Complicated Pleural Effusions Research Articles

Fibrinolytic treatment of complicated pediatric thoracic empyemas with intrapleural streptokinase.

Proper antibiotic treatment and adequate pleural drainage is essential in successful management of pleural effusions. In complicated effusions the increased production of fibrin results in formation of loculations and septations within the thoracic cavity, leading ineffective chest tube drainage. Intrapleural fibrinolytic agents are employed to avoid thoracotomy in such complicated pleural effusions. Our study reviews the results of streptokinase treatment in children with pleural effusion. Thirty-two patients with parapneumonic pleural effusions were admitted to our hospital. The patients beyond the exudative stage were divided into two groups according to the initial radiological findings and biochemical parameters of pleural fluid. Intrapleural streptokinase treatment was started in an average of 2 days following initial chest tube placement in both Group I (14 patients) in fibrino-purulent phase with pleural effusion and fluid volume estimated to be larger than one-third of the involved lung and Group II (18 patients) with additional findings in radiological examination regarding the presence of air-fluid levels, multiple loculations, necrotic debris and pleural thickening. The effectiveness of therapy was assessed by monitoring the volume of the fluid, the level of LDH, glucose, pH and by radiological imaging, pre- and post-instillation. There was statistically significant difference between two groups according to date of admission (6.8 vs 10.4 days), mean of total pleural fluid drainage before (106.9 vs 309.7 ml) and after (258.9 vs 511.2 ml) SK treatment, mean of total number of instillations (2.1 vs 3.6) required and total length of hospital stay (16.6 vs 22.4 days). There was a significant difference regarding pleural chemical analysis. Finally, surgical intervention was necessary in six intractable cases, all of which initially presented a significant small amount of pleural drainage in volume when compared to rest of the patients. The overall success rate of our treatment was calculated as 96% for G-I and 72.2% for G-II cases. Intrapleural streptokinase is an effective and safe adjunct in facilitating drainage in early and late stage II empyemas. A tendency of decreased rate of drainage besides persisting fever and respiratory symptoms, despite fibrinolytic treatment may be a clue for early surgical intervention.

Management of Community-Acquired Pneumonia

Management of Community-Acquired Pneumonia

Techniques de la décortication

Decortication is a surgical procedure that consists in restoring the ventilatory function of the lung by removing the constricting membrane that compresses it over the mediastinum. The constricting membrane is the last stage of loculated and complicated pleural effusions: haemothorax, empyemas, pleural tuberculosis, various other pleural diseases and sequellae of earlier collapsotherapeutic procedures. Decortication typically involves removal of the entire complicated pleural disease, freeing the visceral pleura (decortication strico sensu) and the parietal pleura (pleurectomy). After decortication the lung can expand again and improved functioning can be expected. Multiple technical procedures are available. When the pleural thickening is induced by underlying lung disease, it may be necessary to resect the underlying diseased parenchyma during the same intervention. In chronic parapneumonic empyemas, the current availability of video-assisted procedures allows to avoid thoracotomy for decortication.

P-693 A simple solution for complicated pleural effusions

P-693 A simple solution for complicated pleural effusions

Tratamiento con fibrinolisis intrapleural del empiema y el derrame pleural complicado

Intrapleural fibrinolysis (IPF) can avoid surgery in patients with loculated pleural effusions. Few clinical trials on IPF for the treatment of empyemas (PEM) and complicated pleural effusions (CPE) have been reported. We describe here our experience with IPF in the treatment of PEM/CPE patients. 81 patients with PEM/CPE were included. Urokinase, 100000 U, was instilled into the pleural cavity, three times a day. A mean of 12.9 doses of urokinase were administered. The mean of days having a chest tube was 7.7 days and the mean hospital stay was 22.2 days. No radiological sequelae were observed or these were mild in 66 cases (81.5%). There were four deaths and three patients needed surgery. IPF is an efective and reliable method for the treatment of PEM/CPE.

Utilidad de la ecografía torácica en una unidad de técnicas respiratorias

Chest ultrasound, a diagnostic technique used mainly by radiologists, is useful for managing pleural effusion. Sonography and computed tomography (CT) are complementary, although the former is more accessible to clinicians because it is safe and easy to use and because results are available quickly. We evaluated the utility of chest sonograms in a respiratory medicine unit managed by pneumologists. During the period under study, requests for CT scans to manage complicated pleural effusions decreased as the use of sonograms increased. We conclude that ultrasound imaging is useful in the hands of pneumologists who use the technique to diagnose pleural effusions.

