Infectious Pleural Effusions Research Articles

Épanchements pleuraux en réanimation

Critically ill patients have many reasons to present with pleural effusions whose incidence in the intensive care unit (ICU) varies from about 8% (clinically documented effusions) to more than 60% (effusions detected using routine ultrasonography). Management of pleural effusions in ICU patients is similar to this used in overall patients. Indeed, pleurocentesis is safe in mechanically ventilated patients, pleurocentesis has an impact on diagnosis and treatment, and no clinical parameter allows to exclude pleural infection. This review discusses various aspects of pleural effusions in the ICU and suggests a research agenda for pleural effusions in ICU patients, particularly regarding management of infectious pleural effusions and these associated with Acute Respiratory Distress Syndrome.

Pleural effusions in the intensive care unit

The incidence of pleural effusions in the intensive care unit varies depending on the screening methods, from approximately 8% for physical examination to more than 60% for routine ultrasonography. Several factors contribute to the occurrence of pleural effusions in intensive care unit patients: large amounts of intravenous fluid are often administered, pneumonia is common, and heart failure, atelectasis, extravascular catheter migration, hypoalbuminemia, or liver disease are present in many intensive care unit patients. In surgical intensive care units, cardiac or abdominal surgery is often followed by pleural effusions, and in trauma patients, hemothorax is a dreaded event. Because no clinical parameter excludes pleural infection, and because of the impact of thoracentesis on diagnosis and treatment, this procedure should be performed unless contraindicated. Thoracentesis is safe in mechanically ventilated patients. The author discusses the following points regarding pleural effusions in the intensive care unit: screening intensive care unit patients for pleural effusion, safety of thoracentesis in patients receiving invasive mechanical ventilation, distinguishing exudates from transudates, and diagnosing and managing infected pleural effusions in critically ill patients. Lastly, the author suggests a research agenda for pleural effusions in intensive care unit patients.

Pleural fluid myeloperoxidase as a marker of infectious pleural effusions

Background: The aim of this study was to establish the diagnostic accuracy of neutrophil markers (elastase, lysozyme, myeloperoxidase) found in pleural fluid in differentiating between infectious and non-infectious pleural effusions (PE). Methods: We studied 184 patients over 18 years of age with PE, classified as either infectious (34 complicated parapneumonic, 32 non-complicated parapneumonic, 45 tuberculous) or non-infectious (31 neoplasms and 42 undiagnosed exudates). Polymorphonuclear elastase (PMN-E) was determined using an immunoactivation method and lysozyme using a turbidimetric method. Myeloperoxidase (MPO) was measured by double antibody competitive radioimmunoassay. Receiver operating characteristic (ROC) curves were used to evaluate diagnostic accuracy. Results: Pleural fluid MPO was the biochemical marker that best differentiated between infectious and non-infectious PE. The ROC area under the curve (AUC) for myeloperoxidase was 0.86. MPO values over 550 μg/l diagnosed infectious PE with a specificity of 90.4% and a sensitivity of 77.4%. After excluding purulent parapneumonic PE, the sensitivity of a pleural MPO value ≥550 μg/l was 72.6%. Conclusions: Pleural fluid MPO was the marker that best differentiated between infectious and non-infectious PE.

