| |
Important Note: The following information
is provided for your education. It should not be relied upon for
personal diagnosis or treatment. If you believe that a
particular therapy applies to you or someone you care about, be
sure to consult a doctor before trying it.
Pleurisy
Research: 2002-2006
J Gynecol Obstet Biol Reprod (Paris). 2006 Nov;35(7):652-657.
[Emergency thoraco amniotic shunting in cases with compressive
pleural effusion with hydrops: a retrospective study of 60 cases.]
[Article in French]
Picone O, Benachi A, Mandelbrot L, Ruano R, Dumez Y, Dommergues M.
Maternite, Hopital Necker-Enfants Malades (AP-HP) et Universite Paris V, 149,
rue de Sevres, 75015 Paris.
OBJECTIVES: To study perinatal outcome following thoraco-amniotic shunting for
fetal pleural effusions with hydrops. Materials and methods. Retrospective study
(1984-2004) to evaluate a policy of emergency thracoamniotic shunting in
hydropic fetuses with suspected chylothorax, on the basis of the rationale that
mediastinal compression could lead to acute fetal distress. RESULTS: Shunting
was performed immediately following diagnosis, and was successful in all 60
cases attempted. There were 7 pregnancy terminations, 10 in utero deaths, and 43
live births, of which 7 children died in the neonatal period and 36 survived (33
without sequels). Among the liveborn, 26 were delivered preterm (72%), of which
7 (19%) had preterm premature rupture of membranes and 4 (11%) had
chorioamnionitis. Perinatal death (24/60, 40%) was related to underlying
anomalies (7 cases), pulmonary hypoplasia (5 cases), chorioamnionitis (2 cases),
or treatment failure for unknown reasons (10 cases). All 36 survivors had
chylothorax, 33 of which were primary, and 3 were secondary to right congenital
diaphragmatic hernia, pulmonary sequestration, or Noonan syndrome. CONCLUSION:
Following shunting, pleural effusion with hydrops has survival rate>50%, but
still have a high rate of morbidity and mortality.
-----
Eur Respir J. 2006 Nov;28(5):1051-9.
Advanced techniques in medical thoracoscopy.
Tassi GF, Davies RJ, Noppen M.
Divisione di Pneumologia, Spedali Civili di Brescia, Piazzale Spedali Civili 1,
25103 Brescia, Italy. gf.tassi@tin.it.
For expert pulmonologists, advanced procedures in medical thoracoscopy are the
nonroutine and more complex applications of the method. The main current
indications are the treatment of infected pleural space, forceps lung biopsy and
sympathectomy. In parapneumonic effusions and empyema, medical thoracoscopy is
as a drainage procedure, intermediate between tube thoracostomy and
video-assisted thoracoscopic surgery (VATS), which is efficient, significantly
lower in cost and avoids surgical thoracoscopy under general anaesthesia. It is
essential that it is performed early in the course of the disease and is
particularly advisable for frail patients at high surgical risk. The efficacy of
forceps lung biopsy has been demonstrated in diffuse lung diseases, whereas
results in localised lung diseases and chest-wall lesions have been less
positive. However, VATS is currently the preferred approach for these
indications. The technique still maintains its efficacy for visceral pleura and
peripheral lung biopsy, in particular in the presence of pleural effusion and
lung disorders. At the present time, thoracoscopic sympathectomy is minimally
invasive and is an accepted intervention for patients with a variety of
autonomous nervous system disturbances. Essential hyperhidrosis patients, and
well-selected patients with other disorders, can be helped with this procedure,
which can also be performed by interventional pulmonologists.
-----
J Pediatr Surg. 2006 Oct;41(10):1732-7.
Thoracoscopy in pediatric pleural empyema: a prospective study of
prognostic factors.
Kalfa N, Allal H, Lopez M, Saguintaah M, Guibal MP, Sabatier-Laval E, Forgues D,
Counil F, Galifer RB.
Visceral Pediatric Surgery Department, Lapeyronie-Arnaud de Villeneuve Hospital,
Montpellier Cedex 5 34295, France.
PURPOSE: The indications for thoracoscopy remain imprecise in cases of pleural
empyema. This study aimed to identify preoperative prognostic factors to help in
the surgical decision. METHODS: From 1996 to 2004, 50 children with
parapneumonic pleural empyema underwent thoracoscopy either as the initial
procedure (n = 26) or after failure of medical treatment (n = 24). Using
multivariate analysis, we tested the prognostic value of clinical and
bacteriological data, the ultrasonographic staging of empyema, and the delay
before surgery. Outcome measures were technical difficulties, postoperative
complications, time to apyrexia, duration of drainage, and length of
hospitalization. RESULTS: The clinical and bacterial data did not significantly
predict the postoperative course. Echogenicity and the presence of pleural
loculations at ultrasonography were not independent significant prognostic
factors. A delay between diagnosis and surgery of more than 4 days was
significantly correlated (P < .05) with more frequent surgical difficulties,
longer operative time, more postoperative fever, longer drainage time, longer
hospitalization, and more postoperative complications, such as bronchopleural
fistula, empyema relapse, and persistent atelectasia. CONCLUSION: The main
prognostic factor for thoracoscopic treatment of pleural empyema is the interval
between diagnosis and surgery. A 4-day limit, corresponding to the natural
process of empyema organization, is significant. The assessment of loculations
by ultrasonography alone is not sufficient to predict the postoperative course.
-----
Treat Respir Med. 2006;5(5):295-304.
Diagnosis and management of infectious pleural effusion.
Rahman NM, Chapman SJ, Davies RJ.
Oxford Centre for Respiratory Medicine, Headington, Oxford, England.
Pleural infection remains a common illness, with a high morbidity and mortality.
The development of frank empyema from a simple exudative pleural effusion is a
result of biochemical changes within the pleural space in response to bacterial
invasion. These changes can be used in the diagnosis of pleural infection and
used to predict which patients will require intercostal drainage for resolution
of infection. Recent large trials in empyema have further advanced our knowledge
of microbiologic patterns, informing important decisions about empiric
antibacterial therapy. Diagnosis of pleural infection relies on high clinical
suspicion in association with clinical features, radiology, and pleural fluid
characteristics. Treatment of pleural infection is based upon accurate and often
empiric choice of antibacterial agents, intercostal drainage in certain
contexts, and appropriate surgical referral. Intrapleural thrombolytic therapy
is not currently recommended for the treatment of pleural infection, on the
basis of evidence from the largest randomized trial in empyema to date.
-----
Lung Cancer. 2006 Oct;54(1):51-5. Epub 2006 Aug 21.
Efficacy of short-term versus long-term chest tube drainage
following talc slurry pleurodesis in patients with malignant pleural effusions:
a randomised trial.
Goodman A, Davies CW.
Wellcome Trust Centre for Human Genetics, Roosevelt Drive, Oxford OX3 7BN,
United Kingdom.
Talc pleurodesis is commonly used in the palliative treatment of malignant
pleural effusions but the shortest and most effective regime has not been
determined. In particular, it is not clear when the intercostal drain should be
removed following the insertion of sclerosant. We conducted a single-centre,
randomised, open trial of drain removal at 24 h versus 72 h following talc
slurry pleurodesis. The primary outcome measure was success of pleurodesis (no
recurrence of effusion on chest radiograph at 1-month follow-up) and secondary
outcome measures included length of hospital stay and mortality. We found no
difference between recurrence of pleural effusion in those randomised to drain
removal at 24 h and those randomised to drain removal at 72 h (p>0.5). However,
length of stay was significantly reduced when the chest drain was removed at 24
h (4 days versus 8 days; p<0.01). Mortality did not differ between the two
groups. We conclude that this shorter pleurodesis regime is safe and effective.
-----
Lung Cancer. 2006 Oct;54(1):1-9. Epub 2006 Aug 7.
Malignant pleural effusion, current and evolving approaches for
its diagnosis and management.
Neragi-Miandoab S.
Thoracic and Cardiovascular Surgery, Loyola University Chicago, Stritch School
of Medicine, 2160 South First Ave., Building 110, Room 6243, Maywood, IL 60153,
USA. Sneragi@yahoo.com
Malignant pleural effusion is a common and debilitating complication of advanced
malignant diseases. This problem seems to affect particularly those with lung
and breast cancer, contributing to the poor quality of life. Approximately half
of all patients with metastatic cancer develop a malignant pleural effusion at
some point, which is likely to cause significant symptoms such as dyspnea and
cough. Evacuation of the pleural fluid and prevention of its re-accumulation are
the main goals of management. Optimal treatment is controversial and there is no
universally standard approach. Intervention options range from observation in
the case of asymptomatic effusions through simple thoracentesis to more invasive
methods such as chemical and mechanical pleurodesis, pleur-X catheter drainage,
pleuroperitoneal shunting, and pleurectomy. The best results are reported with
thoracoscopy and talc insufflation, with an acceptable morbidity. Development of
novel methods to control malignant pleural effusion should be a high priority in
palliative care of cancer patients. This article reviews the current, as well
as, novel approaches that show some promise for the future. The aim is to
identify the proper approach for each individual patient.
-----
Pediatrics. 2006 Sep;118(3):e547-53. Epub 2006 Aug 14.
Therapy of parapneumonic effusions in children: video-assisted
thoracoscopic surgery versus conventional thoracostomy drainage.
Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW.
Department of Pediatrics, DeVos Children's Hospital, 100 Michigan St NE, MC 117,
Grand Rapids, Michigan 49503, USA.
OBJECTIVE: Controversy surrounds the optimal treatment of parapneumonic
effusions. This trial of pediatric patients with community-acquired pneumonia
and associated parapneumonic processes compared primary video-assisted
thoracoscopic surgery with conventional thoracostomy drainage. DESIGN: A
prospective, randomized trial was conducted at DeVos Children's Hospital (Grand
Rapids, MI) between November 2003 and May 2005. All of the patients under 18
years of age with large parapneumonic effusions were approached for enrollment
in the study. After enrollment, each patient was randomly assigned to receive
either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the
effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage
procedures) were similar for each group per protocol. RESULTS: Eighteen patients
were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in
conventional thoracostomy. The groups were demographically similar. No
mortalities were encountered in either group, and everyone was discharged from
the hospital with acceptable outcomes. Yet, there were multiple variables that
demonstrated statistical difference. Hospital length of stay, number of chest
tube days, narcotic use, number of radiographic procedures, and interventional
procedures were all less in the patients who underwent primary video-assisted
thoracoscopic surgery. In addition, no patient in the video-assisted
thoracoscopic surgery group required fibrinolytic therapy, which was also
statistically different from the thoracostomy drainage group. CONCLUSIONS: The
outcomes of this study strongly suggest that primary video-assisted
thoracoscopic surgery for evacuation of parapneumonic effusions is superior to
conventional thoracostomy drainage.
-----
Chest. 2006 Jun;129(6):1709-14.
Ultrasound-guided thoracentesis.
Feller-Kopman D.
Interventional Pulmonology, Beth Israel Deaconess Medical Center, One Deaconess
Rd, Suite 201, Boston, MA 02215, USA. dfellerk@bidmc.harvard.edu
Pleural effusions are an extremely common problem affecting approximately 1.5
million people in the United States each year. Over the last several years, the
use of portable ultrasound machines has greatly enhanced the evaluation and
management of patients with pleural disease. This article will review the
relevant literature supporting the use of ultrasound for the evaluation of
patients with pleural disease and address some practical practice management
issues regarding ultrasonography.
-----
Semin Arthritis Rheum. 2006 Jun;35(6):368-78.
Rheumatoid pleural effusion.
Balbir-Gurman A, Yigla M, Nahir AM, Braun-Moscovici Y.
B. Shine Department of Rheumatology, Rambam Medical Center, Haifa, Israel.
a_balbir@rambam.health.gov.il
OBJECTIVES: To describe the clinical and laboratory features of rheumatoid
pleural effusion (RPE) and the diagnostic and therapeutic approaches to this
condition. METHODS: The review is based on a MEDLINE (PubMed) search of the
English literature from 1964 to 2005, using the keywords "rheumatoid arthritis"
(RA), "pulmonary complication", "pleural effusion", and "empyema". RESULTS:
Pleural effusion is common in middle-aged men with RA and positive rheumatoid
factor (RF). It has features of an exudate and a high RF titer. Underlying lung
pathology is common. Generally RPE is small and resolves spontaneously but
symptomatic RPE may require thoracocentesis. Rarely, RPE has features of a
sterile empyematous exudate with high lipids and lactate dehydrogenase, and very
low glucose and pH levels. This type of effusion eventually leads to fibrothorax
and lung restriction. Superimposed infective empyema often complicates RPE.
Oral, parenteral, and intrapleural corticosteroids, pleurodesis and
decortication, have been used for the treatment of sterile RPE. Infected empyema
is treated with drainage and antibiotics. CONCLUSIONS: RPE may evolve into a
sterile empyematous exudate with the development of fibrothorax. Symptomatic
effusions or suspicion of other causes of exudate (infection, malignancy)
require thoracocentesis. The "rheumatoid" nature of the pleural exudate in
patients without arthritis mandates a pleural biopsy to exclude tuberculosis or
malignancy. The optimal therapy of RPE has yet to be established. The role of
cytokines in the course of RPE and the possible usefulness of cytokine blockade
in the treatment of this RA complication require further evaluation.
-----
Surg Endosc. 2006 Jun;20(6):919-23. Epub 2006 May 2.
Thoracoscopic palliative treatment of malignant pleural
effusions: results in 273 patients.
Arapis K, Caliandro R, Stern JB, Girard P, Debrosse D, Gossot D.
Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, F-75014,
Paris, France.
BACKGROUND: The aim of this study was to analyze the results of pleurodesis for
malignant pleural effusion performed by surgeons. PATIENTS AND METHODS: A series
of 273 patients with malignant pleural effusion underwent thoracoscopy with the
aim of performing a palliative pleurodesis. There were 94 males (34.4%) and 175
females (64.1%), ranging in age from 15 to 94 years (mean age: 60.6 years). The
effusion was on the right side in 136 patients (49.8%), on the left side in 110
(40.3%), and bilateral in 27 (9.9%). Thoracoscopy was performed under general
anaesthesia in all patients. Pleural biopsy was performed in two thirds of the
patients (70.7%). Pleurodesis was produced by instillation of 5g of sterile
asbestos-free talc; the chest tube was left in place a minimum of 3 days. It was
removed when fluid drainage was less than 200 ml/24 h. Patients were usually
discharged the day after chest tube removal. RESULTS: There was no
intraoperative mortality. Two patients (0.7%) had intraoperative complications;
17 (6.2%) underwent a bilateral pleurodesis, and 10 (3.7%) had a
pericardiopleural window. In 32 patients (11.7%) no pleurodesis was done, either
because the lung did not properly re-expand (5.2%), or because of suspected
infection, e.g., false membranes (1.9%), or because of multiple adhesions
(4.6%). Finally, only 241 patients (88.3%) had a talc poudrage at the time of
thoracoscopy. Duration of postoperative pleural drainage ranged between 1 and 11
days (mean: 3.64 days). The postoperative hospital stay ranged from 2 to 21 days
(mean: 7.1 days). Pleural empyema occurred in 4 patients (1.5%) and was lethal
in one patient. The mean follow-up period was 8.39 (7.2 months, and 172 patients
had regular follow up. In this group, there were 24 recurrences (14%), 12 of
which were treated by repeat pleurodesis. The results were very good in 133
patients (77.3%), acceptable in 35 patients (20.3%), and there was a failure in
4 patients (2.4%). CONCLUSIONS: Results of surgical thoracoscopy for malignant
pleural effusion are good, with low morbidity. However, in debilitated patients,
bedside talc slurry may be preferable.
-----
Clin Chest Med. 2006 Jun;27(2):253-66.
The approach to the patient with a parapneumonic effusion.
Rahman NM, Chapman SJ, Davies RJ.
Oxford Pleural Diseases Unit, Oxford Centre for Respiratory Medicine, Churchill
Hospital Site, Oxford Radcliffe Hospital, Headington, Oxford OX3 7LJ, UK.
naj_rahman@yahoo.co.uk
Parapneumonic effusion is a common clinical problem, and those that go on to
develop pleural infection have high morbidity and mortality. The process of
pleural infection evolution involves changes in pleural physiology that are
increasingly being elucidated and understood. The microbiology of pleural
infection has changed over recent years, with clear differences emerging between
hospital- and community-acquired infections. Using biochemical surrogates of
infection, chest drainage can be undertaken rationally for those who do not
respond to antibiotics alone. Recent data suggest that fibrinolytics do not
influence outcomes in pleural infection. The optimal type and timing of surgery
remain controversial.
-----
Monaldi Arch Chest Dis. 2006 Mar;65(1):26-33.
Pleural tuberculosis.
Chakrabarti B, Davies PD.
Aintree Chest Centre, University Hospital Aintree, Liverpool, United Kingdom.
biz@doctors.org.uk
Pleural effusions in tuberculosis are commonly seen in young adults as an
immunological phenomenon occurring soon after primary infection. However, the
epidemiology and demographics of tuberculous pleurisy are changing due to the
impact of HIV co-infection and the increasing number of pleural effusions seen
as part of re-activation disease. Pleural biopsy for histology and culture is
the mainstay of diagnosis with closed needle biopsy adequate in the majority of
cases. Techniques such as PCR of biopsy specimens and the role of pleural fluid
ADA are still being evaluated as a diagnostic aid. Tuberculous empyema is less
commonly seen in the western world and the diagnostic yield from pleural fluid
here is greater than in "primary" effusions. Treatment with appropriate
antituberculous chemotherapy is generally successful though there is currently
insufficient evidence to recommend the routine use of corticosteroids in this
condition.