Comparative analysis of outcome and clinical features in children with pleural empyema caused by penicillin-nonsusceptible and penicillin-susceptible Streptococcus pneumoniae

Objective: To describe the clinical characteristics of pleural empyema in children caused by Streptococcus pneumoniae nonsusceptible to penicillin and compare their clinical outcome with pleural empyemas caused by penicillin-susceptible organisms. Methods: Records of 109 children with complicated pleural effusions between January 1996 and December 1998 were retrospectively reviewed. Results: Pathogens were recovered in 45 of these cases. Streptococcus pneumoniae represented 71 % of the isolates, with 20 (62%) and 12 (38%) of the strains proving susceptible and non-susceptible to penicillin, respectively. The average age for children with penicillin-nonsusceptible infections was 18.3 months compared with an average age of 40.9 months for those with penicillin-susceptible infections (P = 0.03). Previous antibiotic treatment was more frequent in children with penicillin-non-susceptible organisms (P = 0.05). No significant differences were found between the two groups for gender, underlying diseases, duration of fever and tachypnea, need of surgical treatment, bacteremia incidence, mean duration of therapy, or length of hospital stay. Conclusions: Pleural empyemas caused by penicillin-nonsusceptible S. pneumoniae appear to be associated with younger age and previous antibiotic treatment. By contrast, the outcome was not influenced by the penicillin susceptibility of the pneumococcus strains.

Treatment of complicated pleural effusion with intracavitary urokinase in children

Treatment of complicated pleural effusion with intracavitary urokinase in children

Effects of Intracavitary Urokinase Instillation in Complicated Pleural Effusion

Background : Complicated exudative pleural fluid collections have traditionally been treated by either closed tube thoracostomy drainage or by open surgical drainage. Complete drainage is important in order to control pleural sepsis, restore pulmonary function, and entrapment. Recently intracavitary fibrinolytic therapy has been advocated as a method to facillitate drainage of complicated exudative pleural effusion and to allow enzymatic debridemant of the restrictive fibrinous sheets covering the pleural surface. The purpose of this study is to prospectively evaluate the effects of image-guided catheter drainage with high dose urokinase(UK) instillation in the treatment of complicated pleural effusions. Patients : Twenty complicated pleural effusion patients that poorly respond to image-guided drainage were allocated to receive UK. There were 8 pneumonia and 12 tuberculosis. Methods : Drugs were diluted in 250 mL normal saline and were infused intrapleurally through the chest tube or pig-tail catheter in a daily dose of 250,000 IU of UK. Response was assessed by clinical outcome, fluid drainage, chest radiography, pleural ultrasound and/or computed tomography. Results : The mean UK instillation time was . The mean volume drained UK instillation was , and post-UK was . The follow up duration after UK therapy was mean days. We had successful results in 19 cases (95.0%). There were 12 pleural thickenings (60.0%), 2 markedly decreased effusions (10.0%) and 5 cases of no thickening or effusion. There was recurrence after treatment in only one patient(5%) with complicated pleural effusiondue to tuberculosis. Conclusions : Image-guided drainage with high dose UK instillation (250,000 U/day) in complicated pleural effusion is a safe and more effective method than closed thoracostomy drainage. And this management, in turn, can obviate surgery in most cases.

Intrapleural fibrinolytic therapy for complicated pleural effusions

Intrapleural administration of fibrinolytic agents can be used to degrade the fibrin present in complicated pleural effusions, thus decreasing viscosity of the fluid and enhancing evacuation of the pleural space via chest tube drainage. Patients who may otherwise need surgical intervention could benefit from this treatment. As more knowledge is gained through clinical experience and research studies, patients' outcomes may show major improvement.

Urokinase vs streptokinase for complicated pleural effusions

Urokinase vs streptokinase for complicated pleural effusions

Urokinase vs streptokinase for complicated pleural effusions

Urokinase vs streptokinase for complicated pleural effusions

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy.

To determine the usefulness and the results of a strategy using intrapleural streptokinase (SK) instillation guided by repeated computed tomography (CT) scan examinations in pleural empyemas unresponsive to chest tube drainage. A retrospective chart review. The medical Intensive Care Unit and Department of Radiology, in a university hospital. Sixteen patients with empyema who had a persistent pleural effusion despite drainage, among 37 patients with infectious pleural effusion. In the 16 patients, CT examination was performed before and at least once after SK. Intrapleural SK was instilled, either through the chest tube or via a needle puncture, according to the CT scan results. The first CT scan confirmed a persistent effusion in all, showing a multiloculated effusion in 13 patients, and an ectopic loculus in one. The first SK instillation resulted in a dramatic increase of fluid drained per day (from 68 +/- 28 ml to 567 +/- 262 ml; p < 0.001), leading to complete resolution in 11 patients, while the others required a second CT scan-guided procedure. In one, the chest tube was misplaced, while in two, transparietal injection was needed. Finally, a complete resolution was observed in 14 (87.5%) of the patients. Two patients had a poor initial response to SK and were eventually scheduled for video-thoracoscopy. A single episode of chills and fever was observed among 32 SK instillations. CT-guided SK instillation in pleural empyema appears to be safe, and allowed complete resolution in 87.5% of our patients.

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy

Intrapleural administration of streptokinase in complicated purulent pleural effusion: a CT-guided strategy