Surgical closure of atrial septal defect (ASD) in childhood in the current era

Surgical closure of ostium searndum ASD is associated with low mortality (~1%). Morbidity can be associated with hospitalisation, general anaesthesia, stemotomy, cardiopulmonary bypass and intensive care stay. This is of increased interest as comparative data, with wider use of catheter closure. Objective: Determine perioperative morbidity of surgical closure of ASD. Methods: Retrospective review of the last 100 consecutive cases from July lQQO36, FM). Total days of hospitalisation: 683 (range 5-44 days; median 6 days). Total intensive care days: 127.4 (range 0.8-21.8 days; median 1 dav1. Ninetv-nine patients were ventilated for < 24 hours. There were-no deaths. 86% of patients had an uncomplicated course, with hospital davs 549 #aWe 510 days, median 6 days). 14% had complicatio&: 1 patiint required proionged ventilation for pulmonary hypertension/ presumed viral respiratory tract infection. Re-operation was required at 7 months post-operatively for 1 patient for painful sternal wires. Pericardial effusion developed in 4 patients, 2 cases requiring readmission, one drainage. One patient was readmitted for 2 days of IV antibiotics for pneumonia. Two patients had right Homer’s syndrome presumed secondary to insertion of internal jugular lines. Minor complications included left lower lobe atelectasis(3), postoperative ileus(l), intravenous line site infection(l) and left pleural effusion(l), no drainage required. Ninety-four patients were seen at follow-up. On echocardiogram SE/89 patients had IX) residual defect One patient had a small residual defect at 1 month post-operation. Conclusion: Surgical secundum ASD repair is associated with short hospital stay and a low rate of significant complication with 99% complete closure.

Diagnostic Accuracy of Pleural Fluid Polymorphonuclear Elastase in the Differentiation between Pyogenic Bacterial Infectious and Non-Infectious Pleural Effusions

Background and Objectives: To establish the diagnostic accuracy of the markers of neutrophil activity (elastase and lysozyme) determined in pleural fluid, for differentiating between pyogenic bacterial infectious and non-infectious pleural effusions. Patients and Methods: At our tertiary referral teaching hospital, 160 patients over 14 years with pleural effusion (PE), classified as pyogenic bacterial infectious (41 parapneumonic complicated, 32 parapneumonic non-complicated) and non-infectious (32 neoplasm and 55 undiagnosed pleural exudates) were examined in a prospective study. Polymorphonuclear elastase (PMN-E) was determined by an immunoactivation method and lysozyme by a turbidimetric method. Receiver operating characteristic (ROC) curves were used to evaluate diagnostic accuracy. Results: Pleural fluid PMN-E was the biochemical marker that best differentiated between pyogenic bacterial infectious and non-infectious PE. The ROC area under the curve (AUC) for PMN-E was 0.8276. A PMN-E value over 230 µg/l diagnosed infectious PE with a specificity of 0.81 and a sensitivity of 0.74. The ROC AUC for proteins plus lactate dehydrogenase was 0.7430. Differences between the two ROC curves were significant (p = 0.032). After excluding purulent parapneumonic complicated PE, the sensitivity of a pleural fluid PMN-E value equal to or greater than 230 µg/l was 0.64 and the specificity 0.81. Conclusions: Pleural fluid PMN-E was the marker that best differentiated infectious from non-infectious PE, and PMN-E values lower than 230 µg/l suggest non-infectious PE.

Ketamine as an Adjunct to Morphine in Postthoracotomy Analgesia

Ketamine as an Adjunct to Morphine in Postthoracotomy Analgesia

Seudoquilotórax. Revisión de 5 casos

We undertook a retrospective review of five patients with pseudo-chylothorax diagnosed at our hospital between 1984 and 1994. Pseudo-chylothorax was diagnosed if crystals of cholesterol were observed (CC) or if cholesterol concentrations were over 150 mg/dl, but chylomicrons were absent from pleural effusions with cloudy supernatants after centrifugation. The five patients were males and their mean age was 53 years. All had history of pulmonary or pleural tuberculosis (mean 31 years since diagnosis). All had received chemotherapy and four had undergone therapeutic pneumothorax. Two patients were diagnosed in the course of examination for other reasons, Three were diagnosed while being examined for the cause of pleural effusion. The diagnosis of four patients was based on the presence of CC. Three patients received specific treatment and Mycobacterium tuberculosis was isolated in the pleural fluid of two. One patient required a pleural drain and antibiotics because of empyema related to pseudo-chylothorax. Decortication was needed by two. 1) Pseudo-chylothorax is at present rare. 2) All the cases we saw were associated with earlier tuberculosis infection with residual pleural lesions. 3) Diagnosis usually occurs in the course of examination for the other motives, but the possibility of infected pleural effusion or reactivation of tuberculosis should be considered.

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.

