Therapeutic approach in non-postoperative pleural empyema

The Authors carried out an retrospective analysis on 81 patients, 67 men and 14 women, suffering from non post-surgical thoracic empyema, to evaluate the different therapeutic procedures and respective indications. The unsuccessful response to the preserving approach (intercostal drainage and pleural lavage twice a day with specific antibiotics or antiseptics) in 56 cases, induced the Authors to carry out a video-thoracoscopy (VAT), that allowed them to define the infection stage and subsequent treatment (the carrying on of a pleural drainage-lavage in 32 cases, the transcurrent pleural irrigation in 10 cases, the open window thoracostomy followed by myoplasty in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases with bronchopleural fistula, the decortication with associated pleural exeresis in 6 cases, the streptokinase in pleural cavity in 2 cases). There were registered totally 3 deaths (3.7%). The Authors in conclusion assert that the VAT, carried out after the unsuccessful preserving treatment, allows the evaluation of the infection stage and consequently suggests therapy.     

Thoracoscopic decortication for chronic empyema thoracis: report of a case]

A clinical case of a woman with AIDS who developed lymphoma of the nasopharynx and paralysis of the VII, IX and XII cranial nerves is reported. The probable origin of the paralysis in relation to AIDS and lymphoma is discussed.     

Determination of likelihood of the development of pleural empyema in patients with cancer after pneumonectomy

Management of 150 patients with lung cancer after pneumonectomy has shown that the basic factors causing the onset of postoperative pleural empyema are chronic nonspecific pulmonary diseases, pronounced obstructive syndrome and right heart overload, tumor histology, local tumor size and cancer complications, duration and techniques of surgery, duration of controlled lung ventilation, as well as the onset of postoperative suppurative tracheobronchitis and surgical wound suppuration. The likelihood of empyema development may be assessed only upon analysis of the combination of risk factors with reference to their low informative value, preoperative patients' condition and intraoperative factors which have an equal impact on the onset of this complication. The efficacy of the algorithm elaborated is as follows: if the likelihood of empyema development exceeds 50%, it occurs in 96.3% of cases, if the likelihood of the complication is less than 10%, the postoperative period is uncomplicated in 87.8% of patients.     

The use of streptokinase preparations in pleural empyema and pyopneumothorax

Prevailing fibrin-formation in the pleural cavity entails hypoactivity of trypsin-like proteinases and a high inhibitory potential in the serum and pleural exudate. Streptokinase preparations appeared an effective means of pharmacological pulmonary decortication in patients with high pleural levels of plasminogen. The authors obtained higher efficacy of conservative therapy for pyothorax when they used a specially designed technique of intrapleural administration of streptokinase-activated fresh frozen plasma of the same group. The outcomes of the disease were also improved noticeably.     

Pulmonary infections in immunosuppressed patients

Pulmonary infections continue to be a significant problem in patients immunosuppressed by cancer or by drugs given for malignancy, or rheumatologic or dermatologic problems. For the neutropenic patient, single-drug rather than combination antibiotic therapy is being increasingly used. The role of growth factors is also being defined. The availability of the new azoles and of alternative forms of amphotericin B have increased treatment options, particularly for invasive pulmonary aspergillosis. Pneumocystis carinii pneumonia continues to be a problem in this population, and controversy remains about the mode of transmission and the mechanism of disease caused by this infection. Exogenous infection rather than reactivation may play a small role. Appreciation of the role of community and opportunistic viruses in causing respiratory infection or other complications in the immunosuppressed population is also being further detailed.     

Surgery for thoracic empyema concurrent with rupture of lung abscesses in a child

The authors report surgical treatment for thoracic empyema concurrent with rupture of lung abscesses and completely collapsed lung in a child. Right middle lobectomy for ruptured abscess, debridement and closure with interrupted sutures for another abscess in the lower lobe, and decortication were performed. Positive-pressure ventilation was needed to prevent reexpansion pulmonary edema because of long-term collapsed lobes. The patient is doing well with no recurrent empyema or thoracic deformity at 3 years postoperation.     