-----
J Exp Clin Cancer Res. 2006 Mar;25(1):15-9.
Management of malignant pleural effusion by multimodality
treatment including the use of paclitaxel administered by 24-hour intrathoracic
infusion for patients with carcinomatous pleuritis.
Ohta Y, Shimizu Y, Matsumoto I, Watanabe G.
Department of General and Cardiothoracic Surgery, Kanazawa University School of
Medicine, Japan. yohta@sf.m.kanazawa-u.ac.jp
For successful intrapleural chemotherapy, intrapleural drug activity should be
maintained for as long as possible. This interim report presents the results of
treatment with paclitaxel administered by 24-hour intrathoracic infusion as an
adjunct to selective surgical management and/or systemic chemotherapy for
controlling malignant pleural effusion. Thirteen patients with carcinomatous
pleuritis were enrolled in the study between October 2001 and September 2004.
The sites of primary disease were the lung in 12 patients and the breast in one
patient. Paclitaxel (120 mg/m2) was administered by 24-hour intrathoracic
infusion. Seven patients underwent elective surgical treatment and 11 patients
received adjuvant systemic chemotherapy. Mild toxicity occurred in 7 cases, and
chest pain and neutropenia were dominant. During a median follow-up period of 9
months (range, 2-33 months), malignant effusion was controlled successfully in
11 patients (84.6%). The multimodality treatment, including the use of
paclitaxel, in this manner merits further investigation for possible
intervention for malignant pleural effusion originating in lung and breast
neoplasms.
-----
J Surg Oncol. 2006 Mar 15;93(4):323-9. Comment in: J Surg Oncol. 2006 Mar
15;93(4):255-6.
Modified intrapleural cisplatin treatment for lung cancer with
positive pleural lavage cytology or malignant effusion.
Muraoka M, Oka T, Akamine S, Tagawa T, Morinaga M, Inoue M, Yamayoshi T,
Hashizume S, Matsumoto K, Hayashi T, Nagayasu T.
Division of Surgical Oncology, Department of Translational Medical Sciences,
Nagasaki Graduate School of Biomedical Sciences, Nagasaki, Japan. ceb17760@hkg.odn.ne.jp
OBJECTIVES: We evaluate the efficacy and safety of the modified intrapleural
cisplatin treatment for lung cancer patients with positive pleural lavage
cytology or malignant effusion. METHODS: The treatment was performed for seven
patients with malignant effusion and 18 patents with positive pleural lavage
cytology. After pulmonary resection, the pleural cavity was filled with
cisplatin with a normal saline solution for 30 min. Complications and survival
of the patients were evaluated. RESULTS: The chest tube duration were
significantly prolonged in the treatment (CDDP) group (5.7 +/- 3.6 vs. 2.8 +/-
2.6 days). We had one operative death that developed a bronchial fistula;
however, the other complications were not severe. The mortality rate was 4% and
the morbidity rate was 60%. We experienced two carcinomatous pleuritis in the
CDDP group. The median survival time of the CDDP group was 47.0 +/- 11.1 months
and the 3- and 5-year survival rate was 52.6% and 11.3%, respectively.
CONCLUSIONS: We were able to perform this treatment for these advanced lung
cancer patients, which had the preventive effect of carcinomatous pleuritis.
This therapy shows the possibility of a treatment that might lead to an
improvement in the prognosis of these patients, without causing severe
complications. (c) 2006 Wiley-Liss, Inc.
-----
Pediatr Surg Int. 2006 Feb 21; [Epub ahead of print]
Conservative use of chest-tube insertion in children with pleural
effusion.
Epaud R, Aubertin G, Larroquet M, Pointe HD, Helardot P, Clement A, Fauroux B.
Pediatric Pulmonology and INSERM U719, Hopital Armand Trousseau, Assistance
Publique-Hopitaux de Paris, 26 avenue Arnold Netter, 75012, Paris, France,
ralph.epaud@trs.ap-hop-paris.fr.
The aim of this work was to evaluate the effect of a more conservative use of
chest-tube insertion on the short-term and long-term outcome of pleural
infection. Sixty-five patients with pleural infection, aged 1 month to 16 years
were each treated according to one of the two protocols: classical management
with chest-tube insertion (classical group, n=33), or conservative use of
chest-tube insertion (conservative group, n=32), with drainage indicated only in
the case of voluminous pleural effusion defined by a mediastinal shift and
respiratory distress and/or an uncontrolled septic situation. The two groups
were comparable with regard to age, baseline C-reactive protein (CRP) value and
white blood cell counts, pleural thickness, identified bacteria, and antibiotic
treatment. Chest-tube insertion was performed in 17 patients (52%) of the
classical group compared to eight patients (25%) of the conservative group
(P=0.03). Duration of temperature above 39 degrees C was shorter in the
conservative group (10+/-1 vs. 14+/-1 days, P=0.01), as was the normalization of
CRP (13+/-1 vs. 17+/-1 days, P=0.03). Duration of hospitalization and
intravenous (IV) antibiotherapy as well as the delay of chest-radiograph
normalization was not significantly different between the two groups. A more
conservative use of chest-tube insertion did not change short- and long-term
outcome of the pleural infection in children. Drainage could be restricted to
the most severely affected patients with pleural empyema causing a mediastinal
shift and respiratory distress and/or presenting with an uncontrolled septic
situation.
-----
Pediatr Surg Int. 2006 Feb;22(2):186-90. Epub 2005 Dec 16.
Complicated pneumonias with empyema and/or pneumatocele in
children.
Kunyoshi V, Cataneo DC, Cataneo AJ.
Thoracic Surgery Discipline of the Surgery and Orthopedics Department, Botucatu
School of Medicine, Sao Paulo State University-UNESP, 18.618-970, Botucatu, SP,
Brazil.
To investigate the incidence, procedure type, characteristics of pleural fluid
and pneumatoceles, and evolution of pneumonia complicated with empyema and/or
pneumatoceles. Review of 394 pediatric pneumonia in patients at Sao Paulo State
University Hospital during 2 years. We studied those with complications such as
pleural effusion and pneumatocele. There were 121 (30.71%) with complications
such as pleural effusion and pneumatocele; these were significantly higher in
infants. One hundred and six children were needle aspirated, of these 78
underwent drainage, and 15 observation only. From the drained, seven needed
thoracotomy or pleurostomy. Fluid was purulent in 50%, and pneumatoceles were
seen in 33 cases (8.3%) with spontaneous involution in 28 (85%). Pleural fluid
culture was negative in 51% cases; in positive cultures, Streptococcus
pneumoniae was the most common agent. Complicated pneumonia incidence was higher
in the second year of life and more than 70% occurred before 4 years of age.
Closed thoracic drainage was effective in over 90%. Large effusions and
mediastinal deviations were submitted to more aggressive procedures.
Pneumatoceles predominated in the under 3s and were generally evident in the
first chest X-ray. Most cases had spontaneous pneumatocele involution, and in
almost half the cases were still present at drain tube removal.
-----
Respirology. 2006 Jan;11(1):105-8.
Efficacy and safety of iodopovidone pleurodesis through tube
thoracostomy.
Agarwal R, Aggarwal AN, Gupta D.
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education
and Research, Chandigarh, India. drritesh1@rediffmail.com
OBJECTIVE: To evaluate the efficacy and safety of iodopovidone as an agent for
pleurodesis through tube thoracostomy in patients with recurrent pleural
effusions and pneumothorax. METHODS: This was a prospective study in which
pleurodesis was performed with a solution of 20 mL 10% iodopovidone and 80 mL
normal saline solution infused through a tube thoracostomy and left in the
pleural cavity for 4 h. RESULTS: A total of 64 patients (34 men) with a mean
(+/-SD) age of 47.1 +/- 15.4 years were included. There were 37 cases of pleural
effusion and 27 of pneumothorax. A complete response (neither reaccumulation of
fluid nor recurrence of pneumothorax) was obtained in 32 (86.5%) patients with
pleural effusion and 25 (92.6%) patients with pneumothorax. A second procedure
(i.e. repeated pleurodesis) was attempted successfully in four patients in the
pleural effusion group. All patients experienced chest pain to a varying degree
as recorded on a Visual Analogue Scale (median 50.5, range 10-95). Seven
patients developed fever and one immunocompromised patient developed empyema
following the procedure. There were no recurrences at a median follow up of 5
months (range 3-15 months) in the pleural effusion group, and 13 months (range
6-24 months) in the pneumothorax group. CONCLUSIONS: Iodopovidone can be used as
an effective and safe agent for (chemical) pleurodesis (through tube
thoracostomy), which is inexpensive and readily available.
-----
J Heart Lung Transplant. 2005 Dec;24(12):2086-90. Epub 2005 Sep 28.
Pleural space problems after living lobar transplantation.
Backhus LM, Sievers EM, Schenkel FA, Barr ML, Cohen RG, Smith MA, Starnes VA,
Bremner RM.
Department of Cardiothoracic Surgery, University of Southern California Keck
School of Medicine, Los Angeles, California 90003, USA.
BACKGROUND: We reviewed our experience with adult living lobar lung transplant
(LL) recipients to assess whether size and shape mismatch of the donor organ to
the recipient pre-disposes to the development of pleural space problems (PSP).
METHODS: Eighty-seven LL were performed on 84 adult recipients from 1993 through
2003. Seventy-six patients had cystic fibrosis. Patient records were examined
for PSP, defined as air leak or bronchopleural fistula for more than 7 days;
pneumothorax, loculated pleural effusions, or empyema in 68 patients for which
complete data were available. RESULTS: There were 24 PSP identified for an
overall incidence of 35%. The most common PSP was air leak/bronchopleural
fistula, accounting for 38% of PSP. The second most common PSP was loculated
pleural effusion (21% of PSP). Empyema was uncommon (2 patients, 3% of total
patients) in our series of patients despite the large population of cystic
fibrosis patients. In 4 of these patients, computed tomography-guided drainage
was used for loculated effusions after chest tube removal. Three LL patients
underwent surgery for persistent air leak and required muscle flap repair. One
of these required subsequent omental transfer. Two LL patients required
decortication for empyema. Many patients with PSP could be managed without
further surgical intervention (14/24 patients). Donor-recipient height mismatch
was not significantly different between PSP and non-PSP patients (p = 0.53).
CONCLUSIONS: The incidence of PSP in LL recipients is similar to that reported
in the literature on cadaveric transplant recipients. The relatively small lobe
in the potentially contaminated chest cavity of cystic fibrosis recipients does
not significantly pre-dispose to development of empyema despite
immunosuppression. Many PSP can be managed non-operatively, although early
aggressive intervention for large air leaks and judicious chest tube management
are essential for a good outcome.
-----
Chir Ital. 2005 Nov-Dec;57(6):703-8.
Surgical outcome of lung cancer patients with carcinomatous
pleuritis.
Pagan V, Fontana P, Zaccaria A, Lo Giudice F, Oniga F.
UOC Chirurgia Toracica, Ospedale Umberto I, Venezia-Mestre.
In sporadic though non-anecdotal series, long-term survival has been reported
for patients operated on for lung cancer with secondary carcinomatous pleuritis.
In a retrospective study, we review the outcomes of 24 surgical patients (20
treated with standard lung resection +/- pleurectomy and 4 with extended
pleuropneumonectomy) out of 48 individuals affected by pleural spread before or
at thoracotomy. We observed a 16.6% major complication rate with no operative
mortality; 5-year and median survival were 20% and 21 months, respectively. Time
of diagnostic (pre- vs intra/postoperative) or pattern (effusion vs
dissemination) of pleural disease, and type of resection (standard vs extended)
did not seem to influence the prognosis, while an adenocarcinoma histotype,
completeness of excision and N(0-1) were favourable prognostic indicators. Since
most (90%) of these IIIB stages are usually associated with N(2-3) and/or
unresectable tumour, it would seem reasonable to employ neo-adjuvant treatment
as the first approach, reserving surgical treatment to responders. Multicentre
studies are necessary to better determine which subgroup of patients with
malignant pleuritis can most benefit from surgical therapy.
-----
Cancer. 2005 Dec 8; [Epub ahead of print]
Video-assisted management of malignant pleural effusion in breast
carcinoma.
Gasparri R, Leo F, Veronesi G, Depas T, Colleoni M, Maisonneuve P, Pelosi G,
Galimberti V, Spaggiari L.
Division of Thoracic Surgery, European Institute of Oncology, Milan, Italy.
BACKGROUND: Advanced breast carcinoma almost always leads to a malignant pleural
effusion, conditioning the performance status of patients and consequently
quality of life. The treatment of malignant pleural effusion should be a
priority in the management of such patients. The results of videothoracoscopic
approach (VATS) chemical pleurodesis was analyzed in patients with recurrent
pleural effusion from breast carcinoma. METHODS: From October 1998 to June 2004,
71 consecutive patients with breast carcinoma-related pleural effusion were
treated by the same thoracic-surgeon team with intracavitary nebulization of 8 g
of asbestos-free sterilized talc via VATS. Multiple pleural biopsies were
performed to determine biologic characteristics of recurrent disease. RESULTS:
Talc pleurodesis was performed in all cases, with no intraoperative or
postoperative complications. Median length of hospital stay was 5 days (range,
5-8). The overall success rate of the surgical procedure was 89% (confidence
interval [CI], 79-95%) with a mean follow-up of 22 months (range, 2-81 mos). The
overall survival time was 17 months (range, 2-80). Biopsies showed a switch on
receptor status and c-erB-2 status from negative (primary tumor) to positive
(pleural metastasis) in 11 (15%) patients. In another 7 (9.8%) patients, we
obtained completely new information that was hitherto unknown. CONCLUSION: Talc
pleurodesis via VATS is an effective and safe procedure that yields a high rate
of success at the first attempt and achieves long-term control of malignant
pleural effusion due to breast carcinoma. Concomitant biopsies performed during
the VATS procedure were a determining factor in the subsequent decision-making
process. Cancer 2006. (c) 2005 American Cancer Society.
-----
Chest. 2005 Nov;128(5):3284-90.
A retrospective analysis of the management of parapneumonic
empyemas in a county teaching facility from 1992 to 2004.
Cheng G, Vintch JR.
Division of Respiratory and Critical Care, Physiology and Medicine, Kaiser
Permanente, Torrance, CA 90706, USA. glenacheng@hotmail.com
OBJECTIVES: To characterize how patients with empyemas are managed initially at
our facility and to determine how "less aggressive" treatments (eg, no drainage,
repeat thoracentesis, or tube thoracostomy) affect short-term outcomes (ie,
inpatient mortality and the need for a second intervention) compared to "more
aggressive" treatments (eg, intrapleural fibrinolytic agents, video-assisted
thoracoscopic surgery, or other surgery). We will also assess whether earlier
diagnosis, earlier antibiotic treatment, fewer patient comorbidities, and
consulting appropriate services improve mortality. DESIGN: Retrospective chart
analysis. SETTING: County teaching hospital in Los Angeles, CA. PATIENTS:
Seventy-two adult inpatients with parapneumonic empyemas. INTERVENTIONS:
Mortality and the need for second intervention rates were calculated and
compared with data published in the 2000 American College of Chest Physicians
consensus statement on the management of parapneumonic effusions using the
Fisher exact test. Comparisons were made between empyema survivors and
nonsurvivors using t tests and chi(2) tests. RESULTS: All 72 patients were
managed with less aggressive initial treatments. There were no differences in
mortality when our patients were compared to the less aggressive group from the
literature (6% vs 9%, respectively; p = 0.40; relative risk, 0.6; 95% confidence
interval [CI], 0.23 to 1.62) or the more aggressive group from the literature
(6% vs 3%, respectively; p = 0.29; relative risk, 1.8; 95% CI, 0.64 to 5.23).
There was no difference between the second intervention rate of our patients and
that of the less aggressive group from the literature (47% vs 43%, respectively;
p = 0.47; relative risk, 1.1; 95% CI, 0.86 to 1.42), although there was a
difference when compared to the more aggressive group (47% vs 11%, respectively;
p < 0.0001; relative risk, 4.5; 95% CI, 3.20 to 6.31). There were no
statistically significant differences in time of diagnosis, the timing of
antibiotic treatment, the number of patient comorbidities, or the number of
services consulted when survivors and nonsurvivors from the study were compared.
CONCLUSIONS: Patients with empyemas at our hospital are treated with less
aggressive initial treatments and have a higher second intervention rate when
compared to patients described in the literature who were initially managed with
more aggressive treatments.
-----
Respirology. 2005 Nov;10(5):649-55.
Prolonged survival after talc poudrage for malignant pleural
mesothelioma: case series.
Aelony Y, Yao JF.