LEUKAEMIA INHIBITORY FACTOR (LIF) PRODUCTION IN PLEURAL EFFUSIONS: Comparison with production of IL-4, IL-8, IL-10 and Macrophage-Colony Stimulating Factor (M-CSF)

Leukaemia inhibitory factor (LIF), a pleiotropic cytokine detected in various inflammatory body fluids, plays a poorly defined role in the pathogenesis of human disease. This study was conducted to correlate the LIF concentrations in pleural effusions with the type of pathology and to compare its levels with those of IL-4, IL-8, IL-10 and M-CSF for a given pathology. Pleural fluids from 97 patients were assayed for cytokines by specific ELISAs. The concentrations of all cytokines tested were higher in infectious pleural effusions than in other pathologies (malignant or transudative). The lowest levels were observed for transudates. Significant differences were noted between pathology groups for each cytokine. A good correlation was observed between LIF and IL-8 for malignant effusions [regression correlation coefficient (RC) = 0.480, P< 0.01], between LIF and IL-4 for infectious disorders (RC = 0.543, P< 0.05) between LIF and IL-10 for transudates (RC = 0.798, P< 0.001) and between M-CSF and IL-8 in all pathologies tested except for primitive neoplasia ( P< 0.05). The LIF concentration in pleural space seems to be strongly associated with the intensity of inflammatory reaction. The LIF production appears to have different regulatory patterns between aetiologic groups.

Pleurodesis con sangre del propio paciente: resultados iniciales en 14 casos

Fourteen adults with spontaneous pneumothorax (SP), 9 of whom had primary SP (PSP) and 5 of whom had secondary forms (SSP), were given intrapleural infusions of self-donated blood for pleurodesis. Instillations of 50 ml were given to all except 1, who required a total volume of 120 ml. The procedure was performed in each patient's bed in all cases. With apical chest tube placement in most cases and the lung expanded, the outer tip of the tube was elevated and the patient's own blood was taken from a superficial forearm vein and instilled. Them, with the tube occluded, the patient's were rotated un bed for a period of 2 hours to distribute the blood evenly throughout the pleural cavity. Tolerance was excellent, with no pain reported by any patient. The only noteworthy complication was 1 case of infectious pleural effusion of unknown etiology which was treated by evacuation and antibiotics. In 13 (92%) patients closure of the fistula was achieved, in under 12 h in 7 (53%), in under 24 h in 3 (23%), in under 48 h in 2 (15%), and in under 72 h in the remaining 2 (15%). In 4 (28.5%) there was recurrence (2 SSP and 2 PSP patients). Over a 10 to 32 month follow-up period (mean 16 months), 10 (71.4%) patients experienced no recurrences or complications. These results allow us to speculate that blood instilled in the pleural cavity may act in 2 ways: in the short term as a blood patch that adheres to and closes the fistula in the visceral pleura, and over the longer term by creating pleural symphysis by adhesions and fibrous tissue. Our limited experience indicates that pleurodesis with self-donated blood is an easy-to-perform, painless, convenient, rapid and inexpensive procedure that is moderately effective in the short and medium term. Its main drawbacks are the lack of consensus on certain technical considerations, such as the optimum amount of blood to be instilled, the number of instillations to perform and, if multiple instillations are carried out, what the interval between them should be. Further study is needed to confirm or discount our results and to determine the place this technique may have in the clinical management of pneumothorax.

Elevated progastrin-releasing peptide(31-98) concentrations in pleural effusions due to small-cell lung carcinoma.

Progastrin-releasing peptide (ProGRP) is a specific and actively secreted product from small-cell lung carcinoma (SCLC) cells. Recently, an enzyme-linked immunosorbent assay, which uses monoclonal and polyclonal antibodies to recombinant proGRP(31-98), a common region of ProGRP, was established. We measured concentrations of ProGRP (31-98), neuron-specific enolase (NSE) and carcinoembryonic antigen (CEA) in carcinomatous and infectious pleural effusions. Significantly increased ProGRP(31-98) and NSE values were found in carcinomatous pleurisy due to SCLC compared to the other carcinomatous pleurisy and infectious pleurisy. CEA values were significantly increased in carcinomatous pleural effusions compared with those in infectious effusions. The ProGRP(31-98) values were not correlated to NSE values in carcinomatous pleurisy due to SCLC. The determination of ProGRP(31-98) in pleural effusions will be helpful for diagnosing carcinomatous pleurisy due to SCLC.

