Complicated Parapneumonic Effusion Research Articles

Metabolomics Reveals Anaerobic Bacterial Fermentation and Hypoxanthine Accumulation for Fibrinous Pleural Effusions in Children with Pneumonia.

Fibrin formation in infectious parapneumonic effusion (IPE) characterizes complicated parapneumonic effusion and is important for providing guidelines for the management of IPEs that require aggressive interventions. We aim to identify metabolic mechanisms associated with bacterial invasion, inflammatory cytokines, and biochemical markers in cases of fibrinous infectious pleural effusions in children with pneumonia. Pleural fluid metabolites were determined by 1H nuclear magnetic resonance spectroscopy. Metabolites that contributed to the separation between fibrinous and nonfibrinous IPEs were identified using supervised partial least squares discriminant analysis ( Q2/ R2 = 0.84; Ppermutation < 0.01). IL-1β in the inflammatory cytokines and glucose in the biochemical markers were significantly correlated with 11 and 9 pleural fluid metabolites, respectively, and exhibited significant overlaps. Four metabolites, including glucose, lactic acid, 3-hydroxybutyric acid, and hypoxanthine, were significantly correlated with plasminogen activator inhibitor type 1 in the fibrinolytic system enzymes. Metabolic pathway analysis revealed that anaerobic bacterial fermentation with increased lactic acid and butyric acid via glucose consumption and adenosine triphosphate hydrolysis with increased hypoxanthine appeared to be associated with fibrinous IPE. Our results demonstrate that an increase in lactic acid anaerobic fermentation and hypoxanthine accumulation under hypoxic conditions are associated with fibrin formation in IPE, representing advanced pleural inflammatory progress in children with pneumonia.

Comparison of analytical performance of i-Smart 300 and pHOx ultra for the accurate determination of pleural fluid pH

BackgroundPleural fluid pH is an essential test for diagnosing complicated parapneumonic effusion. We evaluated the performance of two blood gas analyzers in measuring pleural fluid pH. MethodsThe i-STAT G3+ (Abbott) was used as a reference analyzer to evaluate the pH values obtained from other methods: the i-Smart 300 (i-SENS), the pHOx Ultra (Nova Biomedical), using a clot catcher to filter off microclot, and pH indicator paper. Within-device precision was performed using quality control materials. We compared pleural fluid pH (n = 86) by the above methods and analyzed the concordance rate at the level of the medical decision point, pH 7.2. ResultsThe within-device coefficient of variations of pH were below 0.1% for all blood gas analyzers tested. The slopes of the regression equations for the i-Smart 300, pHOx Ultra, and pH indicator paper against the reference analyzer were 0.850 (95% confidence interval, CI, 0.800–0.896), 0.714 (95% CI, 0.671–0.766), and 1.105 (95% CI, 0.781–1.581), respectively. The kappa values for the i-Smart 300, pHOx Ultra, and pH indicator paper against the reference analyzer were 0.883 (95% CI, 0.656–1.110), 0.739 (95% CI, 0.393–1.084), and 0.464 (95% CI, 0.102–0.826), respectively. ConclusionsThe i-Smart 300 and pHOx Ultra demonstrated good analytical performance and diagnostic accuracy when determining pleural fluid pH compared with that by the i-STAT G3+, whereas the pH indicator paper showed unsatisfactory results.

Community-Acquired Pneumonia with Negative Chest Radiography Findings: Clinical and Radiological Features

Background: Data regarding community-acquired pneumonia (CAP) identified on chest computed tomography (CT) but not on chest radiography (CR) are limited. Objectives: The present study aimed to investigate the clinical and radiological features of these patients. Methods: We retrospectively compared the clinical characteristics, etiological agents, treatment outcomes, and CT findings between CAP patients with negative CR and positive CT findings (negative CR group) and those with positive CR as well as CT findings (control group). Results: Of 1,925 patients, 94 patients (4.9%) were included in the negative CR group. Negative CR findings could be attributed to the location of the lesions (e.g., those located in the dependent lung) and CT pattern with a low attenuation, such as ground-glass opacity (GGO). The negative CR group was characterized by a higher frequency of aspiration pneumonia, lower incidences of complicated parapneumonic effusion or empyema and pleural drainage, and lower blood levels of inflammatory markers than the control group. On CT, the negative CR group exhibited higher rates of GGO- and bronchiolitis-predominant patterns and a lower rate of consolidation pattern. Despite shorter length of hospital stay in the negative CR group, 30-day and in-hospital mortalities were similar between the two groups. Conclusions: CAP patients with negative CR findings are characterized by lower blood levels of inflammatory markers, a higher incidence of aspiration pneumonia, and a lower incidence of complicated para­pneumonic effusion or empyema than those with positive CR findings. Chest CT scan should be considered in suspected CAP patients with a negative CR, especially in bedridden patients.