Department of Internal Medicine, Kaiser Permanente Medical Center, Harbor City,
CA 90710, USA. y.aelony@cox.net
OBJECTIVE: Malignant pleural mesothelioma is a fatal disease with a mean life
expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc
poudrage (TTP) as a primary therapy in mesothelioma patients presenting with
pleural effusion. As the survival data for our patients surpassed that of many
published series, the patient data was analyzed to determine whether talc
poudrage can be considered as a contemporary palliative option. METHODOLOGY: We
reviewed all 26 patients with a final diagnosis of malignant pleural
mesothelioma from our prospective database of 228 consecutive patients who
received thoracoscopy from the same physician for recurrent symptomatic pleural
effusion. Patients were followed up until their death. RESULTS: Mean survival
after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis
palliated dyspnoea in all patients. No perioperative deaths and one
postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/-
2.7 days. CONCLUSION: TTP remains a safe, low-morbidity, inexpensive primary
palliative treatment option for malignant pleural mesothelioma and a valid
control arm option for therapeutic trials. TTP is ideal for patients who wish to
avoid thoracotomy, long hospital stays and morbidity from multimodality therapy.
Prospective randomized studies are needed to compare quality of life and
survival after talc poudrage and other therapies.
-----
Pneumologie. 2005 Oct;59(10):696-703.
[The treatment of parapneumonic effusions and pleural empyemas]
[Article in German]
Hamm H.
Rehabilitationsklinik fur Atemwegs- und Tumorerkrankungen der Asklepios
Nordseeklinik, Westerland/Sylt. h.hamm@asklepios.com
Pleural effusions of infectious origin usually present as a complication of
pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based
upon the clinical picture, the appearance of the pleural fluid, on certain
laboratory parameters, and upon the success of therapeutic interventions. The
initial antibiotic regimen should cover the causative organisms that may
empirically be expected in the individual setting of the patient. Similar to the
situation in pneumonias, the spectrum of organisms in community-acquired
effusions or empyemas differs substantially from that in hospital-acquired
pleural infections. The management of pleural empyemas should follow an
interdisciplinary strategy which involves the pulmonologist and the thoracic
surgeon. The single most important intervention is the early and effective
drainage of the pleural cavity. Loculated effusions that do not promptly improve
after drainage can additionally be treated by a trial of intrapleural
fibrinolysis for a period of approximately three days. However, the precise role
of fibrinolytics in the setting of complicated pleural effusions and empyemas
remains to be better defined. Early definitive surgical treatment,
preferentially by video-assisted thoracoscopic surgery (VATS), should be the
goal in all patients who do not promptly respond to drainage and/or intrapleural
fibrinolytic therapy and who qualify for a surgical intervention.
-----
Chest. 2005 Sep;128(3):1431-5.
Clinical efficacy and safety of thoracoscopic talc pleurodesis in
malignant pleural effusions.
Kolschmann S, Ballin A, Gillissen A.
c/o Adrian Gillissen, St. George Medical Center, Robert-Koch-Hospital, Nikolai-Rumjanzew-Str
100, D-04207 Leipzig, Germany. steffen.kolschmann@web.de.
STUDY OBJECTIVES: In patients with disseminated neoplastic disease, recurrent
pleural effusion is frequently observed. The purpose of this study was to
determine the long-term efficacy and safety of pleurodesis by thoracoscopic talc
poudrage (TTP) in malignant pleural effusions (MPEs). METHODS: We report a
consecutive series of 102 patients (45 women, 57 men; 20 to 83 years of age) who
underwent medical thoracoscopy and TTP for recurrent MPE between 1999 and 2001.
Thoracoscopy was performed utilizing local anesthesia and IV sedation (medical
thoracoscopy). For pleurodesis, an average of 8 g of sterile talc powder was
used. One hundred eighty-day follow-up was completed for all patients, and
outcome measures included time to recurrence of the effusion and survival.
Efficacy was judged by clinical examination, chest radiograph, and/or thoracic
ultrasound examination. Procedure-related complications were documented.
RESULTS: The most common primary neoplasms were lung cancer (n = 48), breast
cancer (n = 16), and malignant pleural mesothelioma (n = 10). Twenty-eight
patients had other types of tumors, including renal cell carcinoma, ovarian
carcinoma, GI tumors, prostate, malignant lymphoma, and unknown primary cancer.
At the end of the primary observation period of 180 days, 38 of 46 surviving
patients (82.6%) had a successful pleurodesis. Type of primary neoplasm had no
significant influence on success rate. The 30-day mortality rate was 16.7% (n =
17). Survival curves after 180 days showed significant differences, with best
survival in mesothelioma and shortest life expectancy in lung cancer (p =
0.005). Adverse effects included empyema in one case and malignant invasion of
the scar. No episode of talc-induced ARDS was observed. CONCLUSION:
Thoracoscopic talc pleurodesis is a safe and effective method to stop recurrent
MPEs. Lasting pleural symphysis is obtained.
-----
J Surg Oncol. 2005 Sep 15;91(4):237-42.
Retrospective review of lung cancer patients with pleural
dissemination after limited operations combined with parietal pleurectomy.
Ohta Y, Shimizu Y, Matsumoto I, Tamura M, Oda M, Watanabe G.
Department of General and Cardiothoracic Surgery, Kanazawa University School of
Medicine, Kanazawa, Japan. yohta@sf.m.kanazawa-u.ac.jp
BACKGROUND AND OBJECTIVES: The long-term control of malignant effusion is
necessary to achieve long-term survival in lung cancer patients with
carcinomatous pleuritis. This report describes our results of limited operations
including parietal pleurectomy (pl) on a hypothesis that the most effective
target area for controlling malignant pleural effusion is the parietal pleura.
METHODS: Forty-two patients with pleural dissemination with/without malignant
pleural effusion were analyzed retrospectively. The operative procedures used
were partial resection of the primary site with pl in 20 cases, segmentectomy
with pl in 2 cases, lobectomy with pl in 19 cases, and pl only in 1 case.
Postoperative adjuvant treatment was performed in 31 patients. RESULTS:
Adenocarcinoma was the dominant histology, and the pathological stages were IIIB
in 34 cases and IV (intrapulmonary metastasis) in 8 cases. The overall 3-, 5-,
and 10-year survival rates were 30.1%, 17.2%, and 10.3%, respectively. When
stratified by the TNM classification, the overall 3-, 5-, and 10-year survival
rates were 56.3%, 32.1%, and 24.1%, respectively, in the T4N0M0 group and 21.1%,
7.0%, and 0%, respectively, in the T4N1-2M0 group (P = 0.0257). Among the 24
patients whose recurrent patterns could be identified, only 2 patients developed
recurrent malignant effusion. CONCLUSIONS: With appropriate patient selection,
the use of limited surgery combined with pl followed by intrapleural and
systemic chemotherapy appears to be effective in management of the disease.
Copyright 2005 Wiley-Liss, Inc.
-----
Hepatobiliary Pancreat Dis Int. 2005 Aug;4(3):375-8.
Prevention and management of pleural effusion following
hepatectomy in primary liver cancer.
Yan JJ, Zhang XH, Chu KJ, Huang L, Zhou FG, Yan YQ.
Department of Hepatic Surgery, Eastern Hepatobiliary Surgery Hospital, Second
Military Medical University, Shanghai 200438, China. Yiqunyan@21cn.com
BACKGROUND: Postoperative pleural effusion occurs frequently after hepatectomy.
The risk factors, prevention and management of postoperative pleural effusion in
patients with primary liver cancer (PLC) who have undergone hepatectomy and the
value of the argon beam coagulator (ABC) for the prevention of pleural effusion
are studied. METHODS: A total of 523 patients with PLC at our institution who
had had right hepatectomy from July 2000 to June 2004 were studied
retrospectively. Comparative analysis was made to identify the factors
contributing to postoperative pleural effusion and the efficacy of various
managements. RESULTS: Of the 523 patients whose livers were dissociated using
argon beam cutting and/or coagulation, 20(3.8%) developed pleural effusions;
whereas in the other 467 patients underwent hepatectomy with suture ligation of
the diaphragmatic secondary wound surface during the same period, 49(10.5%) had
pleural effusion (P < 0.01). The factors contributing to postoperative pleural
effusion included subphrenic collection, postoperative hepatic insufficiency
with ascites, duration of hepatic occlusion and underlying cirrhosis.
CONCLUSIONS: Dissociation of the liver by argon beam cutting and/or coagulation
can save suture ligation of the diaphragmatic secondary wound surface and may
also prevent postoperative pleural effusion. Pleural drainage using an
indwelling central-venous-catheter (CVC) in the pleural cavity is safe and
efficacious.
-----
Chest. 2005 Aug;128(2):684-9.
Prospective randomized trial of silver nitrate vs talc slurry in
pleurodesis for symptomatic malignant pleural effusions.
Paschoalini Mda S, Vargas FS, Marchi E, Pereira JR, Jatene FB, Antonangelo L,
Light RW.
Perola Byington Hospital, Sao Paulo, Brazil.
STUDY OBJECTIVES: To compare the efficacy and the safety of talc slurry and
silver nitrate (SN) in the treatment of symptomatic malignant pleural effusions.
PATIENTS AND METHODS: Sixty patients were enrolled into the study, and all
received a chest tube (26F or 28F) that was placed using local anesthesia. The
patients were randomized to receive either 5 g talc diluted to a total volume of
50 mL with saline solution or 20 mL 0.5% SN through the chest tube. Patients
were clinically evaluated before and after treatment regarding pain, and were
evaluated at monthly intervals with respect to the effectiveness of pleurodesis.
Eleven patients did not return for their 30-day follow-up visit and were
excluded from further analysis. Pleurodesis therapy was considered to be
successful if there was no recurrence of the effusion. The patients who did not
have a pleurodesis at one visit were excluded from subsequent visits. RESULTS:
Forty-nine patients returned at 30 days for follow-up, including 24 patients who
received SN and 25 who received talc. The groups were similar in age (p = 0.23),
sex (p = 0.70), Karnofsky index (p = 0.94), and pathology (p = 0.68). After the
induction of pleurodesis, neither the total mean (+/- SE) fluid drainage (SN,
901 +/- 125 mL; talc, 766 +/- 74 mL; p = 0.36) nor the level of pain (SN, 2.58
+/- 0.26; talc, 2.62 +/- 0.30; p = 0.91) differed significantly between the
groups, and no patient in either group developed ARDS. The mean number of days
spent in the hospital was nearly identical (SN group, 3.7 +/- 0.15 days; talc
group, 3.6 +/- 0.13 days; p = 0.47). Both SN and talc were effective agents.
Thirty days after the procedure, 23 of 24 patients (96%) who had received SN and
21 of 25 patients (84%) who had received talc showed an effective pleurodesis (p
= 0.35). Similar results were observed after 60 days (SN group, 18 of 18
patients [100%]; talc group, 13 of 13 patients [100%]; p = > 0.99), 90 days (SN
group, 16 of 16 patients [100%]; talc, 8 of 9 patients [89%]; p = 0.36), and 120
days (SN group, 4 of 4 patients [100%]; talc group, 4 of 4 patients [100%]; p >
0.99). CONCLUSIONS: The present study suggests that SN is an effective agent for
producing a pleurodesis. In the present study, SN showed a tendency to be more
effective than talc, but the power of the test to detect a significance
difference was low in this small group of patients. The side effects of 0.5% SN
appear to be minimal, but since only a small number of patients received SN and
nearly 20% of the patients were lost to follow-up, significant long-term side
effects cannot be excluded. Since SN appears to be as effective as talc, and
since there is no evidence that it induces ARDS as has been reported with talc,
it should be considered as an alternative to talc for the production of a
pleurodesis.
-----
J Pain Symptom Manage. 2005 Jul;30(1):75-9.
Video-thoracoscopic surgical pleurodesis in the management of
malignant pleural effusion: the importance of an early intervention.
Marrazzo A, Noto A, Casa L, Taormina P, Lo Gerfo D, David M, Mercadante S.
Department of Experimental Oncology and Clinical Application, University of
Palermo, Italy.
Thoracentesis plays an important role in cancer patients with symptomatic
effusions, although its effect is short-lived and symptoms recur in almost all
patients. Early video-thoracoscopic surgical pleurodesis may provide added
benefit to a group of patients with advanced cancer presenting with symptomatic
malignant pleural effusion. Seventy-six patients with advanced cancer and
pleural effusion due to pulmonary-pleural metastases were recruited. In 51 cases
(67.1%), at least one thoracentesis was performed before admission for surgery.
Preoperative staging consisted of chest radiograph, CT scan, and blood gas
analysis. The mean Karnofsky performance status was about 50. Pleurodesis with
talc poudrage was completely successful in all patients, with a morbidity rate
of 2.6%. There was no post-operative mortality. Three patients (3.9%) underwent
further thoracenteses for recurrence of pleural effusion within two months after
the procedure. Early use of talc insufflated by video-thoracoscopic surgery is
an effective and relatively safe method for treating pleural effusion, and
preventing recurrence, in advanced cancer patients.
-----
Surg Today. 2005;35(8):634-8.
Management of recurrent malignant pleural effusion with chemical
pleurodesis.
Kilic D, Akay H, Kavukcu S, Kutlay H, Cangir AK, Enon S, Kadilar C.
Department of Thoracic Surgery, Baskent University School of Medicine, Baskent
University Hospital, Sokak No: 6, 01250 Yuregir Adana, Turkey.
PURPOSE: Malignant pleural effusion is a common complication of primary and
metastatic pleural malignancies. It is usually managed by drainage and
pleurodesis, but there is no consensus as to the best method of pleurodesis. We
compared the effectiveness, side effects, and cost of different chemical
pleurodesis agents used in patients with malignant pleural effusion. METHODS:
Between January 1990 and December 2001, 108 patients with malignant pleural
effusion underwent chemical pleurodesis in our department. Thoracoscopy was
performed in 64 patients (59%), a minithoracotomy in 18 (17%), tube thoracostomy
in 11 (10%), and a small-bore catheter was inserted in 15 (14%). Talc was used
in 68 (63%) patients, tetracycline in 26 (24%), and bleomycin in 14 (13%). Talc
was instilled by insufflation during surgery after drainage, whereas
tetracycline and bleomycin were instilled via tube or catheter for pleural
analgesia. RESULTS: Talc resulted in significantly earlier tube and catheter
removal, after an average 4.1 days versus 5.1 days after tetracyline, and 6.3
days after bleomycin (P = 0.026, P = 0.001, respectively). A significantly lower
reaccumulation ratio in 90 days was achieved by the talc group, with nine
(13.2%) patients, representing an 86.8% success rate, than in the tetracyline
and bleomycin groups, with seven (26.7%) and five (35.7%) patients,
respectively, representing 73.8% and 64.3% success rates (P = 0.04).
CONCLUSIONS: Talc resulted in the earliest expansion, minimal drainage, and the
earliest tube and catheter removal.
-----
Pulm Pharmacol Ther. 2005;18(6):381-9.
Pharmacotherapy in complicated parapneumonic pleural effusions
and thoracic empyema.
Schiza SE, Antoniou KM, Economidou FN, Siafakas NM.
Department of Thoracic Medicine, University Hospital of Heraklion, P.O. Box
1352, 71110 Heraklion, Greece.
Parapneumonic pleural effusions (PPE) and pleural empyema (PE) present a
frequently diagnostic and therapeutic challenge in clinical practice. Although
pleural diseases have received increased attention during the past decade, there
are still many unanswered questions concerning the diagnosis and treatment of
PPE and PE. A lack of controlled studies concerning the management of PPE and PE
was noted in recent guidelines. The use of fibrinolytics intrapleurally appears
to enhance intercostals tube drainage, reducing the requirement for subsequent
surgical mechanical debridement. Recently, there has been interest in other
intrapleural agents including combination drugs consisting of streptokinase and
streptodornase-alpha, Dnase. Factors to be considered in evaluating whether or
not intrapleural instillation of fibrinolytics is effective include an
assessment of clinical responses. This review discusses the use of fibrinolytic
agents as a novel therapeutic options for treating the various stages of
parapneumonic effusions and empyemas.
-----
Curr Opin Pulm Med. 2005 Jul;11(4):340-4.
Alternative widely available, inexpensive agents for pleurodesis.
Dikensoy O, Light RW.
aDepartment of Pulmonary Diseases, School of Medicine, Gaziantep University,
Turkey; bSt. Thomas Hospital, Nashville, Tennessee, USA; and cVanderbilt
University, Nashville, Tennessee.
PURPOSE OF REVIEW: Pleurodesis is the one of the best options for the management
of symptomatic patients with malignant pleural effusion, recurrent benign
pleural effusion, and recurrent pneumothorax. Although talc, parenteral
tetracycline derivatives, and bleomycin are the most commonly used agents for
pleurodesis, parenteral tetracycline derivatives are not available worldwide,
bleomycin is expensive, and concerns about the side effects of talc are growing.
The purpose of this review is to provide information about other widely
available agents for pleurodesis. RECENT FINDINGS: It has recently been shown
that oral tetracycline/doxycycline is as effective and safe as parenteral
doxycycline in producing pleurodesis in rabbits. SUMMARY: Oral forms of
tetracycline derivatives, quinacrine, silver nitrate, iodopovidone, and other
talc preparations such as facial talc can be used to create pleurodesis when
commonly used agents are not available.
-----
Curr Opin Pulm Med. 2005 Jul;11(4):296-300.
Management of malignant pleural effusions.
Bennett R, Maskell N.
Department of Respiratory Medicine, Southmead Hospital, North Bristol NHS Trust,
Bristol, UK.
PURPOSE OF REVIEW: Although malignant pleural effusions are a common medical
problem, research into their optimal management remains sparse. The aim of this
review is to summarise recent developments in this area. RECENT FINDINGS: Talc
remains the most efficacious pleurodesis agent. However, concerns remain about
its side effect profile, with a number of cases of acute respiratory distress
syndrome documented in the literature. A recent trial showed that using
calibrated talc particles reduced the risk of morbidity from this procedure.
