Abstract
RationaleOptimal management of complicated parapneumonic effusions (CPPE) remains controversial.Objectivesto assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital.MethodsPatients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death.ResultsSeventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44–40.67] and 6.97 [95% CI, 1.86–26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed.ConclusionsAlthough not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness.
Highlights
Pleural infection is a common clinical problem associated with significant morbidity and mortality [1,2]
Most guidelines recommend that complicated parapneumonic effusions (CPPE) be evacuated, in addition to appropriate antibiotics [3], but the optimal evacuation method remains controversial and poorly standardized
We report our experience of systematic use of iterative therapeutic thoracentesis (ITTC) as first-line treatment in CPPE, focusing on efficacy, tolerability, and risk factors for failure
Summary
Pleural infection is a common clinical problem associated with significant morbidity and mortality [1,2]. Most guidelines recommend that complicated parapneumonic effusions (CPPE) be evacuated, in addition to appropriate antibiotics [3], but the optimal evacuation method remains controversial and poorly standardized. Current options include iterative therapeutic thoracentesis (ITTC), chest tube drainage, video-assisted thoracoscopic surgery (VATS), or thoracotomy. Few randomized studies compared evacuation methods in CPPE, but no consensus could be reached from these studies, due to their limited sample size, and heterogeneity [5,7]. ITTC has long been the first-line treatment to remove infected pleural fluid in CPPE, in association with systemic antibiotics. The theoretical benefits associated with this procedure include shorter immobilization, and limited use of thromboprophylaxis and analgesics, as compared to chest tube drainage or surgery
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