Low Levels of Functional of 1-Proteinase Inhibitor in the Promotion of C3-Cleavage by Granulocyte-Neutral Proteases in Pleural Empyema

It has been suggested that C3 breakdown by granulocyte-neutral proteases in pleural empyemas may be related to a decreased inhibitor potential for these enzymes. In the present study it was shown that in 17 infected pleural effusions, high proteolytic activity on 125I-labeled C3 (16.3% +/- 4.4%) correlated with low functional levels of alpha 1-proteinase inhibitor (alpha 1-PI), as determined by trypsin-inhibitory capacity (56.2 +/- 20.1 IU/ml; rs = -0.97, P less than .001), whereas in 18 sterile pleural effusions there was no such correlation (125I-labeled C3 cleavage, 2.2% +/- .2%; trypsin-inhibitory capacity, 192.6 +/- 26.7 IU/ml). However, alpha 1-PI and alpha 2-macroglobulin protein concentrations in infected and sterile effusions (as measured by immunodiffusion) were similar. Fifteen strains of three bacterial species--Streptococcus pneumoniae, Pseudomonas aeruginosa, and Proteus mirabilis--isolated from patients with pneumonia or empyema inactivated the elastase-inhibitory capacity of alpha 1-PI in vitro. These results show that in empyemas functional levels of alpha 1-PI were too low to inactivate granulocyte elastase and that some bacterial species may contribute to the low inhibitor potential of infected pleural fluid by direct alpha 1-PI inactivation.

Fibronectin in exudative pleural effusions.

Fibronectin is a glycoprotein found in body fluids, loose connective tissue matrix and in basement membranes. Fibronectin in pleural effusion was found to be immunologically indistinguishable from the plasma form, as shown by double-diffusion analysis. Fibronectin isolated from pleural fluid by affinity chromatography on gelatin-Sepharose had a polypeptide pattern similar to that of plasma fibronectin in SDS-polyacrylamide gel electrophoresis. In 28 patients with infectious or non-specific pleural effusion fibronectin concentrations in pleural fluid were 335 +/- 104 micrograms/ml (mean +/- SD), in 15 patients with malignant disease the concentrations were 369 +/- 173 micrograms/ml and in 26 patients with tuberculosis 441 +/- 103 micrograms/ml. The highest concentrations, 605 +/- 252 micrograms/ml, of fibronectin in pleural fluid were detected in 14 patients with connective tissue diseases. The results suggest that increased fibronectin concentrations reflect the presence of a pleurisy due to connective tissue disease or tuberculosis rather than other infectious or malignant disease.

Pharmacokinetic investigations on the penetration of mezlocillin into the pleural fluid

5 g of mezlocillin were administered by a 30 minute drip infusion to each of ten patients (mean age 59.4 years). Antibiotic concentrations in serum and pleural fluid were assayed microbiologically at regular intervals. The antibiotic concentrations determined 1.5 and 8 hours after beginning the infusion were between 83.9 and 4.0 mg/l in the serum and 53.1 and 6.5 mg/l in the pleural fluid. A comparison of the mean antibiotic concentration found in the pleural secretions (22 mg/l) with the minimal inhibitory concentrations of clinically relevant pathogens shows that mezlocillin covers 69% to 84% of the pathogen spectrum. Mezlocillin can thus be used in the therapy of infectious pleural effusions.

Deficient phagocytosis secondary to breakdown of opsonic factors in infected exudates.