Work on novel pleurodesis agents, such as transforming growth factor-beta,
appears to induce pleurodesis in animal models without any unwanted side
effects. This is a promising development and human trials are awaited. With
regard to mesothelioma, recent chemotherapy trials with pemetrexed/cisplatin and
raltitrexed/cisplatin are encouraging and appear, for the first time, to offer a
small but real survival advantage. SUMMARY: In the authors' opinion, the major
developments in the management of malignant effusions during the past year are
the development of safer pleurodesis agents and the promise of better
combination chemotherapy agents for the treatment of mesothelioma.
-----
Chest. 2005 Jun;127(6):2101-5.
Thoracentesis in patients with hematologic malignancy: yield and
safety.
Bass J, White DA.
Department of Medicine, Pulmonary Section, Memorial Sloan Kettering Cancer
Center, New York, NY, USA.
BACKGROUND: Pleural effusions occur in patients with hematologic malignancies,
particularly during periods of hospitalization. Thoracentesis is often performed
to diagnose infection and to exclude the presence of complicated parapneumonic
effusions. The efficacy and safety of thoracentesis in this setting has not been
well-studied. DESIGN: Retrospective chart review of hospitalized patients with
hematologic malignancies undergoing thoracentesis. The aim of this study was to
assess the role of thoracentesis in establishing a diagnosis of infection in
this population and to determine the risk of complications. RESULTS: A total of
100 thoracentesis findings were analyzed in patients with lymphoma (52 patients)
and leukemia (27 patients), and in patients who had undergone bone marrow or
stem cell transplantation (21 patients). The indication for performing
thoracentesis was to exclude infection in 69% of cases. Fever was present in 59%
of the patients, and a concomitant lung parenchymal abnormality was present in
69% of cases. Effusions were moderate to large in size (87% of cases), and were
both bilateral (62%) and unilateral (38%). Exudates were documented in 83%of the
cases. A specific diagnosis was found in 21 patients and was more frequently
established in those with lymphoma (31%) compared to the other groups of
patients. Diagnoses found included malignancy in 14 cases, chylous effusions in
6 cases, and infection in 1 case. The one patient in whom empyema was found
required drainage. The criteria for a parapneumonic effusion were not found in
any other patients. The complication rate of 9% (pneumothorax, seven patients;
hemothorax, two patients) was comparable to that in other populations of
patients. CONCLUSIONS: Despite a high propensity for developing pulmonary
infections, hospitalized patients with hematologic malignancies rarely developed
complex parapneumonic effusions. The etiology of many of the effusions that
occurred in this setting was unclear.
-----
An Pediatr (Barc). 2005 May;62(5):427-32.
[Intrapleural urokinase in the treatment of parapneumonic
effusions.]
[Article in Spanish]
Mencia Bartolome S, Escudero Rodriguez N, Tellez Gonzalez C, Moralo Garcia S,
Bastida Sanchez E, Torres Tortosa P.
Servicio de Cuidados Intensivos Pediatricos. Hospital Universitario Virgen de la
Arrixaca. Murcia. Espana.
INTRODUCTION: Intrapleural fibrinolytic instillation has been used in the
treatment of loculated pleural effusions and empyemas and has reduced the need
for surgical intervention. Currently, the most commonly used fibrinolytic is
urokinase, although the doses have not yet been standardized in children. The
aim of the present study was to evaluate the utility of urokinase in the
treatment of infectious pleural effusions in children. MATERIAL AND METHODS: A
retrospective study was performed of children with infectious pleural effusions
admitted to the pediatric intensive care unit (PICU) between January 2000 and
December 2003. Age, sex, clinical features, laboratory tests, response to
urokinase treatment and clinical course during hospital stay were analyzed.
RESULTS: Thirty-one children were treated. The mean age was 38.1 months (SD:
22). There were 18 boys and 13 girls. The most frequent month of diagnosis was
November and the number of admission significantly increased from 2002 onwards.
The most frequent antibiotic therapy used before admission to the PICU was
cefotaxime associated with vancomycin (41 %), followed by cefotaxime alone (16
%). Positive cultures for Streptococcus pneumoniae were found in 11 patients (35
%). Pleural loculation was found in 14 patients (45 %). Treatment with
intrapleural urokinase was used in 23 patients (74 %). The mean chest tube
drainage was 140 ml (SD: 175) in the 24 hours before urokinase instillation and
was 406 ml (SD: 289) in the 48 hours after fibrinolytic therapy (p < 0.05).
Twenty-one patients (91 %) who received urokinase treatment had a good response.
There were no complications during the treatment. The mean length of stay in the
PICU was 5.8 days (SD: 2.6). CONCLUSIONS: The incidence of complicated pleural
effusions due to S. pneumoniae has increased in the last few years, despite
antibiotic therapy. Intrapleural urokinase is an effective treatment, including
in empyemas without loculation. None of our patients required thoracotomy and
there were few adverse effects.
-----
Semin Arthritis Rheum. 2005 Apr;34(5):744-9.
Therapeutic options for refractory massive pleural effusion in
systemic lupus erythematosus: a case study and review of the literature.
Breuer GS, Deeb M, Fisher D, Nesher G.
Department of Internal Medicine, Shaare-Zedek Medical Center, Jerusalem, Israel.
OBJECTIVES: Massive refractory pleural effusions are uncommon in patients with
systemic lupus erythematosus. Describing such a patient, the literature was
reviewed to report the various therapeutic options in such cases. METHODS:
MEDLINE search using the terms "lupus" and "pleural effusion," inclusion of
cases with refractory massive effusions with emphasis on treatment. RESULTS:
Only 10 such cases (including the patient described here) were reported in the
English literature over the past 25 years. Those 10 patients suffered symptoms
related to pleural effusion for a long period of time until resolution, ranging
between 2 months to 2.5 years (median 6 months). During that period of time they
underwent multiple fluid aspirations. Seven different types of therapy were
reported in these case descriptions. They can be divided into 2 major groups:
systemic therapy (immunosuppressive therapy, plasmapheresis, and intravenous
immunoglobulin) and local therapy (intrapleural steroid injections, pleurodesis
with talc or tetracycline, and pleurectomy). Pleurodesis with talc seemed to be
the most effective treatment modality. CONCLUSIONS: Due to the small number of
reported patients, the best type of intervention is uncertain. When refractory
pleural effusion is part of lupus exacerbation, the treatment of choice would be
systemic, such as immunosuppressive therapy with high-dose steroids and
cyclophosphamide. Intravenous immunoglobulin may also be considered. Local
measures such as talc pleurodesis should be employed if systemic measures fail,
or when pleural effusion is the only manifestation of lupus.
-----
Respirology. 2005 Mar;10(2):144-8.
Management of tuberculous pleuritis: can we do better?
Wong PC.
Tuberculosis & Chest Unit, Grantham Hospital, Aberdeen, Hong Kong, China. wongpc@ha.org.hk
Management of patients with tuberculous pleuritis can be improved by
establishing early diagnosis accurately, administering effective chemotherapy,
and close monitoring of progress for early detection and prompt management of
severe pleural inflammation in the hope of preventing or reducing subsequent
residual pleural fibrosis. In addition to the conventional diagnostic tools,
chemical markers, especially pleural fluid adenosine deaminase and
interferon-gamma levels and new microbiological tests such as polymerase chain
reaction and BACTEC culture of pleural biopsy specimens for Mycobacterium
tuberculosis, can increase the diagnostic yield for tuberculous pleuritis.
Indicators of the severity of pleural inflammation, including high pleural fluid
tumour necrosis factor-alpha and lysozyme levels, and low pleural fluid glucose
and pH, can help to predict residual pleural fibrosis. It is likely that
patients will require surgery: (i) complete drainage of pleural fluid for
prevention; and (ii) pleurectomy for the treatment of residual pleural fibrosis.
-----
Rev Mal Respir. 2005 Feb;22(1 Pt 1):71-9.
[Diagnosis and management of pleural effusions in critically III
patients]
[Article in French]
Azoulay E.
Service de Reanimation Medicale, hopital Saint-Louis et Universite Paris VII,
Assistance Publique-Hopitaux de Paris, Paris, France. elie.azoulay@sls.ap-hop-paris.fr
INTRODUCTION: Pleural effusions are common in ICU patients. Causes include
massive fluid resuscitation in shock, pneumonia--either community acquired or
nosocomial, cardiac insufficiency, hypoalbuminemia and hepatic impairment.
Pleural effusions frequently complicate cardiac and abdominal surgery and
haemothorax may complicate trauma. STATE OF THE ART: The incidence of pleural
effusions in the intensive care unit (ICU) varies depending on the screening
method used, from about 8% for physical examination to more than 60% for routine
ultrasonography. In the absence of clinical parameters to exclude infection
pleurocentesis remains an essential aspect of management and is not
contraindicated mechanical ventilation. This review of the diagnosis and
management of pleural effusions in ICU patients reports the most recent data
from the literature. Pleurocentesis can be performed safely in the ICU, even in
mechanically ventilated patients. The absence of reliable clinical or laboratory
test criteria for determining the cause of pleural effusions and the potentially
devastating consequences of failing to diagnose and treat pleural infection are
strong reasons to perform pleurocentesis in patients with clinically detectable
pleural effusions and no contraindication to the procedure. PERSPECTIVES:
Although the data reviewed indicate that the diagnosis and treatment of pleural
effusions should follow the same rules in the ICU as they do elsewhere, several
incompletely resolved issues deserve further investigation. These are summarised
in an agenda for future research.
-----
Respir Med. 2004 Dec;98(12):1166-72.
Inflammatory parameters after pleurodesis in recurrent malignant
pleural effusions and their predictive value.
Ukale V, Agrenius V, Widstrom O, Hassan A, Hillerdal G.
Department of Medicine, Thoracic Clinics, Karolinska Sjukhuset, Stockholm S-171
76, Sweden. valiant.ukale@ks.se
Recurrent pleural malignant effusion is a common problem which can be treated by
inducing symphysis of the pleural sheets. Many different drugs administered into
the pleural space can be used to achieve this. The drugs cause an inflammatory
response, which in turn is believed to cause the symphysis. Comparatively little
has been published on the degree of pleural inflammation and the systemic
response and whether this will affect the outcome. The aim of this study was to
describe the systemic inflammatory reaction following instillation of a chemical
agent into the pleura and to investigate whether this had any predictive value
for the outcome (i.e. the pleurodesis). The markers investigated were simple
ones: erythrocyte sedimentation rate, C-reactive protein, and leukocyte count
from venous blood samples, and the fever reaction. Eighty-nine prospective
patients with malignant pleural effusion who underwent pleurodesis with either
talc (48 patients) or quinacrine (41 patients) were included in the study.
Symphysis was achieved in 82 patients (92 per cent) and all had a prominent
transitional elevation of the inflammatory parameters. The unsuccessful attempts
caused negligible or very small elevations, but due to the small numbers only
the degree of fever after 8 and 48 h showed a statistically significant
difference. In conclusion, pleurodesis causes a systemic inflammation and there
is a tendency to a correlation between the success of pleurodesis and the degree
of inflammation. High fever and high inflammatory parameters including CRP are
due to this inflammatory response and do not indicate infection.
-----
Respirology. 2004 Nov;9(4):441-7.
Causes and management of pleural fibrosis.
Huggins JT, Sahn SA.
Division of Pulmonary and Critical Care Medicine, Allergy and Clinical
Immunology Medical University of South Carolina, Charleston, South Carolina
29425, USA. hugginjt@musc.edu
The development of pleural fibrosis follows severe pleural space inflammation
which is typically associated with an exudative pleural effusion. The response
of the mesothelial cell to injury and its ability, along with the basement
membrane, to maintain its integrity, is vital in determining whether there is
normal healing or pleural fibrosis. The formation of a fibrinous intrapleural
matrix is critical to the development of pleural fibrosis. This matrix is the
result of disordered fibrin turnover, whereby fibrin formation is up-regulated
and fibrin dissolution is down-regulated. Cytokines, such as TGF-beta and TNF-alpha,
facilitate the fibrin matrix formation. A complete understanding of the
pathogenesis of pleural fibrosis and why abnormal pleural space remodeling
occurs in some and not in others, remains unknown. Clinically significant
pleural fibrosis requires involvement of the visceral pleura. Isolated parietal
pleural fibrosis, as with asbestos pleural plaques, does not cause restriction
or respiratory impairment. The causes of visceral pleural fibrosis include
asbestos-associated diffuse pleural thickening, coronary bypass graft surgery,
pleural infection (including tuberculous pleurisy), drug-induced pleuritis,
rheumatoid pleurisy, uraemic pleurisy, and haemothorax. Systemic and
intrapleural corticosteroids administered during the initial presentation of
rheumatoid pleurisy in small series may decrease the incidence of pleural
fibrosis. Several randomised control trials using corticosteroids in tuberculous
pleurisy have not shown efficacy in reducing residual pleural fibrosis.
Decortication is effective in treating symptomatic patients regardless of the
cause of pleural fibrosis as long as chronicity has been documented and
significant underlying parenchymal disease has been excluded.
-----
Pediatr Pulmonol. 2004 Nov 30; [Epub ahead of print]
Medical management of parapneumonic pleural disease.
Barnes NP, Hull J, Thomson AH.
Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
Considerable heterogeneity exists in the management of parapneumonic pleural
disease. A randomized controlled trial (RCT) demonstrated the effectiveness of
small-catheter drainage with fibrinolysis, but surgical devotees suggest this
may only be applicable to "early" cases. We examined evidence-based medical
management in "all-comers." We performed a retrospective database analysis of
the management of all children with complex pleural effusion admitted to the
John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten
children were admitted. Ten were excluded as they were part of a multicenter RCT
and had received intrapleural saline instead of urokinase. Of the remaining 100,
51 were female and 49 male. Median age on admission was 5.8 years (range,
0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common
month for presentation. Ninety-six underwent chest ultrasound, confirming an
effusion in all, described as loculated/septated (68) or echogenic (11). In 17
cases, no specific comment was made regarding the nature of the fluid seen on
ultrasound. Ninety-five had subsequent chest tube drainage and then received
intrapleural fibrinolysis with urokinase. An etiological organism was identified
in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5,
Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In
a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid
microscopy, but did not grow on culture. Two (2%) required surgery due to the
persistence of symptoms and an inadequate response to medical management. Median
duration of admission was 7 days (range, 2-21 days); median duration of stay
from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks
(range, 3-20 weeks), all children were symptom-free, with minimal pleural
thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain
insertion and intrapleural urokinase is effective in treating complex
parapneumonic effusion and is associated with a good long-term outcome. (c) 2004
Wiley-Liss, Inc.
-----
Yonsei Med J. 2004 Oct 31;45(5):822-8.
The effects of urokinase instillation therapy via percutaneous
transthoracic catheter in loculated tuberculous pleural effusion: a randomized
prospective study.
Kwak SM, Park CS, Cho JH, Ryu JS, Kim SK, Chang J, Kim SK.
Department of Internal Medicine, Pulmonary Division, Inha University Hospital,
7-206, 3-ga, Shinheung-dong, Jung-gu, Incheon 400-103, Korea. smkwak@inha.ac.kr.
The purpose of this study was to propose that intrapleural urokinase (UK)
instillation could reduce pleural thickening in the treatment of loculated
tuberculous pleural effusion. Forty- three patients who were initially diagnosed
as having loculated tuberculous pleural effusion were assigned at random to
receive either the combined treatment of UK instillation including
anti-tuberculosis agents (UK group, 21 patients) or strictly the unaccompanied
anti-tuberculous agents (control group, 22 patients). The UK group received
100,000 IU of UK dissolved in 150 ml of normal saline daily, introduced into the
pleural cavity via a pig-tail catheter. The control group was treated with anti-tuberculous
agents, excepting diagnostic thoracentesis. After the cessation of treatment,
residual pleural thickening (RPT) was compared between the two groups. Clinical
characteristics and pleural fluid biochemistry were also evaluated. The RPT
(4.59 +/- 5.93 mm) of the UK group was significantly lower than that (18.6 +/-
26.37 mm) of the control group (p < 0.05). The interval of symptoms observed
prior to treatment of patients with RPT > or = 10 mm (6.0 +/- 3.4 wks) was
detected to be significantly longer than in those with RPT < 10 mm (2.1 +/- 1.2
wks) in the control group (p < 0.05). However, there were no discernible
differences were seen in the pleural fluid parameter in patients with RPT > or =
10 mm, as compared to patients with RPT < 10 mm in the UK group. These results
indicate that the treatment of loculated tuberculous pleural effusion with UK
instillation via percutaneous transthoracic catheter can cause a successful
reduction in pleural thickening.
-----
Wien Klin Wochenschr. 2004;116 Suppl 2:28-32.
The significance of thoracoscopic mechanical pleurodesis for the treatment of
malignant pleural effusions.
Crnjac A.
Department of Thoracic Surgery, Maribor Teaching Hospital, Maribor, Slovenia.