Management of parapneumonic effusion and empyema

Parapneumonic effusions are pleural effusions that occur in the pleural space adjacent to a bacterial pneumonia. When bacteria invade the pleural space, a complicated parapneumonic effusion or empyema may result. Empyema is collection of pus in pleural cavity. If left untreated, complicated parapneumonic effusion/empyema leads to chronic encasement and pleural thickening. Simple parapneumonic effusions can be managed conservatively with appropriate antibiotics, but complicated parapneumonic effusions often require some kind of drainage along with antibiotics. Delay in treatment is associated with high morbidity and mortality. Clinically it is diagnosed with persistent fever, stony dull tender percussion, and absent breath sounds. Majority of cases are due to anaerobic infection. Gram-positive as well as Gram-negative organisms are also implicated. Many cases may have mixed organisms. Tuberculosis should be suspected if no organism is grown in empyema. Chest skiagram, thoracic ultrasound, and CT scan help in localization of effusion and detection of loculations. Confirmation is done by thoracocentesis and pleural fluid analysis, which shows exudate with polymorphonuclear leukocytosis. Management includes well-selected antibiotics and drainage by tube thoracostomy. Intrapleural fibrinolytics have been used in multiloculated complicated parapneumonic effusions with success. Advent of thoracoscopy and VATS has left very few cases requiring surgical decortication. Properly treated parapneumonic effusions have good prognosis.

Diagnostic performance of C-reactive protein for parapneumonic pleural effusion: a meta-analysis.

Parapneumonic pleural effusion (PPE) refers to effusion secondary to lung infection, the accurate diagnosis of which remains a clinical challenge. Many studies have suggested that the C-reactive protein (CRP) may be useful for diagnosing PPE, but the results have varied. This study aimed to summarize the overall diagnostic ability of serum/pleural CRP for PPE through a meta-analysis. Eligible studies were searched for within PubMed, EMBASE, and other databases up to March 1, 2018. The main diagnostic indexes, sensitivity, specificity, positive likelihood ratio/negative likelihood ratio (PLR/NLR), and diagnostic odds ratio (DOR), were then pooled from the individual studies. The summary receiver operating characteristic curves and area under the curve (AUC) were used to summarize the overall test performance. Eighteen publications were included in this meta-analysis. Summary estimates of the diagnostic performance of pleural CRP for PPE were as follows: sensitivity, 0.80; specificity, 0.82; PLR, 4.51; NLR, 0.25; DOR, 18.26; and AUC, 0.88. The AUC of serum CRP in diagnosing PPE was 0.79. The diagnostic indexes for pleural CRP in differentiating complicated PPE (CPPE) from uncomplicated PPE were as follows: sensitivity, 0.65; specificity, 0.85; PLR, 4.26; NLR, 0.41; DOR, 10.38; and AUC, 0.83. There was no evidence of publication bias. Both serum and pleural CRP help to diagnose PPE but with moderate diagnostic ability. Pleural CRP measurements also can aid in differentiating CPPE from uncomplicated PPE. However, the results of the CRP assay should be interpreted with additional biomarker tests.

