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Ferreiro L, Porcel JM, Bielsa S, Toubes ME, Álvarez-Dobaño JM, Valdés L. Management of pleural infections. Expert Rev Respir Med 2018; 12:521-535. [DOI: 10.1080/17476348.2018.1475234] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Lucía Ferreiro
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - José M. Porcel
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - Silvia Bielsa
- Pleural Medicine Unit. Department of Internal Medicine, Arnau de Vilanova University Hospital. Lleida, SPAIN
- Dr. Pifarré Foundation Biomedical Research Institute, IRBLLEIDA, Lleida, SPAIN
| | - María Elena Toubes
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
| | - José Manuel Álvarez-Dobaño
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
| | - Luis Valdés
- Pneumology Service, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, SPAIN
- Interdisciplinary Group of Research in Pneumology, Institute of Health Research of Santiago de Compostela (IDIS), Santiago de Compostela, SPAIN
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Abstract
Pleural cavity infection continuously seriously threatens human health with continuous medical progress. From the perspective of pathophysiology, it can be divided into three stages: exudative stage, fibrin exudation and pus formation stage, and organization stage. Due to the pathogenic bacteria difference of pleural cavity infection and pulmonary infection, it is very important for disease treatment to analyze the bacteria and biochemical characteristics of the infectious pleural effusion. Most prognoses of patients have been relatively good, while for some patients, the complicated parapneumonic effusion or empyema could be evolved. Antibiotic treatment and sufficient drainage are the foundation for this treatment. No evidence can support the routine use of a fibrin agent. However, it has been reported that the plasminogen activator and deoxyribonuclease can be recommended to be applied in the pleural cavity. In case of failure on conservative medical treatment, operative treatment can be applied such as thoracoscopy and pleural decortication. According to the clinical characteristics of these patients, it is a key to research prognosis, as well as early evaluation and stratification, in the future.
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Affiliation(s)
- Wei Yang
- Department of Respiratory Medicine, Medical School of Chinese PLA, Beijing 100853, China
| | - Bo Zhang
- Department of Respiratory Medicine, Medical School of Chinese PLA, Beijing 100853, China
| | - Ze-Ming Zhang
- Department of Respiratory Medicine, Pudong New Area Zhoupu Hospital, Shanghai 201318, China
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Hsiao CH, Chen KC, Chen JS. Modified single-port non-intubated video-assisted thoracoscopic decortication in high-risk parapneumonic empyema patients. Surg Endosc 2016; 31:1719-1727. [PMID: 27519590 DOI: 10.1007/s00464-016-5164-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/30/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction are risky to receive surgical decortication under general anesthesia. Non-intubated video-assisted thoracoscopy surgery is successfully performed to avoid complications of general anesthesia. We performed single-port non-intubated video-assisted flexible thoracoscopy surgery in an endoscopic center. In this study, the possible role of our modified surgery to treat fibrinopurulent stage of parapneumonic empyema with high operative risks is investigated. METHODS We retrospectively reviewed fibrinopurulent stage of parapneumonic empyema patients between July 2011 and June 2014. Thirty-three patients with coronary artery disease and reduced left ventricular ejection fraction were included in this study. One group received tube thoracostomy, and the other group received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. Patient demographics, characteristics, laboratory findings, etiology, and treatment outcomes were compared. RESULTS Mean age of 33 patients (24 males, 9 females) was 76.2 ± 9.7 years. Twelve patients received single-port non-intubated video-assisted flexible thoracoscopy surgery decortication, and 21 patients received tube thoracostomy. Visual analog scale scores on postoperative first hour and first day were not significantly different in two groups (p value = 0.5505 and 0.2750, respectively). Chest tube drainage days, postoperative fever subsided days, postoperative hospital days, and total length of stay were significantly short in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication (p value = 0.0027, 0.0001, 0.0009, and 0.0065, respectively). Morbidities were low, and mortality was significantly low (p value = 0.0319) in single-port non-intubated video-assisted flexible thoracoscopy surgery decortication. CONCLUSIONS Single-port non-intubated video-assisted flexible thoracoscopy surgery decortication may be suggested to be a method other than tube thoracostomy to deal with fibrinopurulent stage of parapneumonic empyema patients with coronary artery disease and reduced left ventricular ejection fraction.
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Affiliation(s)
- Chen-Hao Hsiao
- Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, National Taiwan University and Academia Sinica, Taipei, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan S. Rd, Taipei, 10002, Taiwan.
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan.
- Division of Experimental Surgery, National Taiwan University Hospital, Taipei, Taiwan.