BACKGROUND: Malignant pleural effusion (MPE) is a frequent and serious
complication of numerous malignant tumors in the human organism. The patients
are suffering from the primary disease, and the pleural effusion causes dyspnea,
thus reducing the quality of their survival time. In our study we wished to
establish the significance of thoracoscopic mechanical pleurodesis (TMP) as a
new method for the resolution of this pathology, by comparing the results with
those of thoracotomy with pleurectomy (TP) and thoracic drainage (TD). The main
criterion for the effectiveness of each method was the absence of pleural
effusion in a certain time interval. PATIENTS AND METHODS: 84 patients with
recurrent MPE and primary tumors at various locations were divided into three
groups according to the type of palliative intervention. The patients were
classified according to the indication guidelines for individual procedures and
their general condition. Group 1 consisted of 44 patients in whom TMP was
performed, group 2 consisted of 17 patients with primary tumors in the thoracic
region in whom thoracotomy with pleurectomy (TP) was performed, and in group 3
there were 26 patients with TD. We compared the effectiveness of individual
palliative methods by periodical X-ray checks, numbers of complications, length
of TD and hospitalization, and changes in spirometric values after individual
procedures. The t-test was used in statistic processing of the data. RESULTS:
After six months, radiological investigation revealed recurrence of pleural
effusion in three patients in group 1 (93.2% efficacy), no recurrence in group 2
(100% efficacy), and recurrence in 18 patients in group 3 (25.0% efficacy).
There were fewer postoperative complications in group 1, the duration of TD and
hospitalization was significantly shorter, and spirometric values increased.
CONCLUSION: TMP is an effective palliative method for the treatment of recurrent
pleural effusions, with a minimum number of complications and a short period of
hospitalization. After TMP there is significant improvement in respiratory
functions, and for the patient it represents a relatively simple surgical
procedure. TP is indicated in the treatment of tumors and subsequent MPE in the
thoracic region, and TD is indicated in patients who are not suitable candidates
for one of the palliative pleurodesis procedures, because of either their poor
general condition or a trapped lung.
-----
Rev Port Pneumol. 2004 Jul-Aug;10(4):305-17.
[Pleurodesis]
[Article in Portuguese]
Melo R, Goncalves JR.
Servico de Pneumologia, Hospital Santa Maria, Avenida Prof. Egas Moniz, 1699
Lisboa Codex, Portugal. rjmelo2001@yahoo.com
Pleurodesis is a way of inducting an inflammatory process in the pleural surface
in order to create the closure of the pleural space. The exact mechanism isn't
completely understood and there is still a great deal of controversy concerning
pleurodesis. Pleurodesis can be achieved by introduction of a sclerosant agent
trough a chest tube into the pleural space, by medical thoracoscopy, by surgical
thoracoscopy or by thoracotomy. The principal sclerosant agents are talc and
tetracycline. The indications for pleurodesis are malignant recurrent pleural
effusion, primary recurrent pneumothorax, secondary pneumothorax and benign
pleural effusion resistant to medical treatment. There are, although, some
contraindications to performing it. Serious complications of pleurodesis are
rare and depend on the technique and agent used. The method of choice for
pleurodesis is related to the experience and technical facilities available. The
author presents a review about pleurodesis.
-----
Med Pregl. 2004 Jan-Feb;57(1-2):13-7.
[The role of physical rehabilitation in the treatment of exudative pleurisy]
[Article in Serbian]
[No authors listed]
INTRODUCTION: Exudates are due to a variety of diseases, the major and most
common ones being tuberculosis, nonspecific inflammation and malignancy. They
are usually treated conservatively, sometimes combined with surgery and physical
treatment. Physical therapy includes positional exercises, breathing exercises
and biostimulation. AIM OF THE STUDY: The study was aimed to find out the
following: 1) Is lung function improved by physical therapy; 2) Can adhesions be
diminished and mobility of the affected hemidiaphragm improved by physical
treatment; 3) Is there a direct positive correlation between physical treatment
and obtained improvement, or the same can be achieved in patients receiving
medicamentous treatment only; 4) What are the effects of some factors we cannot
influence (sex, age, effusion level, position of adhesions) on lung function and
diaphragm mobility improvement, that is on the efficiency of physical treatment;
5) How do the factors we can influence (the time interval before initiating the
treatment and its duration) affect improvement of the same lung function
parameters, that is treatment efficacy? MATERIAL AND METHODS: Physical treatment
of patients with exudative pleurisy was accomplished at the Department of
Rehabilitation in our Institute and it consisted of directed breathing exercises
and laser biostimulation. Its effects were examined in a group of 175 patients,
who received both conservative and physical treatment, and results were compared
with the control group patients, treated only conservatively (with antibiotics,
antituberculotics, corticosteroids). RESULTS: Comparative analysis confirmed a
significant improvement of lung function parameters (VC, FEV1, PEF) as well as
of hemidiaphragm mobility on the affected side of the thorax in favour of the
examined group. The severity of the lung function and diaphragm mobility
impairments have been found to be in correlation with the localization of
adhesions, whereas the degree of improvement correlated with the time interval
before the treatment initiation, as well as with its duration. DISCUSSION AND
CONCLUSION: The applied physical therapy resulted in: 1) significant improvement
of all examined lung function parameters in the examined group, which was not
registered in the control group; 2) significant improvement of the diaphragm
mobility in general; 3) factors such as sex, age and effusion level have no
effects on the physical treatment results; 4) treatment results are affected by
the time interval passed before the treatment initiation and its duration, as
well as the localization of adhesions; anterior adhesions affected lung function
and diaphragm mobility least, posterior ones more, while the influence of
lateral adhesions was most significant. It is finally concluded that physical
treatment should necessarily be included in the treatment of exudative pleurisy.
-----
J Infect Dis. 2004 Sep 1;190(5):869-78. Epub 2004 Jul 29.
A randomized, double-blind, placebo-controlled trial of the use
of prednisolone as an adjunct to treatment in HIV-1-associated pleural
tuberculosis.
Elliott AM, Luzze H, Quigley MA, Nakiyingi JS, Kyaligonza S, Namujju PB, Ducar
C, Ellner JJ, Whitworth JA, Mugerwa R, Johnson JL, Okwera A.
Uganda Virus Research Institute, Entebbe. alison.tom@infocom.co.ug
BACKGROUND: Active tuberculosis may accelerate progression of human
immunodeficiency virus (HIV) infection by promoting viral replication in
activated lymphocytes. Glucocorticoids are used in pleural tuberculosis to
reduce inflammation-induced pathology, and their use also might reduce
progression of HIV by suppressing immune activation. We examined the effect that
prednisolone has on survival in HIV-1-associated pleural tuberculosis. METHODS:
We conducted a randomized, double-blind, placebo-controlled trial of
prednisolone as an adjunct to tuberculosis treatment, in adults with
HIV-1-associated pleural tuberculosis. The primary outcome was death. Analysis
was by intention to treat. RESULTS: Of 197 participants, 99 were assigned to the
prednisolone group and 98 to the placebo group. The mortality rate was 21
deaths/100 person-years (pyr) in the prednisolone group and 25 deaths/100 pyr in
the placebo group (age-, sex-, and initial CD4+ T cell count-adjusted mortality
rate ratio, 0.99 [95% confidence interval, 0.62-1.56] [P =.95]). Resolution of
tuberculosis was faster in the prednisolone group, but recurrence rates were
slightly (though not significantly) higher, and use of prednisolone was
associated with a significantly higher incidence of Kaposi sarcoma (4.2
cases/100 pyr, compared with 0 cases/100 pyr [P =.02]). CONCLUSIONS: In view of
the lack of survival benefit and the increased risk of Kaposi sarcoma, the use
of prednisolone in HIV-associated tuberculous pleurisy is not recommended.
-----
Curr Med Chem. 2004 Jun;11(11):1479-500.
Natural medicine: the genus Angelica.
Sarker SD, Nahar L.
Phytopharmaceutical Research Laboratory, School of Pharmacy, The Robert Gordon
University, Schoolhill, Aberdeen AB10 1FR, Scotland, UK. s.sarker@rgu.ac.uk
More than 60 species of medicinal plants belong to the genus Angelica (Family:
Apiaceae). Many of these species have long been used in ancient traditional
medicine systems, especially in the far-east. Various herbal preparations
containing Angelica species are available over-the-counter, not only in the
far-eastern countries, but also in the western countries like USA, UK, Germany,
etc. For centuries, many species of this genus, e.g. A. acutiloba, A.
archangelica, A. atropupurea, A. dahurica, A. japonica, A. glauca, A. gigas, A.
koreana, A. sinensis, A. sylvestris, etc., have been used traditionally as
anti-inflammatory, diuretic, expectorant and diaphoretic, and remedy for colds,
flu, influenza, hepatitis, arthritis, indigestion, coughs, chronic bronchitis,
pleurisy, typhoid, headaches, wind, fever, colic, travel sickness, rheumatism,
bacterial and fungal infections and diseases of the urinary organs. Active
principles isolated from these plants mainly include various types of coumarins,
acetylenic compounds, chalcones, sesquiterpenes and polysaccharides. This review
evaluates the importance of the genus Angelica in relation to its traditional
medicinal uses, alternative medicinal uses in the modern society and potential
for drug development, and summarises results of various scientific studies on
Angelica species or Angelica-containing preparations for their bioactivities
including, antimicrobial, anticancer, antitumour, analgesic, anti-inflammatory,
hepatoprotective, nephroprotective, etc.
-----
Ann Chir. 2004 Apr;129(3):177-81.
[Closed thoracic drainage for purulent pleurisy]
[Article in French]
Riquet M, Badia A.
Service de chirurgie thoracique, hopital europeen Georges-Pompidou, 20-40, rue
Leblanc, 75015 Paris, France.
In purulent pleuresia, thoracenthesis is the gold standard treatment.
Fiblinolytics should be infused through the drain at an early stage in order to
prevent or treat fibrotic encystement. The cause of the pleuresia should be
treated parallely to the drainage.
-----
Probl Tuberk Bolezn Legk. 2004;(6):17-9.
[Efficacy of chemotherapy in patients with complicated first
detected destructive pulmonary tuberculosis]
[Article in Russian]
[No authors listed]
A hundred and fifty-six patients with first detected destructive pulmonary
tuberculosis were examined. 43.6% of the patients were found to have various
complications: bronchial tuberculosis and exudative pleurisy were more common.
All the patients received conventional chemotherapy. The studies have
demonstrated that the efficiency of chemotherapy during the complicated course
was less than in the uncomplicated one: closure of decay cavities was observed
in 69.4% of the patients with specific lesion of the bronchial system, in 78.8%
of those with a complication, such as exudative pleurisy (in 81.8% with
uncomplicated course). In these groups of patients, cessation of bacterial
isolation, as verified both bacterioscopically and culturally, was slower.
-----
Med Pregl. 2004 Jan-Feb;57(1-2):13-7.
[The role of physical rehabilitation in the treatment of
exudative pleurisy]
[Article in Serbian]
[No authors listed]
INTRODUCTION: Exudates are due to a variety of diseases, the major and most
common ones being tuberculosis, nonspecific inflammation and malignancy. They
are usually treated conservatively, sometimes combined with surgery and physical
treatment. Physical therapy includes positional exercises, breathing exercises
and biostimulation. AIM OF THE STUDY: The study was aimed to find out the
following: 1) Is lung function improved by physical therapy; 2) Can adhesions be
diminished and mobility of the affected hemidiaphragm improved by physical
treatment; 3) Is there a direct positive correlation between physical treatment
and obtained improvement, or the same can be achieved in patients receiving
medicamentous treatment only; 4) What are the effects of some factors we cannot
influence (sex, age, effusion level, position of adhesions) on lung function and
diaphragm mobility improvement, that is on the efficiency of physical treatment;
5) How do the factors we can influence (the time interval before initiating the
treatment and its duration) affect improvement of the same lung function
parameters, that is treatment efficacy? MATERIAL AND METHODS: Physical treatment
of patients with exudative pleurisy was accomplished at the Department of
Rehabilitation in our Institute and it consisted of directed breathing exercises
and laser biostimulation. Its effects were examined in a group of 175 patients,
who received both conservative and physical treatment, and results were compared
with the control group patients, treated only conservatively (with antibiotics,
antituberculotics, corticosteroids). RESULTS: Comparative analysis confirmed a
significant improvement of lung function parameters (VC, FEV1, PEF) as well as
of hemidiaphragm mobility on the affected side of the thorax in favour of the
examined group. The severity of the lung function and diaphragm mobility
impairments have been found to be in correlation with the localization of
adhesions, whereas the degree of improvement correlated with the time interval
before the treatment initiation, as well as with its duration. DISCUSSION AND
CONCLUSION: The applied physical therapy resulted in: 1) significant improvement
of all examined lung function parameters in the examined group, which was not
registered in the control group; 2) significant improvement of the diaphragm
mobility in general; 3) factors such as sex, age and effusion level have no
effects on the physical treatment results; 4) treatment results are affected by
the time interval passed before the treatment initiation and its duration, as
well as the localization of adhesions; anterior adhesions affected lung function
and diaphragm mobility least, posterior ones more, while the influence of
lateral adhesions was most significant. It is finally concluded that physical
treatment should necessarily be included in the treatment of exudative pleurisy.
-----
Medicina (Kaunas). 2004;40 Suppl 1:145-8.
[Video-assisted thoracoscopic surgery in diagnosis
and treatment of pleuritis]
[Article in Lithuanian]
Piscikas DA, Cicenas S, Jackevicius A, Krasauskas A, Jakubauskiene
R.
Institute of Oncology, Vilnius University, Santariskiu 1, 2021
Vilnius, Lithuania. vuoipiscikas@yahoo.com
OBJECTIVE. To evaluate possibilites of video-assisted thoracoscopic
surgery in diagnosis and treatment of pleuritis. 1997-2002 in
Department of Thoracic Surgery and Oncology of Vilnius University
Institute of Oncology 206 patients underwent videothoracoscopic
procedures (146 (70.8%) of them for pleuritis). All procedures
were performed in general anesthesia using double lumen tube.
Mean patient age was 61+/-10 years. One hundred three women (71%)
and 43 men (29%) were operated. Seventy four (51%) chemopleurodesis
was performed with pleural biopsies: for 2 patients (1.36%) bleocine
was used, and for 74 patients (50.6%) sterile talk. RESULTS. Significance
of pleural videobiopsies reaches 93%. Eleven patients (7%) failed
in diagnosis: in 5 cases (3.4 %) due to adhesions, in 6 cases
(3.4%) we made false positive diagnosis. Complications: postoperative
pneumonia - 12 patients (8.8%), pneumothorax - 2 patients (1.5%),
pleural empiema - 1 patient (0.75%), bleeding - 1 patient (0.75%).
CONCLUSIONS. Specificity of video-assisted thoracoscopic surgery
in pleural diseases reaches 93.0%. Video-assisted thoracoscopic
surgery is necessary even in cases of failed "blind"
biopsies and possible in eldery patients. Video-assisted thoracoscopic
surgery provides not only easy morphologic verification of pleural
diseases but also performance of chemopleurodesis.
-----
Chest. 2004 Apr;125(4):1546-55.
Pleural effusions in hematologic malignancies.
Alexandrakis MG, Passam FH, Kyriakou DS, Bouros D.
Department of Hematology, University Hospital of Heraklion, and
Medical School, University of Crete, Greece.
Nearly all hematologic malignancies can occasionally present
with or develop pleural effusions during the clinical course of
disease. Among the most common disorders are Hodgkin and non-Hodgkin
lymphomas, with a frequency of 20 to 30%, especially if mediastinal
involvement is present. Acute and chronic leukemias, myelodysplastic
syndromes, are rarely accompanied by pleural involvement. Furthermore,
10 to 30% of patients receiving bone marrow transplantation develop
pleural effusions. In cases of hematologic pleural effusions,
drug toxicity, underlying infectious, secondary malignant or rarely
autoimmune causes should be carefully sought. In most cases, the
pleural fluid responds to treatment of the primary disease, whereas
resistant or relapsing cases may necessitate pleurodesis.
-----
J Clin Oncol. 2004 Apr 1;22(7):1228-33.
Prospective randomized trial of intrapleural bleomycin
versus interferon alfa-2b via ultrasound-guided small-bore chest
tube in the palliative treatment of malignant pleural effusions.
Sartori S, Tassinari D, Ceccotti P, Tombesi P, Nielsen
I, Trevisani L, Abbasciano V.
Department of Internal Medicine, St Anna Hospital, Ferrara, Italy.
srs@unife.it
PURPOSE: To compare bleomycin pleurodesis and immunotherapy
with intrapleural interferon alfa-2b (IFN) in the palliation of
malignant pleural effusions. PATIENTS AND METHODS: One hundred
sixty patients with rapidly recurrent malignant pleural effusion
were randomly assigned to intrapleural bleomycin (83 patients)
or IFN (77 patients). A 9-French intrapleural catheter was placed
under sonographic guidance, and pleural effusion was completely
drained before starting the treatment. Bleomycin 0.75 mg/kg was
administered as a single dose. An additional dose was given if
daily fluid output did not drop to less than 100 mL/d within 3
days. IFN 1 million units/10 kg was administered for six courses
at 4-day intervals. Thirty-day and long-term responses were evaluated
under the intention-to-treat principle. RESULTS: Thirty-day response
was 84.3% in the bleomycin arm and 62.3% in IFN arm (P =.002).
Median time to progression was 93 days (range, 12 to 395 days)
in bleomycin group, and 59 days (range, 7 to 292 days) in the
IFN group (P <.001). Median survival was 96 days (range, 15
to 395) and 85 days (range, 16 to 292) in the bleomycin and IFN
groups, respectively. Twenty-three patients received two doses
of bleomycin, as their daily fluid output remained higher than
100 mL after the first dose. Thirteen of them had complete response,
which lasted until death. CONCLUSION: Intrapleural bleomycin is
more effective than IFN and is a valid option for the palliative
treatment of massive, rapidly recurrent malignant pleural effusions.
