EMPYEMA NEW MEDİCAL THERAPY MODALİTİES. Dr.Hüseyin YILDIRIM Eskişehir Osmangazi University Medical Faculty Department of Chest Disease. PRESENTATION. Definition Etiology Microbiology Radiology Classification Medical therapy. DEFINITION. Pneumonia , Bronchiectasis Lung abscesses - PowerPoint PPT Presentation
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AMPYEM MEDKAL TEDAVDEK YENLKLERDr.Hüseyin YILDIRIM
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Pneumonia
EXUDATIVE
Ruptured lung abscess
Primary pleural infection from hematogenous spread
Extension of infection from neck, abdomen, or mediastinum
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Chronic lung disease,
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Microbiology
Using the conventional methods achieves a bacterial diagnosis in
approximately 60% of pleural-fluid samples.
Anaerobes play an important role in pleural space infection.
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Bacteriology of complicated parapneumonic effusions.
Foster, Sarah; Maskell, Nick
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Foster, Sarah; Maskell, Nick
Hastane kaynakl enfeksiyon ajanlar
Chest 2000; 118: 1158-1171
principles:
with antimicrobial agents
full expansion of the underlying lung, and
prevention of the complication
pleural empyema
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Medical thoracoscopy
Intrapleural fibrinolytic debridement
Observation
Observation is an acceptable option for category I pleural
effusions because the risk of a poor outcome without drainage is
very low.
In patients with other categories of parapneumonic effusion,
observation without examination of the pleural fluid is not
acceptable.
It is important not to delay drainage
Proc Am Thorac Soc. 2006;3(1):75-80
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Antibiotherapy
with antibiotics.
Intravenous antibiotics are recommended as initial therapy.
The choice of antibiotic should be based on the results of blood
and pleural fluid cultures and sensitivities
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Amoksicillin-klavulanate
Karbapenem
mipenem,
Cefotaxime,
Piperacillin-tazobaktam
Pleural fluids characteristics
Aspiration of pus,
prolonged pneumonia symptoms
presence of anaerobic organisms
a putrid odor associated with an anaerobic infection,
a positive Gram stain or culture result,
pH<7.20, a glucose level <40 mg/dL, and an LDH level> 1000
IU/L
Tube Thoracostomy
The optimal duration of drainage is unknown,
Successful closed-tube drainage of empyema is evidenced by
improvement in the clinical and radiological status within
24h.
If the patient has not demonstrated significant improvement within
24 h of initiating tube thoracostomy, either the pleural drainage
is unsatisfactory or the patient is receiving the wrong
antibiotic.
Drain removal may be considered when the output falls to less than
150 mL daily for 2 days in the setting of clinical and radiographi
improvement.
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21/58 (36)
75/208 (36)
28/70 (40)
30/69 (44)
Death at 1 y, N (%)
10/58 (17)
46/208 (22)
18/70 (25)
17/69 (25)
Surgery at 1 y, N (%)
11/58 (19)
35/208 (17)
13/70 (19)
13/69 (19)
Hospital stay,[a] d (SD)
26 (29)
24 (32)
31 (39)
28 (23)
FEV1 at 3 mo, L (SD)
2.46 (1.0)
2.16 (0.79)
2.30 (0.88)
2.15 (0.90)
FVC at 3 mo, L (SD)
3.30 (1.19)
2.98 (0.98)
3.18 (1.13)
2.84 (1.00)
Two-way ANOVA, 3 df, F = 1.42, P = .24
Reduction in chest radiograph abnormality from baseline at 3 mo,[b]
median % hemithorax (IQR)
90, (77-90)
90, (77-90)
90, (52-90)
90, (77-90)
Chest 2010; 137: 536-543
Image-guided drainage
US and CT are the most commonly used modality to guide
drainages.
Entry site should be chosen close to the dependent portion of the
effusion.
Trocar or Seldinger technique can be used for the catheter
placement depending on operator preference.
The catheter size can be tailored according to the
thickness of the fluid.
Contrast injections under fluoroscopy can also be used to evaluate
the presence and onnection of residual collections with the
catheter tip.
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The pathogenesis of fibrin deposition in exudative pleural
effusions includes alterations in the balance of procoagulant and
fibrinolytic activity.
Streptokinase
Urokinase
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the Lancefield group C strain of b-hemolytic streptococci
(exotoxin), which activates the fibrinolytic system
indirectly
The usual regimens for streptokinase are 250,000 IU
daily, or 12 hourly,
Fibrinolytic drugs are usually diluted in 30–100mL of
normal saline, with the chest tube clamped for 2–4 h
after instillation before water-seal or suction drainage
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Urokinase
isolated from human urine.
It is manufactured from cultured human embryonic kidney
cells.
In contrast to streptokinase, urokinase is not antigenic and its
efficacy is not reduced by antibody production
The usual regimens for urokinase are 100,000 IU
daily.
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The usual regimens for tPA are 25 mg /1-5 day
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Chest 2006; 129: 783-790
Contraindications for fibrinolytic therapy
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The obscuring effects of systemic responses to the underlying
disease
Immunulugic reaction to streptokinase represent the most commonly
reported adverse effects.
The initial use of streptokinase resulted in febrile reaction,
general malaise, andleukocytosis.
Local or systemic hemorrhage
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Streptodornase
The increased viscosity of pleural pus in patient with empyema is
attributable to high concentration of DNA resulting from the
breakdown of phagocytes, bacteria, and other intrapleural
cells.
Streptodornase is a mixture of four DNAase enzymes released by
streptococci that reduced the viscosity of pus through the
digestion of DNA.
Clinical trial are needed to evaluate the efficacy of
streptodornase
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Commercially available hrDNAase digests DNA and may potentially
decrease the viscosity of empyema pus without the risk of allergic
reactions.
Minimal side effects
No randomised trial
ntrapleural generation of these agents promotes the
formation of fibrotic bands leading to pleural loculations.
Anti-TGF ve anti-VEGF may prevent the formation of
loculations
Pulm Pharmacol Ther 2007; 20: 616-626
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Respiratory insufficiency
Non-coopere patients
J Thorac Oncol 2007; 2: 663-670
Diagnostic algoritm for the management of
patients with pleural infection
Yes
Check tube position
Consider CT scan
Consider intrapleural fibrinolytics
Fluid drained and sepsis improved?
Remove tube