Syndrome Evaluation System Contributes to Higher and Faster Pathogen Identification with Superior Clinical Correlation as Compared to Conventional Cultures in Patients with Empyema and Parapneumonic Effusions

Background & Objective: Pleural fluid culture is the standard of diagnosis for infectious etiology in parapneumonic effusion and empyema. However, the sensitivity is poor in tertiary centers due to prior antibiotic therapy. Newer nonculture-based molecular diagnostics are emerging as effective alternatives for microbial diagnosis. This prospective study evaluates the efficacy of Syndrome Evaluation System (SES), a multiplex molecular diagnostic test, in establishing the microbial etiology of empyema and clinical correlations of SES results with severity, interventions, and outcomes. Materials and Methods: Pleural fluid samples from 31 adult patients clinically diagnosed with empyema/complicated parapneumonic effusion were subjected to routine culture and SES. Routine laboratory tests, imaging, and antibiotic therapy were instituted as per standard care. Results: SES had 2.6-fold higher detection rate as compared to pleural fluid culture. A total of 16 samples (52%) were positive for pathogens on SES, whereas only six samples (20%) were positive on culture. SES was 83.33% concordant with culture. SES results were available within 24 h as compared to >72 h for culture. Prevalence of Gram-negative bacteria was 73.1%. SES positives were significantly associated with severity of disease and need to conduct more invasive procedures like thoracotomy and decortication. SES negatives had superior clinical outcomes compared to SES positives. Conclusion: SES has higher yield in microbial diagnosis compared to standard culture. It is sensitive, specific, and provides valuable information regarding a number of clinical correlates associated with empyema and complicated parapneumonic effusion. SES opens up new possibilities in understanding pathogenesis, management, and outcome in empyema.

Uniportal video-assisted thoracic surgery in the treatment of pleural empyema.

The efficacy of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has recently been proven. Till today, very few works evaluated the role of uniportal-VATS (U-VATS) approach in the treatment of pleural empyema even if it currently represents the most innovative and less invasive thoracoscopic approach. We report our experience with U-VATS in the treatment of pleural empyema. A retrospective bicentric analysis of 35 consecutive patients who underwent surgical treatment of stage II and stage III pleural empyema was performed, from January 2015 to May 2017. The mean age of patients was 57.26±18.29 years and 54.3% of them were males. In 85.7% of the cases, empyema was related to a complicated parapneumonic effusion; in only 5 cases it was a post-surgical consequence. All patients were treated with broad-spectrum antibiotics and subsequent target therapy for 14.62±21.76 days prior to operation and 23 patients needed the placement of a chest tube. Twenty patients (57.1%) presented with stage III, 11 patients (31.4%) stage II and 4 patients (11.4%) stage I empyema. Complete debridement and decortication were obtained in all patients through U-VATS approach and no conversion or further access was needed for any reason. No major complication was recorded. Only 2 cases of trapped lung were not responsive to surgical treatment. At a mean follow-up of 247.42±306.29 days, 33 patients (94.3%) were alive with no recurrence, 2 patients died for causes unrelated to the operation. According to our experience, we consider U-VATS as an adequate procedure in the treatment of "stages II and III" empyemas when the necessary surgical expertise has been achieved. Indeed, U-VATS permits an easier performance and complete debridement and decortication, with a very low risk for conversion and excellent postoperative outcomes in terms of less pain, fast recovery and cosmetic results.

RELATIONSHIP BETWEEN CLINICAL FEATURES AND CT FINDINGS IN HOSPITALIZED ADULT PATIENTS WITH COMMUNITY-ACQUIRED PNEUMONIA

SESSION TITLE: Chest Infections 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 PM - 02:00 PM PURPOSE: Data on the relationship between the clinical and microbiological features of community-acquired pneumonia (CAP) and its computed tomography (CT) findings are limited. The aim of the present study was to investigate the clinic-microbiological features of patients with CAP presenting with ground-glass opacity (GGO) and centrilobular nodules or tree-in-bud pattern on CT images. METHODS: Patients with CAP that underwent a CT scan at presentation were retrospectively classified using CT findings into consolidation, GGO, and bronchiolitis groups. These three groups were compared in terms of clinical parameters and microbiological data. RESULTS: Forty (2.4%) patients were allocated to the bronchiolitis group and 46 (2.8%) to the GGO group. The most common pathogen in the bronchiolitis group was Mycoplasma pneumoniae, which was significantly more frequently isolated in this group. The bronchiolitis group was characterized by a higher percentage of cough, a lower percentage of chest pain, and lower blood levels of inflammatory markers. Common pathogens in the GGO group were not significantly different from those in the other two groups. Unlike that observed in the consolidation group, complicated parapneumonic effusion or empyema was not observed in the bronchiolitis or GGO group. Outcome variables were similar in the three groups. CONCLUSIONS: The bronchiolitis group was characterized by a higher frequency of M. pneumoniae and a less severe form of CAP. The GGO and consolidation groups was similar with respect to causative microorganisms and the clinical features of CAP. No patient in the bronchiolitis or GGO group exhibited complicated parapneumonic effusion or empyema. CLINICAL IMPLICATIONS: 1) The bronchiolitis group was associated with a higher M. pneumoniae frequency, a less severe form of CAP, and the absence of complicated parapneumonic effusion or empyema. 2) The GGO group was similar to the consolidation group in terms of causative microorganisms, severity, and prognosis, but unlike the consolidation group, was not found to be associated with complicated parapneumonic effusion or empyema. 3) The bronchiolitis and GGO groups were similar to the consolidation group in terms of 30-day or in-hospital mortality and LOS. DISCLOSURES: No relevant relationships by Seung Ick Cha, source=Web Response No relevant relationships by Hyewon Seo, source=Web Response