The administration of a second dose of bleomycin to patients not
responding to the first one can remarkably improve the overall
outcome of the treatment.
-----
Respirology. 2004 Mar;9(1):4-11.
The management of pleural space infections.
Chapman SJ, Davies RJ.
Wellcome Trust Centre for Human Genetics, Oxford University, Oxford,
UK.
The management of pleural space infections CHAPMAN SJ, DAVIES
RJO. Respirology 2004; 9: 4-11Abstract: Pleural infection is responsible
for significant morbidity and mortality worldwide, and its clinical
management is challenging. The diagnosis of empyema and tuberculous
pleurisy may be difficult, and these conditions may be confused
with other causes of exudative pleural effusions. Complicated
parapneumonic effusion or empyema may present with 'atypical'
clinical features; delays in diagnosis are common and may contribute
to the high mortality of these infections. Pleural aspiration
is the key diagnostic step; pleural fluid that is purulent or
that has a pH < 7.2, or organisms on Gram stain or culture,
is an indication for formal intercostal drainage. In order to
achieve a definitive diagnosis of tuberculous pleurisy, Mycobacterium
tuberculosis must be isolated in the culture of pleural fluid,
pleural tissue or sputum; demonstration of granulomas in pleural
tissue is also suggestive of tuberculosis. The use of pleural
fluid biochemical markers, such as adenosine deaminase, in the
diagnosis of tuberculous pleurisy varies among clinicians; the
diagnostic value of such markers is affected by the background
prevalence of tuberculosis and the likelihood of an alternative
diagnosis. Uncertainties also remain regarding the treatment of
pleural infection. Treatment of complicated parapneumonic effusion
and empyema involves prolonged courses of antibiotics and attention
to the patient's nutritional state. The role of intrapleural fibrinolytics
and the optimal timing of surgical intervention are unknown. The
lack of clear predictors of clinical outcome in empyema contributes
to the difficulty in treating this condition. The pharmacological
treatment of tuberculous pleurisy is the same as for pulmonary
tuberculosis; the precise role of steroids in the treatment of
tuberculous pleurisy remains uncertain.
-----
Cochrane Database Syst Rev. 2004;(1):CD002916.
Pleurodesis for malignant pleural effusions.
Shaw P, Agarwal R.
Department of Clinical Oncology, Velindre Hospital, Whitchurch,
Cardiff, Wales, UK, CF4 7XL.
BACKGROUND: Approximately half of all patients with metastatic
cancer develop a malignant pleural effusion which is likely to
lead to a significant reduction in quality of life secondary to
symptoms such as dyspnoea and cough. The aim of pleurodesis in
these patients is to prevent re-accumulation of the effusion and
thereby of symptoms, and avoid the need for repeated hospitalization
for thoracocentesis. Numerous clinical studies have been performed
to try to determine the optimal pleurodesis strategy, and synthesis
of the available evidence should facilitate this. OBJECTIVES:
The aims of this review were to ascertain the optimal technique
of pleurodesis in cases of malignant pleural effusion; to confirm
the need for a sclerosant; and to clarify which, if any, of the
sclerosants is the most effective. SEARCH STRATEGY: The Cochrane
Central Register of Controlled Trials was searched for studies
on 'pleurodesis'. Studies for inclusion were also identified from
MEDLINE (1980 to June 2002) and EMBASE (1980 to May 2002). No
language restriction was applied. SELECTION CRITERIA: RCTs of
adults subjects undergoing pleurodesis for pleural effusion in
the context of metastatic malignancy (or a malignant process leading
to pleural effusion) were included. DATA COLLECTION AND ANALYSIS:
Two reviewers independently selected studies for inclusion in
the review, and extracted data using a standard data collection
form. Primary outcome measures sought were effectiveness of pleurodesis
as defined by freedom from recurrence of effusions, and mortality
after pleurodesis. Secondary outcomes were adverse events due
to pleurodesis. Dichotomous data were meta-analysed using a fixed
effect model and expressed as relative risk. The number-needed-to-treat
(NNT) was calculated for pleurodesis efficacy. In addition, for
adverse events, the overall percentage of patients across studies
exhibiting a particular adverse effect such as fever, pain, or
gastrointestinal symptoms was calculated. MAIN RESULTS: A total
of 36 RCTs with 1499 subjects were eligible for meta-analysis.
The use of sclerosants (mitozantrone, talc and tetracycline combined)compared
with control (instillation of isotonic saline or equivalent pH
isotonic saline or tube drainage alone) was associated with an
increased efficacy of pleurodesis. The relative risk (RR) of non-recurrence
of an effusion is 1.20 (95% CI 1.04 to 1.38) in favour of the
use of sclerosants based on five studies with a total 228 subjects.
Comparing different sclerosants, talc was found to be the most
efficacious. The RR of effusion non-recurrence was 1.34 (95% CI
1.16 to 1.55) in favour of talc compared with bleomycin, tetracycline,
mustine or tube drainage alone based on 10 studies comprising
308 subjects. This was not associated with increased mortality
post pleurodesis. The RR of death was 1.19 (95% CI 0.08 to 1.77)
for talc compared to bleomycin, tetracycline, mustine and tube
drainage alone based on six studies of 186 subjects. Death was
not reported in all studies and, when reported, was attributed
to underlying disease, only one death being reported as procedure-related.In
the comparison of thoracoscopic versus medical pleurodesis, thoracoscopic
pleurodesis was found to be more effective. The RR of non-recurrence
of effusion is 1.19 (95% CI 1.04 to 1.36) in favour of thoracoscopic
pleurodesis compared with tube thoracostamy pleurodesis utilizing
talc as sclerosant based on two studies with 112 subjects. Comparing
thoracoscopic versus bedside instillation (with different sized
chest tubes) of various sclerosants (tetracycline, bleomycin,
talc or mustine) the RR of non-recurrence of effusion is 1.68
(95% CI 1.35 to 2.10) based on five studies with a total of 145
participants.Adverse events were not reported adequately to enable
meta-analysis. REVIEWER'S CONCLUSIONS: The available evidence
supports the need for chemical sclerosants for successful pleurodesis,
the use of talc as the sclerosant of choice, and thoracoscopic
pleurodesis as the preferred technique for pleurodesis based on
efficacy. There was no evidpreferred technique for pleurodesis
based on efficacy. There was no evidence for an increase in mortality
following talc pleurodesis.
-----
Chest. 2003 Dec;124(6):2229-38.
Pleurodesis practice for malignant pleural effusions
in five English-speaking countries:
survey of pulmonologists.
Lee YC, Baumann MH, Maskell NA, Waterer GW, Eaton TE, Davies
RJ, Heffner JE, Light RW.
University of Oxford and Osler Chest Unit, Churchill Hospital,
Oxford OX3 7BN, UK. ycgarylee@hotmail.com
BACKGROUND: Pleurodesis is important in the management of malignant
pleural effusions, but no consensus exists on the optimal agent
or methods of pleurodesis. How pleurodesis is practiced worldwide
has not been studied. OBJECTIVES: To identify variations in the
clinical practice of pleurodesis in major English-speaking countries,
and to quantify the experience of pulmonologists on the effectiveness
and adverse effects of different pleurodesis agents worldwide.
METHODS: Eight hundred fifty-nine pulmonologists practicing in
the United States, United Kingdom, Canada, Australia, and New
Zealand participated in a Web-based survey. RESULTS: The respondents
collectively perform > 8,300 pleurodesis annually. Talc was
the preferred agent by most respondents (slurry, 56%; poudrage,
12%), followed by tetracycline derivatives (26%), and bleomycin
(7%). Differences were seen in pleurodesis practice patterns among
practitioners among and within the surveyed countries. Physicians'
overall satisfaction with the available pleurodesis agents was
modest (5.0 out of 8), and the reported success rate averaged
only 66%. Talc (both poudrage and slurry) was perceived as significantly
more effective, but was associated with significantly more pain,
nausea, and fever (p < 0.05). Respiratory failure occurred
more commonly with talc poudrage than with other agents (p <
0.05), and had been observed by 70% and 54% of physicians who
used talc poudrage and slurry, respectively. CONCLUSIONS: Significant
variations exist in how pleurodesis is performed worldwide. Pleurodesis
agents currently available are perceived as suboptimal. Talc poudrage
and slurry were perceived to be more effective, but were associated
with more complications, including respiratory failure.
-----
Khirurgiia (Mosk). 2003;(8):30-4.
[Ultrasonic technologies in diagnosis and treatment
of patients with surgical diseases of lungs and pleura]
[Article in Russian]
Pavlov IuV, Ablitsov IuA, Chistov LV, Kharnas SS, Rybin VK, Ablitsov
AIu.
The results of complex examination and treatment of 376 patients
with different diseases of the lungs and pleura were analyzed.
High-frequency ultrasound was used in 256 patients for diagnosis
of lungs and pleura surgical diseases, 412 ultrasonic examinations
were performed. Intraoperative treatment of pleura with low-frequency
ultrasound was carried out 134 times for prophylaxis and treatment
of acute postoperative pleura empyema in 120 patients operated
on for malignant tumors and chronic purulent diseases of the lungs.
High efficacy of high-frequency ultrasound for diagnosis of pleura
empyema, diffuse and encapsulated pleurisy is demonstrated. Ultrasound-assisted
pleural punctures an transthoracic aspiration biopsies permit
to avoid complications. Ultrasonic examination of the lungs during
surgery in patient suspected of lung cancer permits to study tumor
structure. Treatment of pleura with low-frequency ultrasound and
combination of this method with photodynamic therapy promote reliable
sanation of pleural cavity. Limited rethoracotomy and treatment
of pleura with low-frequency ultrasound is the method of choice
in the treatment of acute postoperative empyema when there is
no effect of conservative treatment.
-----
Anticancer Res. 2003 Nov-Dec;23(6a):4459-65.
Combined immunotherapy with intracavital injection
of activated lymphocytes, monocyte-derived dendritic cells and
low-dose OK-432 in patients with malignant effusion.
Morisaki T, Matsumoto K, Kuroki H, Kubo M, Baba E, Onishi
H, Tasaki A, Nakamura M, Inaba S, Katano M.
Department of Cancer Therapy and Research, Collaboration Center,
Graduate School of Medical Sciences, Kyushu University, 3-1-1
Maidashi, Higashi-ku, Fukuoka 812-8582.
We have conducted a pilot study with combined immunotherapy
using autologous lymphocytes activated ex vivo and monocyte-derived
dendritic cells in combination with low-dose OK-432, a streptococcal
preparation, in five patients with peritoneal or pleural carcinomatosis
who were resistant to standard chemotherapy. All patients were
given 3 to 10 courses of the combined immunotherapy. No severe
adverse reactions occurred. Effusion production was decreased
in all of the patients. Significant decreases in tumor markers
of both effusions and sera as well as effusion volume occurred
in all of the patients. Cytological examinations revealed a marked
decrease or disappearance of cancer cells in those effusions.
Three patients showed increase in IFN-gamma levels in the effusions.
The overall prognosis of the patients was acceptable and the mean
survival time was more than 9 months. The locoregional immunotherapy
seems to be encouraging in view of therapeutic modality in patients
who are resistant to standard chemotherapy. Our study provides
a new protocol for immunotherapy and warrants further phase I/II
clinical study for chemo-resistant patients with malignant effusion.
-----
Arch Dis Child. 2003 Oct;88(10):915-7.
Management of parapneumonic effusion and empyema.
Hilliard TN, Henderson AJ, Langton Hewer SC.
Bristol Royal Hospital for Children, UK.
AIMS: To gather data on the clinical presentation of parapneumonic
effusion and empyema and to examine the effect of different management
strategies on short term outcomes. METHODS: Retrospective case
note review of 48 children admitted to a tertiary unit between
January 1998 and March 2001. Effusions were classified into three
stages dependent on ultrasound findings. RESULTS: The stage of
effusion was not associated with duration of previous symptoms
or length of previous admission. An interventional procedure was
performed on median day 2 of admission in 46 children: eight (17%)
had an intercostal drain alone, 14 (29%) had an intercostal drain
followed by intrapleural fibrinolytic therapy, and 24 (50%) had
a thoracotomy. Three children who had an initial intercostal drain
alone returned to theatre for thoracotomy, and two children who
had intrapleural fibrinolysis returned for thoracotomy. Median
length of stay (interquartile range) for each initial procedure
was 15 days (6-20) for intercostal drain alone, 8 days (6-12)
for fibrinolytic therapy, and 6.5 days (5-9) for thoracotomy.
Stay for intercostal drain alone was significantly longer than
for thoracotomy. CONCLUSION: Early surgical management of empyema
is associated with a favourable outcome.
-----
Radiology. 2003 Aug;228(2):370-8.
Intrapleural fibrinolysis for parapneumonic effusion
and empyema in children.
Wells RG, Havens PL.
Department of Radiology, MS 721, Children's Hospital of Wisconsin,
9000 W Wisconsin Ave, Milwaukee, WI 53226, USA. rwells@chw.org
PURPOSE: To assess the safety and efficacy of urokinase and
alteplase for intrapleural fibrinolysis in children with parapneumonic
pleural fluid collections. MATERIALS AND METHODS: A retrospective
review was performed of 71 children with parapneumonic pleural
fluid accumulations who were treated with thoracostomy tube placement
and intrapleural instillation of either urokinase or alteplase.
The procedures were performed with urokinase between September
2, 1995, and March 27, 1998, and with alteplase between March
30, 1998, and January 2, 2002. The medical records and daily chest
radiographs were reviewed by a pediatric radiologist to ascertain
demographic information, signs and symptoms, laboratory results,
thoracostomy tube output, treatment details, and radiographic
pleural thickness and lung opacification. Multiple variables were
compared for the alteplase and urokinase groups by using univariate
and multivariate statistics. We defined primary treatment success
as resolution of signs and symptoms at the time of discharge,
without surgical intervention. RESULTS: Primary treatment success
was 98% for alteplase and 100% for urokinase, with no major complications.
Greater pleural fluid drainage occurred with alteplase than urokinase
during the 1st (P =.001) and 2nd (P =.002) days of fibrinolytic
therapy, and for the duration of thoracostomy drainage (P <.001).
Multivariate models showed greater total drainage with alteplase
(P <.001), greater patient age (P <.001), larger tube size
(P =.002), and greater volume of drainage during the 24 hours
prior to fibrinolysis (P <.001). CONCLUSION: Intrapleural fibrinolysis
with urokinase or alteplase facilitates thoracostomy tube drainage
of parapneumonic pleural fluid. With the dosing regimen used in
this study, alteplase produces greater thoracostomy tube output
than does urokinase. Copyright RSNA, 2003.
-----
Tumori. 2003 Jul-Aug;89(4 Suppl):233-6.
[The treatment of malignant pleural effusions:
the experience of a multidisciplinary thoracic
endoscopy group]
[Article in Italian]
Bertolaccini L, Zamprogna C, D'Urso A, Massaglia F.
UOa Chirurgia Generale I, ASL 3, Ospedale Maria Vittoria, Torino.
More than half of neoplastic patients show in their clinical
history the onset of pleural effusion. Malignant pleural effusion
produces dyspnea, decreases respiratory function and quality of
life in patients with advanced cancers. Optimal treatment is actually
controversial. The aim of this study is to analyze the experience
of malignant pleural effusion treatment of the Multidisciplinary
Group of Thoracic Endoscopy. Patients are been subdivided in two
group, depending on respiratory performance status and they are
been submit to a Video-Assisted Thoracic Surgery (VATS) with talc
pleurodesis and to positioning of a chronic indwelling pleural
catheter. The treatment of malignant pleural effusion with the
methods reported above allows, not only to achieve palliation
of symptomatology, but also to achieve pleurodesis in patients
with limited life-expectancy with good cost-beneficial ratio.
-----
Ann Thorac Surg. 2003 Jul;76(1):231-3.
Pleurovenous shunting in the treatment of nonmalignant
pleural effusion.
Artemiou O, Marta GM, Klepetko W, Wolner E, Muller MR.
Department of Cardiothoracic Surgery, University of Vienna, Vienna,
Austria. omeros.artemiou@univie.ac.at
BACKGROUND: The goals of treatment of chronic nonmalignant
pleural effusion are relief of dyspnea and improved quality of
life. Treatment options include needle thoracentesis, tube thoracostomy
chemical pleurodesis, and pleurectomy. Pleurovenous shunting (PVS)
represents an alternative, minimally invasive method. METHODS:
Since 1999, 12 patients underwent pleurovenous shunting for right-sided
pleural effusion in our center. Indications were hepatic hydrothorax
(n = 6, one as bridging to liver transplantation), nephrotic syndrome
(n = 4), and chylothorax (n = 2, one as bridging to lung transplantation).
All patients received Denver shunt systems from the pleural cavity
to either the subclavian or jugular vein. RESULTS: Shunt occlusion
was observed in one case (chylothorax) 4 weeks after implantation.
There was one early death, which was not related to the procedure
(hepatic failure). No air embolism or infection was observed.
All systems were patent throughout the observation period of 1
to 40 months (mean = 13.3 months), and none of the patients required
further treatment for pleural effusion. CONCLUSION: Pleurovenous
shunting offers an efficient, minimally invasive alternative to
other surgical methods for treatment of recurrent nonmalignant
pleural effusion.