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Safety and Efficacy of Intrapleural Tissue Plasminogen Activator and DNase during Extended Use in Complicated Pleural Space Infections. Can Respir J 2016; 2016:9796768. [PMID: 27445574 PMCID: PMC4944060 DOI: 10.1155/2016/9796768] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 06/01/2016] [Accepted: 06/13/2016] [Indexed: 11/24/2022] Open
Abstract
The use of intrapleural therapy with tissue plasminogen activator and DNase improves outcomes in patients with complicated pleural space infections. However, little data exists for the use of combination intrapleural therapy after the initial dosing period of six doses. We sought to describe the safety profile and outcomes of intrapleural therapy beyond this standard dosing. A retrospective review of patients receiving intrapleural therapy with tissue plasminogen activator and DNase was performed at two institutions. We identified 101 patients from January 2013 to August 2015 receiving intrapleural therapy for complicated pleural space infection. The extended use of intrapleural tissue plasminogen activator and DNase therapy beyond six doses was utilized in 20% (20/101) of patients. The mean number of doses in those undergoing extended dosing was 9.8 (range of 7–16). Within the population studied there appears to be no statistically significant increased risk of complications, need for surgical referral, or outcome differences when comparing those receiving standard or extended dosing intrapleural therapy. Future prospective study of intrapleural therapy as an alternative option for patients who fail initial pleural drainage and are unable to tolerate/accept a surgical intervention appears a potential area of study.
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Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. THE LANCET RESPIRATORY MEDICINE 2016; 3:563-77. [PMID: 26170076 DOI: 10.1016/s2213-2600(15)00185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/09/2023]
Abstract
Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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Abstract
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.
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Croft DP, Philippo SM, Prasad P. A case of Lemierre's syndrome with septic shock and complicated parapneumonic effusions requiring intrapleural fibrinolysis. Respir Med Case Rep 2015; 16:86-8. [PMID: 26744664 PMCID: PMC4681974 DOI: 10.1016/j.rmcr.2015.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/20/2015] [Indexed: 12/03/2022] Open
Abstract
Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein, which can lead to severe systemic illness. We report a case of an otherwise healthy 26-year-old man who suffered from pharyngitis followed by septic shock requiring intubation and vasopressor support from Fusobacterium necrophorum bacteremia. The septic emboli to his lungs caused complicated bilateral parapneumonic effusions, which recurred after initial drainage. He required bilateral chest tubes and intrapleural tPA to successfully drain his effusions. His fever curve and overall condition improved with the resolution of his effusions and after a 33-day hospitalization, he recovered without significant disability. The severity of his illness and difficult to manage complicated parapneumonic effusions were the unique facets of this case. Using an evidence-based approach of tPA and DNase for complicated parapneumonic effusions in Lemierre's syndrome can be safe and effective.
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Affiliation(s)
- Daniel P. Croft
- University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA
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Ferreiro L, San José ME, Valdés L. Management of Parapneumonic Pleural Effusion in Adults. Arch Bronconeumol 2015; 51:637-46. [PMID: 25820035 DOI: 10.1016/j.arbres.2015.01.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/15/2015] [Accepted: 01/16/2015] [Indexed: 11/30/2022]
Abstract
Pleural infections have high morbidity and mortality, and their incidence in all age groups is growing worldwide. Not all infectious effusions are parapneumonic and, in such cases, the organisms found in the pleural space are not the same as those observed in lung parenchyma infections. The diagnostic difficulty lies in knowing whether an infectious effusion will evolve into a complicated effusion/empyema, as the diagnostic methods used for this purpose provide poor results. The mainstays of treatment are to establish an early diagnosis and to commence an antibiotic regimen and chest drain as soon as possible. This should preferably be carried out with fine tubes, due to certain morphological, bacteriological and biochemical characteristics of the pleural fluid. Fluid analysis, particularly pH, is the most reliable method for assessing evolution. In a subgroup of patients, fibrinolytics may help to improve recovery, and their combination with DNase has been found to obtain better results. If medical treatment fails and surgery is required, video-assisted thoracoscopic surgery (VATS) is, at least, comparable to decortication by thoracotomy, so should only undertaken if previous techniques have failed. Further clinical trials are needed to analyze factors that could affect the results obtained, in order to define new evidence-based diagnostic and therapeutic strategies that provide more effective, standardized management of this disease.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - María Esther San José
- Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
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Affiliation(s)
- Gene L Colice
- George Washington University School of Medicine & Health Sciences, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington, DC.
| | - Steven Idell
- School of Medical Biological Sciences, The University of Texas Health Science Center at Tyler, Tyler, TX
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Thommi G, Shehan CJ, Mcleay MT. Fibrinolytics in parapneumonic effusions/empyemas. Chest 2015; 146:e103-e104. [PMID: 25180732 DOI: 10.1378/chest.14-0706] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- George Thommi
- Pulmonary Department, Creighton Medical Center, Omaha, NE.
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Corcoran JP, Rahman NM. Response. Chest 2014; 146:e105-e106. [PMID: 25180734 DOI: 10.1378/chest.14-1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford Respiratory Trials Unit, University of Oxford, Oxford, England
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals; Oxford Respiratory Trials Unit, University of Oxford, NIHR Oxford Biomedical Research Centre, Oxford, England.
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Corcoran JP, Rahman NM. Response. Chest 2014; 146:e71-2. [PMID: 25091777 DOI: 10.1378/chest.14-1007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Affiliation(s)
- Gene L Colice
- George Washington University School of Medicine & Health Sciences, Washington, DC; Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington, DC.
| | - Steven Idell
- School of Medical Biological Sciences, The University of Texas Health Science Center at Tyler, Tyler, TX
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