Pleural empyema, a clinical entity characterized by the simultaneous presence of large number of PMNLs and viable bacteria, is a biological paradox which has not been fully explained yet. Our preliminary studies suggest that receptor and bactericidal functions of PMNL isolated from purulent exudates, can be close to normal in this condition. Supernatants of these empyemas however have been shown to be low in heat labile opsonic activity and complement hemolytic activity. These observations have been extended by the demonstration of breakdown of IgG, C3 and factor B in infected pleural effusions as opposed to pleural fluids obtained under other conditions. The breakdown of Ig and C3 seems to be enzymatic and to occur, at least for C3, even in the absence of Ca and Mg ions: thus, direct cleavage of C3, possibly by PMNL enzymes, has to be postulated to explain these results. Present work in our laboratory is trying to explore this possibility.

The pleuropulmonary consequences of esophageal rupture: an experimental model.

Esophageal rupture is a catastrophic clinical event, characterized by late diagnosis and high morbidity and mortality. The pathophysiologic consequences of the low pleural fluid pH and other events...

Decreased Heat-Labile Opsonic Activity and Complement Levels Associated with Evidence of C3 Breakdown Products in Infected Pleural Effusions

Heat-labile opsonic activity was measured simultaneously in serum and pleural fluid of patients with transudates, infectious exudates (with positive or negative bacterial culture) and neoplastic exudates, using two different complement-dependent phagocytic tests: the killing of Staphylococcus aureus Wood 46 variant strain (K50 opsonic titers) and the assessment of ingestion rate of endotoxin-coated paraffin particles (Oil Red 0 uptake test). K50 opsonic titers were lower in culture-positive pleural effusions as compared to culture-negative (P < 0.002) or neoplastic effusions (P < 0.002). These results were corroborated by the Oil Red 0 uptake test. The data obtained with the two assays showed a significant correlation (P < 0.001). The hemolytic activity of complement (CH50) as well as the levels of C3 breakdown product, C3d, were measured in the same sera and pleural fluid samples and in an additional group of patients with pleural effusions of the same etiology. Effusions with positive cultures showed lower CH50 values (P < 0.01) and higher C3d values (P < 0.05) when compared to culture-negative pleural fluids. Finally, evidence for immune complexes in pleural effusions and sera was looked for by determination of Clq binding activity. Levels were higher in culture-positive effusions when compared to culture-negative fluids (P = 0.005).K50 opsonic titers showed a positive correlation with CH50 values (P < 0.001) for all fluids tested. Similarly Clq binding activity correlated with C3d levels in effusions of infectious origin (P = 0.05). Recovery experiments using the various bacterial species isolated from culture-positive pleural effusions showed evidence of complement inactivation upon incubation with pooled sera at concentrations of 10(7)-10(8) microorganisms/ml. These results indicate that one important reason for bacterial persistence in empyema may be decreased opsonization secondary to local consumption of complement.

Superior Vena Cava Obstruction

The effects of superior vena cava obstruction vary according to the degree and location of the obstruction and the suddenness of its development. To determine the tolerance of animals to this condition, to measure the effect on venous pressure and to trace the paths of collateral circulation, experimental obstruction of the superior vena cava was produced in dogs. The vein was exposed through an intercostal incision and completely occluded by dividing between ligatures. The usual aseptic technique was followed and the operations were performed under intratracheal ether anesthesia administered with positive pressure. Obstructions were of 2 types, (1) above the junction of the azygos vein, and (2) including the azygos vein. Two attempts were also made to obstruct the superior vena cava below the junction of the azygos vein but both dogs died within a few minutes. Obstruction above the level of the azygos vein was produced in 7 dogs. One died within 24 hours and 3 died within 12 to 14 days as a result of a propagating thrombus or an empyema. Three recovered. Of the latter, one was sacrificed for study after 30 days. Another was later subjected to azygos vein obstruction and the third is alive after more than 5 months. One dog survived the immediate effects of a 2-stage obstruction of the superior vena cava and azygos vein but died at the end of 21 days from an infected bilateral pleural effusion. The most striking general results of superior vena cava obstruction were cyanosis of the tongue and oral mucosa and injection of the conjunctivae. Somnolence, listlessness and slow deep respirations were also noted. The dogs with obstruction just above the right atrium, dying within a few minutes, had extreme cyanosis of the upper part of the body.