-----
Radiology. 2003 Jul;228(1):241-5.
Pleural effusions in lung transplant recipients:
image-guided small-bore catheter drainage.
Marom EM, Palmer SM, Erasmus JJ, Herndon JE, Zhang C, McAdams
HP.
Department of Radiology, Duke University Medical Center, Durham,
NC, USA. emarmom@di.mdacc.tmc.edu
PURPOSE: To assess the efficacy of treating pleural effusions
in lung transplant recipients with small-bore catheter drainage.
MATERIALS AND METHODS: Chest radiographs and computed tomographic
(CT) scans obtained in 31 lung transplant recipients who had pleural
effusions treated with catheter drainage were retrospectively
reviewed. Duration of drainage and volume of fluid drained were
recorded. Results were evaluated 1 and 3 months after chest tube
removal. There was complete response (CR) when no pleural fluid
remained, partial response (PR) when fluid remaining was less
than the pretreatment level, and no response (NR) when fluid recurred
to a level at or above the pretreatment level. Associations between
cause of effusion (empyema, parapneumonic effusion, rejection,
other), response (CR, PR, NR), and type of transplantation (unilateral,
bilateral) were examined by using chi2 tests. RESULTS: Of 31 patients,
25 had bilateral effusions; eight of these 25 patients had small-bore
catheters inserted bilaterally. Nine patients had multiple sequential
catheter insertions. Duration of drainage ranged from 2 to 44
days (median, 6 days). Fluid output was 110-9,726 mL (median,
1,350 mL). One-month follow-up data were available for 31 of 39
treated pleural effusions: 11 (35%) had CR, 18 (58%) had PR, and
two (6%) had NR (percentages do not add up to 100% due to rounding).
Three-month follow-up data were available for 28 of 39 treated
effusions: 22 (79%) had CR, five (18%) had PR, and one (4%) had
NR (percentages do not add up to 100% due to rounding). One- and
3-month response rates, respectively, were not related to cause
of effusion (P =.82 and.535) or type of transplantation (P =.568
and >.999). CONCLUSION: Small-bore catheter drainage of persistent
pleural effusions in lung transplant recipients is usually successful,
but drainage is often prolonged and may require multiple catheter
placements.
-----
Curr Opin Pulm Med. 2003 Jul;9(4):282-90.
Ultrasound in the diagnosis and management of
pleural disease.
Tsai TH, Yang PC.
Department of Internal Medicine, National Taiwan University Hospital,
Taipei, Taiwan, ROC.
The authors summarize the current applications of chest ultrasonography
in the diagnosis and management of various pleural diseases. Ultrasound
has been proved to be valuable for the evaluation of a wide variety
of chest diseases, particularly when the pleural cavity is involved.
Chest ultrasound can supplement other imaging modalities of the
chest and guides a variety of diagnostic and therapeutic procedures.
Pleural effusion, pleural thickening, pleural tumors, tumor extension
into the pleura and even the chest wall, pleuritis, and pneumothorax
can be detected easily and accurately with chest ultrasound. Many
ultrasound features and signs of these diseases have been well
characterized and widely applied in clinical practice. Under real-time
ultrasound guidance the success rates of invasive procedures on
pleural diseases increase significantly whereas the risks are
greatly reduced. The advantages of low-cost, bedside availability
and no radiation exposure have made ultrasound an indispensable
diagnostic tool in modern pulmonary medicine.
-----
Curr Opin Pulm Med. 2003 Jul;9(4):291-7.
Pleural effusions in the intensive care unit.
Azoulay E.
Service de Reanimation Medicale, Hopital Saint-Louis et Universite
Paris, France. elie.azoulay@sls.ap-hop-paris.fr
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.
-----
Med Clin (Barc). 2003 Jun 21;121(3):98-9.
[Treatment of empyema and complicated pleural
effusion with intrapleural fibrinolysis]
[Article in Spanish]
Montero Ruiz E, Daguerre Talou M, Lopez Alvarez J, Hernandez Ahijado
C.
Servicio de Medicina Interna. Hospital Universitario Principe
de Asturias. Alcala de Henares. Madrid. Spain. emonteror@wanadoo.es
Background and objective: 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.Patients
and method: 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.Results:
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.Conclusions: IPF is an efective
and reliable method for the treatment of PEM/CPE.
-----
Chest. 2003 Jun;123(6):1895-8.
Rapid pleurodesis for malignant pleural effusions.
Spiegler PA, Hurewitz AN, Groth ML.
Winthrop University Hospital, Mineola, NY, USA. pspiegler@pulmonary.winthrop.org
STUDY OBJECTIVE: To determine the feasibility of rapid pleurodesis
in patients with malignant pleural effusions in order to reduce
hospital length of stay in patients with a limited life expectancy.
DESIGN: Prospective case series. SETTING: Two university hospital
programs. PATIENTS: Thirty-eight patients with symptomatic pleural
effusions associated with malignancy. INTERVENTIONS: A 14F catheter
was inserted percutaneously into the pleural space after radiographic
confirmation of free fluid by lateral decubitus views. Following
radiographic confirmation of complete fluid evacuation, a sclerosing
agent (ie, talc slurry or bleomycin) was instilled into the pleural
space. This was accomplished within 2 h of chest tube insertion,
unless the tube was inserted in the evening or if the lung was
trapped. After clamping the tube for 90 min, the pleural space
was drained for 2 h, after which the chest tube was removed. The
intervention was scored as "successful" if no radiographic
evidence of fluid reaccumulation was noted at 4 weeks. A "partial
successful" score indicated reaccumulation of fluid that
did not produce symptoms and did not require repeat pleural drainage
of any sort. All other outcomes were scored as "unsuccessful."
Measurements and results: Forty chest tubes were inserted into
38 patients. Four procedures revealed the presence of a trapped
lung and did not result in any attempt at pleurodesis. Five patients
who received pleurodesis died in less than 1 month and therefore
were not evaluable. Two patients had technical problems with the
chest tube and were not evaluable. Of the remaining 29 procedures,
drainage procedures with pleurodesis were performed in 27 patients,
a complete response was seen in 14 patients (48%), a partial response
was seen in 9 patients (31%), and 6 patients (21%) did not respond
to pleurodesis. Chemical pleurodesis was completed as an outpatient
procedure in only two patients. In one of these, the outcome was
unsuccessful. In the remainder, insertion of the chest tube in
the evening or additional medical problems necessitated hospital
admission, but the entire procedure was completed within 24 h.
CONCLUSIONS: Chemical pleurodesis can be accomplished with good
results in < 24 h in the majority of patients with malignant
pleural effusions.
-----
Am Surg. 2003 Mar;69(3):198-202; discussion 202.
Use of an indwelling pleural catheter compared
with thorascopic talc pleurodesis in the management of malignant
pleural effusions.
Ohm C, Park D, Vogen M, Bendick P, Welsh R, Pursel S, Chmielewski
G.
Division of Thoracic Surgery and Department of Surgery, William
Beaumont Hospital, Royal Oak, Michigan 48073, USA.
Therapy for recurrent malignant pleural effusion (MPE) is palliative.
Video-assisted thoracic surgery with talc pleurodesis (VATS/TP)
is limited to inpatients with completely expandable lung parenchyma.
We evaluated the outcomes, safety, and efficacy of an indwelling
pleural drainage catheter (PDC) system compared with VATS/TP.
Forty-one consecutive patients with symptomatic MPE seen between
September 2000 and April 2002 were studied. Patients able to fully
re-expand their lungs were treated with VATS/TP; those who could
not had PDC placement. Twenty-four (59%) were women. The mean
age was 64 +/- 13 years. VATS/TP was performed in only seven patients
(17%), and 34 patients had PDC placement. The length of stay (LOS)
was 2.8 +/- 5.1 days in the 18 PDC patients who were initially
seen as outpatients and 9.4 +/- 9.0 days in the inpatient population
(P = 0.013). Short (< 2 days) LOS occurred in 19 (56%) PDC
patients but in no VATS/TP patients (P = 0.007). Twenty-eight
patients (68%) died during follow-up: three VATS/TP patients (43%)
and 25 (74%) PDC patients (P = 0.112). We conclude that the PDC
system is an efficacious treatment of patients with MPEs and trapped
lungs. The LOS is short in patients initially evaluated as outpatients
which contributes to the perception of increased quality of life.
-----
Radiol Med (Torino). 2003 Jan-Feb;105(1-2):12-6.
Intrapleural fibrinolysis in the management of
empyemas and haemothoraces. Our experience.
[Article in English, Italian]
Basile A, Boullosa-Seoane E, Dominguez Viguera L, Certo A, Mundo
E, Garcia-Medina J, Casal-Rivas M.
Istituto di Radiologia, Policlinico G. Martino, Universita degli
Studi, Messina, Italy. antodoc@yahoo.com
PURPOSE: We evaluate our experience in the management of empyemas
and haemothoraces by means of intracavitary trans-catheter instillation
of urokinase (UK). MATERIAL AND METHODS: We reviewed 54 patients
(44 men and 10 women) ranging in age from 12 to 86 years (average
56.3) admitted between May 1999 and April 2001 with loculated
pleural effusions (45 empyemas and 9 haemothoraces) and treated
by percutaneous drainage and intrapleural urokinase instillation.
The criteria for withdrawal of the catheter were: ceased drainage
or the drainage of <80-100 ml of clear liquid per day. RESULTS:
The duration of the drainage ranged from 2 to 15 days (average:
5.9). Total remission of symptoms occurred in 40 patients (74.07%);
7 patients presented a slight reduction in lung function tests
(12.96%); 4 patients required surgery (7.4%); 3 displayed persistent
pleural loculated effusions (5.55%) and 1 developed a bronchopleural
fistula (1.85%); 2 patients were lost to our review (3.7%). CONCLUSIONS:
In our experience percutaneous drainage with intrapleural UK instillation
is an effective approach to the management of loculated pleural
effusions (empyemas and haemothoraces), able to obviate the need
for other more invasive pulmonary interventions.
-----
Eur Respir J 2003 Mar;21(3):539-44
Immunological mechanisms in pleural disease.
Antony VB.
Indiana University School of Medicine, Pulmonary and Critical
Care Medicine, RL Roudebush VA Medical Center, 1481 West 10th
Street, Indianapolis, IN 46202, USA. vantony@iupui.edu
The pleural membrane consisting of pleural mesothelial cells
and its underlying connective tissue layers play a critical role
in immunological responses in both local and systemic diseases.
The pleura, because of its intimate proximity to the lung, is
positioned to respond to inflammatory changes in the lung parenchyma.
Importantly, several systemic diseases have a predilection for
expression on the pleural surface. Immunological responses in
the pleura include the development of pleural permeability and
pleural effusion formation as well as the development of pleural
fibrosis and scarring. Under either circumstance, the normal functioning
of the pleura is impaired and has multiple consequences leading
to increased morbidity and even mortality for the patient. During
infections in the pleural space, the pleural mesothelium responds
by actively recruiting inflammatory phagocytic cells and allowing
the movement of proteins from the vascular compartment into the
pleural space. The release of chemokines by the pleural mesothelium
allows for directed migration of phagocytic cells from the basilar
surface of the pleura towards the apical surface. In malignant
disease, the pleura may be the site of primary tumours such as
mesothelioma and also the site for malignant metastatic deposits.
Certain cancers such as cancers of the breast, ovary, lung, and
stomach have a predilection for the pleural mesothelium. The process
whereby malignant cells attach to the pleural mesothelium and
develop autocrine mechanisms for survival in the pleural space
are elucidated in this review. The pleura functions not only as
a mechanical barrier, but also as an immunologically and metabolically
responsive membrane that is involved in maintaining a dynamic
homeostasis in the pleural space.
-----
Thorax 2003 Feb;58(2):149-51
Pigtail drainage in the treatment of tuberculous
pleural effusions: a randomised study.
Lai YF, Chao TY, Wang YH, Lin AS.
Division of Pulmonary Medicine, Department of Internal Medicine,
Chang Gung Memorial Hospital, Niao Sung Hsiang, Kaohsiung, Taiwan.
young@adm.cgmh.org.tw
BACKGROUND: Tuberculous pleurisy can result in obvious clinical
symptoms, pleural fibrosis, and pleural thickening. Some studies
of tuberculous pleurisy have suggested that symptomatic improvement
and minimisation of sequelae can be achieved by completely draining
the effusion during treatment, although the results have not been
conclusive. METHODS: Sixty one patients with tuberculous pleurisy
were divided into two groups; 30 patients received pigtail drainage
combined with antituberculosis (TB) drug treatment and 31 received
only anti-TB drugs. Outcome measurements were assessed for a period
of 24 weeks after treatment and included symptom scores and the
incidence of residual pleural thickening (RPT). RESULTS: Although
the duration of dyspnoea was significantly shortened by the use
of pigtail drainage (median 4 days (IQR 4-5) v 8 days (IQR 7-16),
p<0.001), a comparison of combined mean (SD) visual analogue
scale (VAS) scores showed no significant difference between the
groups after one week of treatment (57.1 (33.2) v 68.5 (44.7)
or at any time during the follow up period. The incidence of RPT
of more than 10 mm in the group treated with pigtail drainage
and anti-TB drugs was 26% compared with 28% in the group receiving
drug treatment only. The incidence of RPT levels of more than
2 mm in the two groups was 50% and 51%, respectively. No statistical
difference between the two groups in terms of forced vital capacity
was found at the end of treatment (median (IQR) 85.5% (69-94)
of predicted v 88% (78-96) of predicted). CONCLUSION: The addition
of pigtail drainage to an effective anti-TB regimen is not clinically
relevant and does not reduce the level of RPT.
-----
Heart Lung 2003 Jan-Feb;32(1):59-64
Current management of bronchiectasis: Review and
3 case studies.
Silverman E, Ebright L, Kwiatkowski M, Cullina J.
Rehabilitation Institute of Chicago and Northwestern Memorial
Hospital, Chicago.
Bronchiectasis is the abnormal, irreversible dilatation of
diseased bronchi. Permanently dilated airways, usually in the
medium-sized bronchi, are inflamed and often obstructed with thick,
purulent secretions. Known causative factors include postinfection
bronchial damage, postinhalation injury, hypersensitivity reactions,
and congenital airway obstructive disorders. Typical symptoms
include sputum overproduction, fever, pleurisy, dyspnea, and chronic
cough. Diagnosis involves radiographic studies and pulmonary function
testing. Treatment includes oral, aerosolized, or intravenous
antibiotic therapy according to the severity of the exacerbation,
and mucus clearance by means of bronchial hygiene assistive devices,
chest physiotherapy, postural drainage, and high-frequency chest
compression. We present a review of bronchiectasis and offer 3
case studies illustrating current management of different presentations,
including use of aerosolized antibiotics for patients infected
with Pseudomonas aeruginosa. Although an adjunctive program of
pulmonary rehabilitation may be useful for patients with bronchiectasis,
no confirming studies have been performed to date, and additional
research in this area is warranted.
-----
Pediatr Crit Care Med 2003 Jan;4(1):39-43
Intrapleural instillation of fibrinolytic agents
for treatment of pleural empyema.
Cochran JB, Tecklenburg FW, Turner RB.
Division of Pediatric Emergency/Critical Care, Medical University
of South Carolina, Charleston, SC, USA.
OBJECTIVE: To describe the use of intrapleural instillation
of fibrinolytic agents as adjunctive therapy for children with
complicated pleural effusions and empyema. DESIGN: Retrospective
chart review. SETTING: Tertiary care children's hospital in an
academic medical center. PATIENTS: Nineteen consecutive patients
(median age, 36 months; range, 9 months to 13 yrs) with complicated
pleural effusion or empyema by clinical, radiographic, and laboratory
criteria who failed to have adequate drainage of the fluid collection
by tube thoracostomy. INTERVENTIONS: Patients who remained symptomatic
with fever or respiratory distress and who had pleural fluid that
could not be drained by tube thoracostomy were treated by intrapleural
instillation of either urokinase (13 patients) or streptokinase
(six patients) 8-72 hrs after chest tube insertion. MEASUREMENTS
AND MAIN RESULTS: Fibrinolytic therapy increased the volume of
chest tube drainage in 15 (79%) of 19 patients. Fourteen of the
19 patients were successfully managed without referral for surgical
drainage. No significant adverse events or side effects were noted.
CONCLUSION: Intrapleural instillation of fibrinolytic agents appears
to be an effective and less invasive alternative to surgical drainage
for children who have complicated pleural effusions or empyemas
that do not drain adequately with tube thoracostomy alone.
-----
Ann Pharmacother 2003 Mar;37(3):376-9
Intrapleural alteplase in a patient with complicated
pleural effusion.
Walker CA, Shirk MB, Tschampel MM, Visconti JA.
Charlotte A Walker PharmD BScPharm, Clinical Pharmacy Specialist,
Chalmers P Wylie Veterans Affairs Outpatient Clinic, Columbus,
OH.