Predicting Complicated Parapneumonic Effusion in Community Acquired Pneumonia: Hospital Based Case-Control Study.

To identify predictors of complicated parapneumonic effusion (CPE)/empyema in patients of community acquired pneumonia (CAP) by using clinical and simple laboratory variables like hemoglobin (Hb), serum C-reactive protein (CRP), serum albumin (SA) levels and total leukocyte counts (TLC). This prospective case-control study was conducted after institutional ethical approval. Subjects between ages of 2-59 mo with World Health Organization (WHO) defined CAP with written, informed parental consent were included. Cases had CAP with CPE/empyema diagnosed by pleurocentesis. Controls had severe CAP without significant pleural collection on chest X-ray (CXR). Patients with congenital and chronic diseases/infections and possible immune deficiency were excluded. Variables with univariate association with case-control status were considered as potential predictors. Final prediction model was developed by Forward Stepwise Logistic Regression (FSLR). Adjusted odd's ratios (Adj OR) were smoothened into nearest whole numbers to develop KGMU-CPE score. From 2016 to 17, 30 cases (66.6% males, age 38.7 + 14.9 mo) and 118 controls (78% males, age 17.8 + 16.9 mo) were included. In FSLR, predictors of CPE/empyema were ibuprofen intake (adj OR 6.8; 95%CI: 1.07-43.6), infective focus elsewhere (adj OR 28.2; 95%CI: 1.4-563.1), hypoalbuminemia <3.1g/dL (adj OR 6.9; 95%CI: 1.22-39.3), serum CRP >20mg/dL (adj OR 59; 95%CI: 1.86-1874.7), Hb <10g/dL (adj OR 21.1; 95%CI: 2.8-158.1) and TLC >10,000 (adj OR 37; 95%CI: 5.7-239.8) and these six variables formed KGMU-CPE Score with a minimum score of 0 and maximum of 25. KGMU-CPE score area under the ROC curve was 0.97 and cut- off 15.55 had sensitivity of 80% and specificity of 94% for predicting CPE/empyema. Using simple clinical and laboratory parameters it is possible to predict CAP with CPE/empyema. Use of ibuprofen is to be avoided in CAP as it associated with CPE. KGMU-CPE score had good diagnostic accuracy and needs external validation.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score

Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. Treatment success rate was 71%, and the 90day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

Features of Parapneumonic Effusions.

Abstract 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 &lt;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.

Chest imaging for the diagnosis of complicated parapneumonic effusions.

To provide an overview of the contribution of thoracic ultrasound (TUS) and computed tomography (CT) in the identification of complicated parapneumonic effusions (CPPE), defined as those which need chest tube drainage for resolution. A recent retrospective study found that visualization of complex (nonanechoic) effusions on TUS (likelihood ratio positive = 6.92) outperformed the recognition of loculated/septated effusions on CT (likelihood ratio = 2.20) or chest radiographs (likelihood ratio = 1.54) for predicting a CPPE. In another retrospective study, a weighted CT scoring system consisting of pleural contrast enhancement (three points), pleural microbubbles, increased extrapleural fat attenuation, and fluid volume at least 400 ml (one point each) had relatively good accuracy for labeling CPPE (likelihood ratio positive = 3.4; likelihood ratio negative = 0.22) when four or more points were achieved. Although a gold standard for CPPE diagnosis is lacking, bedside TUS primarily, and CT scan in certain circumstances, may help to drive clinical decisions regarding chest tube placement in parapneumonic effusions (PPE). However, recommendations are limited by the absence of prospective trials.

Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children \u2013 16-year, single-centre experience of radiologically placed drains

BackgroundChest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion.ObjectiveTo evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital.Materials and methodsThis was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre.ResultsThree hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery.ConclusionOur technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.

Relationship Between Clinical Features and Computed Tomographic Findings in Hospitalized Adult Patients With Community-Acquired Pneumonia

BackgroundData on the relationship between the clinical and microbiological features of community-acquired pneumonia (CAP) and its computed tomography (CT) findings are limited. The aim of the present study was to investigate the clinic-microbiological features of patients with CAP presenting with ground-glass opacity (GGO) and centrilobular nodules or tree-in-bud pattern on CT images. MethodsPatients with CAP who underwent a CT scan at presentation were retrospectively classified using CT findings into consolidation, GGO and bronchiolitis groups. These 3 groups were compared in terms of clinical parameters and microbiological data. ResultsA total of 40 patients (2.4%) were allocated to the bronchiolitis group and 46 (2.8%) to the GGO group. The most common pathogen in the bronchiolitis group was Mycoplasma pneumoniae, which was significantly more frequently isolated in this group. The bronchiolitis group was characterized by a higher percentage of cough, a lower percentage of chest pain and lower blood levels of inflammatory markers. Common pathogens in the GGO group were not significantly different from those in the other 2 groups. Unlike that observed in the consolidation group, complicated parapneumonic effusion or empyema was not observed in the bronchiolitis or GGO group. Outcome variables were similar in the 3 groups. ConclusionsThe bronchiolitis group was characterized by a higher frequency of M. pneumoniae and a less severe form of CAP. The GGO and consolidation groups was similar with respect to causative microorganisms and the clinical features of CAP. No patient in the bronchiolitis or GGO group exhibited complicated parapneumonic effusion or empyema.

Videothoracoscopic surgery before and after chest tube drainage for children with complicated parapneumonic effusion

ObjectivesTo evaluate the effectiveness of videothoracoscopic surgery in the treatment of complicated parapneumonic pleural effusion and to determine whether there is a difference in the videothoracoscopic surgery outcome before or after the chest tube drainage. MethodsThe medical records of 79 children (mean age 35 months) undergoing videothoracoscopic surgery from January 2000 to December 2011 were retrospectively reviewed. The same treatment algorithm was used in the management of all patients. Patients were divided into two groups: in group 1, videothoracoscopic surgery was performed as the initial procedure; in group 2, videothoracoscopic surgery was performed after previous chest tube drainage. ResultsVideothoracoscopic surgery was effective in 73 children (92.4%); the other six (7.6%) needed another procedure. Sixty patients (75.9%) were submitted directly to videothoracoscopic surgery (group 1) and 19 (24%) primarily underwent chest tube drainage (group 2). Primary videothoracoscopic surgery was associated with a decrease of hospital stay (p = 0.05), time to resolution (p = 0.024), and time with a chest tube (p < 0.001). However, there was no difference between the groups regarding the time until fever resolution, time with a chest tube, and the hospital stay after videothoracoscopic surgery. No differences were observed between groups regarding the need for further surgery and the presence of complications. ConclusionsVideothoracoscopic surgery is a highly effective procedure for treating children with complicated parapneumonic pleural effusion. When videothoracoscopic surgery is indicated in the presence of loculations (stage II or fibrinopurulent), no difference were observed in time of clinical improvement and hospital stay among the patients with or without chest tube drainage before videothoracoscopic surgery.

Rethinking the Doses of Tissue Plasminogen Activator and Deoxyribonuclease Administrated Concurrently for Intrapleural Therapy for Complicated Pleural Effusion and Empyema.

