effusions and allow initiation of appropriate tube thoracotomy drainage and use of fibrinolytics. With appropriate management, morbidity and mortality may be limited and outcomes generally favorable.
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