OBJECTIVE: To report the intrapleural use of alteplase in a
patient diagnosed with complicated pleural effusion (CPE). CASE
SUMMARY: A 62-year-old white woman admitted with respiratory distress
and hypotension developed a right-sided multi-loculated pleural
effusion. Thoracentesis and chest tube drainage were not successful
in resolving the effusion. In an attempt to increase the drainage
of the pleural effusion, alteplase 16 mg was administered into
the pleural cavity via the chest tube on 6 consecutive days. As
a result, the volume drained from the patient's chest tube increased,
there was improvement on the chest X-ray, and she did not require
surgical intervention. DISCUSSION: While streptokinase and urokinase
have been shown to be useful adjuncts to chest tube drainage in
the treatment of complicated pleural effusion and empyema, there
have been no reports on the use of intrapleural alteplase. This
report demonstrates that intrapleural administration of alteplase
is a useful adjunct to tube drainage in resolving CPE. CONCLUSIONS:
This patient's CPE resolved when intrapleural alteplase was used
as an adjunct to chest tube drainage and antibiotics. Controlled
trials need to be conducted to investigate fully the efficacy,
dosing, and safety of intrapleural alteplase in the treatment
of patients with CPE and empyema.
-----
Chest 2003 Mar;123(3):822-7
A Randomized, Phase III, Double-Blind, Placebo-Controlled
Trial of Intrapleural Instillation of Methylprednisolone Acetate
in the Management of Malignant Pleural Effusion.
North SA, Au HJ, Halls SB, Tkachuk L, Mackey JR.
Department of Oncology, University of Alberta, Edmonton, AB, Canada.
STUDY OBJECTIVE:s: To determine if intrapleural administration
of methylprednisolone acetate (MA) after therapeutic thoracentesis
for symptomatic malignant pleural effusion improved time to repeat
thoracentesis for symptom control, quality of life (QOL), and
dyspnea. DESIGN: Double-blind, randomized, placebo-controlled
trial. SETTING: A tertiary care cancer treatment center in Edmonton,
AB, Canada. Patient selection: Patients with symptomatic pleural
effusions secondary to disseminated malignancy requiring therapeutic
thoracentesis for symptom control. INTERVENTIONS: Sixty-seven
patients underwent ultrasound-guided therapeutic thoracentesis
for management of symptomatic malignant pleural effusion. Patients
were randomly and blindly assigned to either 160 mg (8 mL) of
MA or 8 mL of saline solution instilled into the pleural space.
Patients were followed up for 6 weeks to determine the time to
repeat therapeutic thoracentesis. All patients completed the Functional
Assessment of Cancer Therapy-General (FACT-G) QOL questionnaire
and a dyspnea visual analog scale (VAS) at baseline and again
2 weeks later. Measurements and results: Thirty-three patients
received MA, and 34 patients received placebo; baseline characteristics
for the two groups were similar, apart from a slightly higher
use of concurrent systemic therapy in the placebo group. At 6
weeks follow-up, 50% of MA-treated patients required repeat thoracentesis
compared to 56% of placebo-treated patients (not significant [NS]).
The mean of the individual FACT-G change scores (2 weeks - baseline)
was similar in the two groups (NS). VAS scores improved for both
groups over the 2-week period, but the mean change scores (2 weeks
- baseline) were not statistically different. CONCLUSION: Despite
previous case series describing benefit from intrapleural MA in
malignant pleural effusion, this controlled study of intrapleural
MA instillation did not delay reaccumulation of symptomatic pleural
effusion compared to placebo, nor were differences in QOL or dyspnea
observed.
-----
Chirurg 2003 Feb;74(2):99-107
[Thoracic drainage. What is evidence-based?]
[Article in German]
Gambazzi F, Schirren J.
Klinik fur Thoraxchirurgie,Dr.-Horst-Schmidt-Kliniken,Wiesbaden.
Pleural drainage becomes a vital measure to restore physiological
conditions in cases of loss of pleural negative pressure, regardless
its etiology.Therefore, it is not surprising that hardly any evidence-based
publications on this topic are available.For the treatment of
pleural empyema,the history of pleural drainage goes back to antiquity.Nowadays,
quite a number of synonymously used terms are wrongly employed
instead of the correct terms of thoracic or pleural drainage.
Indications for placing a pleural drainage are: pneumothorax,
pleural effusion, pleural empyema,hemothorax and chylothorax.As
a standard method, it is recommended that the pleural drainage
be placed in the fifth or sixth intercostal space in the anterior
axillary line. It is not advisable to use a closed insertion with
the help of a trocar due to the significantly increased risk of
injury.The insertion of a pleural drainage when correctly placed
is a safe procedure; rare typical complications involve the wrong
placement of the drainage, hemorrhage or infection like pleural
empyema.The complication rate, however, does not exceed 3%.
-----
Chest 2003 Feb;123(2):432-5
Effect of intrapleural streptokinase administration
on antistreptokinase antibody level in patients with loculated
pleural effusions.
Laisaar T, Pullerits T.
Department of Thoracic and Cardiovascular Surgery, Tartu University,
Estonia. tanel.laisaar@kliinikum.ee
BACKGROUND: Streptokinase is widely used IV for the treatment
of myocardial infarction and intrapleurally for the treatment
of loculated pleural effusions. IV administration of streptokinase
is known to cause the production of antistreptokinase antibodies.
OBJECTIVE: The aim of this study was to evaluate whether the intrapleural
administration of streptokinase results in a similar elevation
of the serum antistreptokinase antibody level. METHODS: During
1 year, venous blood samples were taken from 16 consecutive patients
(10 men and 6 women; age range, 22 to 60 years) requiring intrapleural
streptokinase administration (250,000 IU once a day, for 2 to
6 days). Blood samples were taken before treatment, on day 5,
and day 14. Antistreptokinase antibodies were measured using enzyme-linked
immunosorbent assay (ELISA) and were expressed in arbitrary ELISA
units. Four patients with myocardial infarction treated with IV
streptokinase (1,500,000 IU) were included as control subjects
for the method. RESULTS: Before treatment, the median antistreptokinase
antibody level in patients with loculated pleural effusions was
729 ELISA units (range, 196 to 13,529 ELISA units) and increased
to 9,240 ELISA units (range, 1,456 to 77,389 ELISA units) by day
14 (p < 0.0001). In the control group, the median pretreatment
level was 119 ELISA units, and by day 14 it had increased to 20,495
ELISA units. Four patients who developed an elevated body temperature
after intrapleural administration of streptokinase had a significantly
higher pretreatment antistreptokinase antibody level compared
to other patients. CONCLUSIONS: The intrapleural administration
of streptokinase results in the elevation of the serum antistreptokinase
antibody level, which is similar to the case with IV administration.
An increased pretreatment antistreptokinase antibody level does
not influence the result of intrapleural fibrinolysis but can
cause an elevation of body temperature after the administration
of streptokinase.
-----
Chest 2003 Jan;123(1):209-16
Interferons and their application in the diseases
of the lung.
Antoniou KM, Ferdoutsis E, Bouros D.
Interstitial Lung Disease Unit, Department of Pneumonology, Medical
School University of Crete, Crete, Greece.
Interferons (IFNs) are a family of cytokine mediators that
are critically involved in alerting the cellular immune system
to viral infections of host cells. There are three major classes
of IFNs, as follows: IFN-alpha; IFN-beta; and IFN-gamma. IFNs
are being investigated and applied in various respiratory disorders,
including interstitial lung diseases, lung cancer, malignant mesothelioma,
malignant pleural effusions, and respiratory infections. Recent
promising preliminary results concerning patients with idiopathic
pulmonary fibrosis who have been treated with IFN-gamma1b should
prompt the performance of further confirmatory well-designed multicenter
trials. IFN-gamma is emerging as an important cytokine for use
in the treatment of patients with infectious diseases, including
multidrug-resistant pulmonary TB. A better understanding of IFN
biology, indications, side effect profiles, and toxicity management
will aid in optimizing its use in the treatment of patients. The
purpose of this article is, therefore, to review the current clinical
use of IFNs in the treatment of patients with respiratory diseases.
-----
Paediatr Respir Rev 2002 Dec;3(4):349-55
Pleural fluids associated with chest infection.
Quadri A, Thomson AH.
Department of Paediatrics, John Radcliffe Hospital, Headley Way,
Headington, Oxford OX3 9DU, UK.
Pleural effusions are commonly associated with pneumonias and
a small number of these progress to empyema. An understanding
of the physiology and pathophysiology of pleural fluid aids the
clinician in the management of empyema. There remains much debate
about the optimal treatment of empyema in children. Early recognition
of the condition is important since delayed therapy may result
in unnecessary morbidity. Conventional management with high dose
parenteral antibiotics and chest tube drainage remains the mainstay
of therapy. However, this treatment modality may fail if the pleural
fluid becomes viscous and loculated and, therefore, a more aggressive
approach is required. Intrapleural fibrinolytic therapy has been
shown to decrease the length of hospital stay and may reduce the
need for surgical intervention. The prognosis in children with
parapneumonic empyema is excellent with the vast majority retaining
normal lung function at long term follow-up.
-----
Int J Cardiol 2002 Oct;85(2-3):297-299]
Prolonged pleural effusion following Fontan operation:
effective pleurodesis with talc slurry.
Kiziltepe U, Eyileten ZB, Uysalel A, Akalin H.
Department of Cardiovascular Surgery, Cardiac Center, Ankara University
School of Medicine, Ankara, Turkey. uk9316@hotmail.com
Prolonged pleural effusions following a Fontan operation are
a difficult problem. Although fenestrations and embolizations
of systemic-pulmonary artery collaterals were suggested to treat
and to decrease the risk of this complication, talc slurry pleurodesis
may successfully augment and accelerate the beneficial effects
of those techniques against the resistant effusions.
-----
Probl Tuberk 2002;(11):28-31
[Surgical policy in tuberculous pleurisy]
[Article in Russian]
Motus IIa, Gaponiuk PF, Krasnoborova SIu, Savel'ev AV, Sokolov
VIu.
Two hundred and eighty seven cases of tuberculous pleurisy
are analyzed. According to the pleural contents, four phases of
development of this disease are identified. These include: 1)
free pleurisy; 2) partially encysted pleurisy; 3) encysted pleurisy,
and 4) adhesive pleurisy. An algorithm of use of draining procedures
and surgical interventions depending on the phase of pleurisy
is proposed. Among other things, indications for thoracoscopy
that was performed in 66 patients with tuberculous pleurisy for
its therapy were stated. Thoracoscopy is ineffective in adhesive
pleurisy, in the presence of a rigid residual cavity in particular,
and thus preference should be given to thoracotomy with pleurectomy
and decortication of the lung. This operation was made in 39 cases.
Timely use of draining procedures and surgical interventions make
it possible to achieve recovery from tuberculous pleurisy over
shorter periods of time and with minimal residual changes.
-----
Can Respir J 2002 Sep-Oct;9(5):335-7
Fibrothorax and severe lung restriction secondary
to lupus pleuritis and its successful treatment
by pleurectomy.
Sharma S, Smith R, Al-Hameed F.
Section of Respirology, University of Manitoba, Winnipeg, Canada.
ssharma@sbgh.mb.ca
Pleural disease is a common pulmonary manifestation of systemic
lupus erythematosus (SLE) that usually responds to corticosteroids
and other immunosuppressive agents. In the present report, a new
approach, pleural decortication, was used in a patient with medically
refractory chronic pleuritis secondary to severe SLE. A 26-year-old
woman with known SLE developed progressive dyspnea and pleuritic
chest pain over several months. The other systemic manifestations
of her lupus were controlled with cyclophosphamide and prednisone.
A computed tomography scan revealed a persistent, small, loculated
right pleural effusion; pleural thickening; and atelectasis of
the right middle and lower lobes. Pulmonary function tests showed
a severe restrictive defect. The patient was disabled by her severe
dyspnea despite maximal medical therapy, and, therefore, surgery
was considered. A right thoracotomy revealed entrapment of the
right lung by dense visceral pleura. Decortication was performed.
On pathology, pleuritis with vascular pleural adhesions was found.
No lupus pneumonitis was noted. Postoperatively, a significant
clinical improvement in dyspnea was evident within several weeks.
On a 6 min walk test, the patient achieved 384 m with a Borg dyspnea
scale rating of 2 compared with 220 m and a Borg dyspnea scale
rating of 4 preoperatively. Her forced vital capacity improved
from 24% predicted to 47% predicted, and her total lung capacity
improved from 35% predicted to 54% predicted. Medical therapy
of systemic lupus erythematosus has been proven to be effective
in controlling pleuritis in most cases. However, in the event
of refractory pleuritis or pleural thickening, decortication may
be a viable alternative.
-----
Mol Pharmacol 2002 May;61(5):997-1007
The cyclopentenone prostaglandin 15-deoxy-Delta(12,14)-prostaglandin
J(2) attenuates the development of acute and chronic inflammation.
Cuzzocrea S, Wayman NS, Mazzon E, Dugo L, Di Paola R, Serraino
I, Britti D, Chatterjee PK, Caputi AP, Thiemermann C.
Institute of Pharmacology, School of Medicine, University of Messina,
Messina, Italy. salvator@unime.it
Peroxisome proliferator-activated receptors (PPARs) are members
of the nuclear hormone receptor superfamily of ligand-activated
transcription factors that are related to retinoid, steroid, and
thyroid hormone receptors. The PPAR-gamma receptor subtype seems
to play a pivotal role in the regulation of cellular proliferation
and inflammation. Recent evidence also suggests that the cyclopentenone
prostaglandin (PG) 15-deoxyDelta(12,14)-PGJ(2) (15d-PGJ(2)), which
is a metabolite of prostaglandin D(2), functions as an endogenous
ligand for PPAR-gamma. We postulated that 15d-PGJ(2) would attenuate
inflammation. In the present study, we have investigated the effects
of 15d-PGJ(2) of acute and chronic inflammation (carrageenan-induced
pleurisy and collagen-induced arthritis, respectively) in animal
models. We report for the first time, to our knowledge, that 15d-PGJ(2)
(given at 10, 30, or 100 microg/kg i.p. in the pleurisy model
or at 30 microg/kg i.p every 48 h in the arthritis model) exerts
potent anti-inflammatory effects (e.g., inhibition of pleural
exudate formation, mononuclear cell infiltration, delayed development
of clinical indicators, and histological injury) in vivo. Furthermore,
15d-PGJ(2) reduced the increase in the staining (immunohistochemistry)
for nitrotyrosine and poly (ADP-ribose) polymerase and the expression
of inducible nitric-oxide synthase and cyclooxygenase-2 in the
lungs of carrageenan-treated mice and in the joints from collagen-treated
mice. Thus, 15d-PGJ(2) reduces the development of acute and chronic
inflammation. Therefore, the cyclopentenone prostaglandin 15d-PGJ(2)
may be useful in the therapy of acute and chronic inflammation.
-----
Probl Tuberk 2001;(9):34-6
[Videothoracoscopy in diagnosing and treating
exudative pleuritis]
[Article in Russian]
Ots ON, Samokhin AIa, Strel'tsov VP, Solov'eva IP, Sokolova VS,
Belostotskii AV, Perel'man MI.
Telethoracoscopy (TT) was performed in 76 patients with exudative
pleurisy of unclear etiology. A correct diagnosis was made in
all (100%) cases. Tuberculosis was detected in 41 (54%) patients.
In this group of patients, the results were analyzed by taking
into account the duration of disease, the nature of an operation,
and morphological findings. In tuberculous pleurisy, TT may be
conducted at any time; however, it is most effective when an acute
period subsides and an exudate begins forming. At this time (2-3
months after the onset of the disease), surgery is not diagnostic,
but also remedial as sanitation of the pleural cavity with partial
pleurectomy.
-----
Zhonghua Jie He He Hu Xi Za Zhi 2002 Oct;25(10):595-7
A study on the use of mycobacterium vaccine in
the treatment of tuberculous pleurisy.
Zhou X, Lan J, Zhang T.
Department of Respiration, Second Affiliated Hospital, Chongqing
University of Medical Sciences, Chongqing 400010, China.
OBJECTIVE: To study the effects of immunotherapy with mycobacterium
vaccine in patients with tuberculous pleurisy. METHODS: The time
for effusion resolution and lymphocyte counts in the effusions
were observed in patients with tuberculous pleurisy who received
anti-tuberculous therapy and thoracentesis (group A) or anti-tuberculous
therapy and thoracentesis plus intramuscularly administered polysaccharide
nucleic acid fraction of Bacillus Calmette Guerin (PSN-BCG,) (group
S). In situ end-labeling technique of fragment DNA was used to
detect the apoptosis of lymphocytes in the effusions. RESULTS:
The average resolution times in group A and group S were 21.2
days and 28.7 days respectively (P < 0.01). The lymphocyte
counts in the two groups after 1 week, 2 week, and 3 week therapy
were 1.6 x 10(9)/L (A) and 2.1 x 10(9)/L (S) (P < 0.01), 0.83
x 10(9)/L and 1.52 x 10(9)/L (P < 0.01), 0.55 x 10(9)/L and
1.16 x 10(9)/L (P < 0.01) respectively. The average apoptotic
half-time was 94 h (A) and 124 h (S) (P < 0.01), 84 h and 123
h (P < 0.01), 79 h and 120 h (P < 0.01) respectively. CONCLUSIONS:
Mycobacterium vaccine was found to prolong lymphocyte activation,
inhibit lymphocyte apoptosis, and delay the resolution of pleural
effusions. It was found not helpful as an adjunct therapy for
tuberculous pleurisy.
©Copyright 1992-date by The Center
for Current Research. The Pleurisy File is a proprietary compilation
of the Center for Current Research. The information in the File
is solely for your use, and the use of your family, friends, and
doctors. The information is the property of the individual researchers
and institutions that produced it. It is an infringement of copyright
law to attempt to "resell" the information as it is
presented here.
|