BackgroundComplicated parapneumonic effusions empyema (CPEE) is fairly common and associated with increased morbidity and mortality. The Multicenter Intrapleural Sepsis Trial 2 (MIST 2) established the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (tPA) as an effective treatment for CPEE, thereby avoiding surgery and decreasing the length of hospitalization. MIST 2, however, used a labor-intensive protocol with some risk of bleeding. We hypothesize the simpler regimen of concurrent administration of intrapleural tPA and DNase (lower dose of tPA and a higher DNAse dose) to be equally effective with a decreased risk of bleeding.MethodsRetrospective analysis of the concurrent administration of intrapleural tPA and DNase for CPEE during November 2014 to February 2016 was done at a tertiary care center. The inclusion criteria included 1) pleural fluid with any of the following: (a) exudative and loculated effusion in a patient with pneumonia, (b) gram stain/culture positive, (c) macroscopically purulent 2) chest tube placement during current hospitalization 3) concurrent administration of intrapleural tPA and DNase (4mg and 10mg per instillation respectively). The exclusion criteria was 1) chest tube placement prior to current hospitalization and 2) age < eighteen.ResultsSeventeen patients received concurrent tPA and DNase therapy for CPEE in the study period. Two had chest tubes placed prior to current hospitalization and were excluded. Twelve patients (80%) were successfully discharged with clinical resolution of CPEE with medical therapy. One (7%) patient required surgery. No mortality due to pleural sepsis was noted. The median number of concurrent tPA and DNase treatment was two. Median cumulative tPA dose was 8 mg (mean: 14.1±17 mg) and median cumulative DNase dose was 20mg (mean: 19.7 ± 12.2 mg). The median dwell time for the chest tubes was 8.5 days. Our regimen had similar success when compared to MIST 2 and allowed for lesser treatments and cumulative doses. No complication of intrapleural therapy with hemorrhagic conversion of CPEE, or worsening pain leading to discontinuation of therapy was noted.ConclusionThe concurrent administration of intrapleural therapy at lower doses than the current standard MIST 2 protocol is practical, efficient and effective. We suggest a higher DNase dose with a lower tPA dose which may further decrease hemorrhagic complications. Further randomized trials are required to establish the optimal dose of intrapleural therapy for CPEE.

TPA/DNase for Complicated Parapneumonic Effusions and Empyemas

tPA/DNase for Complicated Parapneumonic Effusions and Empyemas

Minimally invasive treatment of complicated parapneumonic effusions and empyemas in adults.

To summarize the evidence underlying the non-surgical management of patients with complicated parapneumonic effusions (CPPE) or empyemas. All articles published in PubMed according to their relevance with the subject were identified. There is a lack of powered randomized controlled studies comparing medical and surgical approaches to CPPE/empyemas in adults. In addition to antibiotics for an unspecified period of time, CPPE/empyemas can initially be treated with a therapeutic thoracentesis (which can be repeated if necessary), the insertion of a small-bore chest catheter under ultrasound guidance, or the administration through the catheter of fibrinolytics alone, saline alone or fibrinolytics in combination with either saline or deoxyribonuclease. These conservative measures resolve more than 90% of the cases, thus making a rescue surgery unnecessary.

Infectious pleural effusion status and treatment progress.

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.

Outcome and mortality analysis in complicated parapneumonic effusion and empyema

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Pleural infection is a clinical problem with high mortality and morbidity; 20% of patients with empyema die and approximately 20% require surgery to recover within 12 months of their infection. Studies on pleural infection and their outcome are relevant in developing a scoring system by which failing cases and cases at risk of death can be identified. &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The study is retrospective analysis of patient cohort admitted to the tertiary care institute from the period of July 2014 to July 2016 to determine the prognostic factors in the outcome of pleural space infection. The study included all complex, complicated parapneumonic effusion and empyema including tuberculosis above the age of fifteen years.&lt;/span&gt;&lt;span lang="EN-IN"&gt; The primary end of the present study was the success or failure. Possible predicting factors for the success or failure of therapy were assessed against this end. Pearson chi square test, χ2 (Fisher’s exact test when needed) test was used for discrete data. Logistic regression analysis was applied to adjust for confounding variables to assess the possible predicting factors. Survival plot and analysis using Kaplan Meier method was used.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;220 with parapneumonic effusion and empyema were analyzed. Successful outcome was seen in 107 and 113 had failed outcome. Mortality was 30.50%. By logistic regression method the odds of failed outcome were high with diabetes, hypoalbuminemia, loculation, tuberculosis which can predict the outcome especially complicated and complex parapneumonic effusion, empyema (p&amp;lt;0.05). &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Diabetes, hypoalbuminemia, loculation, tuberculosis should be used in the prediction scoring system&lt;/span&gt;.&lt;/p&gt;