Use of the omentum in the treatment of chronic thoracic empyema

Thoracic empyema (development of suppuration in the thoracic cavity, usually after pneumonectomy) remains a serious complication which is difficult to treat. Failure of classical procedures (lavage-drainage) in the treatment of certain forms of pleural empyema (post-pulmonary resections), with or without associated fistula, led the authors to use the pedicled omental flaps filling material for the chronic empyema cavity. They report their experience (6 cases over a period of 4 years) and define the indications. Omentoplasty has a real place, next to myoplasty, in the therapeutic arsenal for chronic empyema due to its detersion capacity, particularly useful in a "septic" context and because of its volume which is usually sufficient in retracted cavities. The existence of an associated bronchial fistula, history of radiotherapy, posterolateral thoracostomy (sectioned latissimus dorsi) are additional reasons to prefer omentoplasty over myoplasty.     

Video-assisted thoracoscopic surgery in the management of acute purulent mediastinitis and pleural empyema

Anaesthetic pollution is still a problem and recent UK Control of Substances Hazardous to Health (COSHH) recommendations require employers to attempt to control the risk. Fifteen day-case urology operating lists were studied to compare the level of nitrous oxide exposure using face mask or laryngeal mask anaesthesia. Nitrous oxide was avoided in one group until the laryngeal mask was inserted. The use of the laryngeal mask airway showed a significant reduction in the level of pollution, such that recent COSHH recommendations were attained. However, (US) NIOSH levels were only reliably attained by avoiding nitrous oxide until the laryngeal mask was inserted. The laryngeal mask was therefore shown to be a reliable antipollution device.     

Mediastinal abscesses and empyema of the pleural cavity after iatrogenic fracture of the sternum

A case report presents fracture of sternum during the resuscitation and in continuity iatrogenic hematoma and afterwards abscessus of mediastinum, and empyema the both of pleura cavities. Fracture of thorax wall is rather often event, but in the most, it has not adverse effects. This case refers to 68 years old patient, who had one of the most serious complications: abscessus of mediastinum, empyema of left and right pleura cavities with perforation outside the anterior wall of thorax. He was treated in General Hospital Bia?a Podlaska, Department of Surgery with good results and was extracted home as well-being patient after 35 days spent in hospital the second hospitalisation.     

Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas

In the treatment of multiloculated pleural effusions and empyemas tube thoracostomy often fails and more aggressive surgical therapy is required. Intrapleural administration of fibrinolytics is a valuable alternative. Between October 1994 and December 1995 28 patients (aged 22 to 62 years) with multiloculated pleural effusions were treated with intrapleural instillations of streptokinase after unsuccessful conventional chest tube drainage. Twenty-three pleural effusions were grossly purulent, others were loculated effusions with low pH. The most common cause of the pleural effusions was pneumonia. Duration of illness before hospitalization was 3 to 105 (mean 21.8) days. Treatment with streptokinase was started most commonly one day after chest tube placement. Once a day after clamping the chest tube streptokinase was administered intrapleurally for 10-15 minutes as a solution of 250,000 units in 100 ml normal saline. The tube remained clamped for 3 hours. Two to 8 (mean 3.7) instillations per patient were needed. Twenty-one cases (72.4%) showed excellent resolution of pleural effusion and needed no more therapy. However, one patient died in hospital due to purulent meningitis and bilateral pneumonia. Eight patients needed further surgical treatment, e.g. decortication, in 5 cases together with wedge lung resection. Eleven patients experienced some adverse effects of streptokinase therapy, most frequently chest pain and elevation of body temperature in one case pleural effusion became hemorrhagic, and one patient had nasal bleeding. We conclude that usage of intrapleural streptokinase in the treatment of multiloculated pleural effusions (including pleural empyemas) reduces the need for major surgical interventions in quite a large group of patients.     

Thoracic empyema in HIV-infected patients: microbiology, management, and outcome

OBJECTIVES: To evaluate etiology, bacteriology, stage of disease, treatment, and outcome of HIV-infected patients with thoracic empyema (TE) over a 9-year period at a hospital teaching center. DESIGN: We have retrospectively reviewed the charts of all HIV-infected patients with a hospital discharge diagnosis of empyema between January 1985 and November 1993. PATIENTS: Twenty-three patients were identified (22 male and 1 female). The average patient age was 28.7+/-5.3 years. All the patients were injection-drug users, and 10 (43%) fulfilled criteria for an AIDS diagnosis. In 15 cases (65%), the empyema was the first cause of medical consultation, which then led to an HIV infection diagnosis in 11 of them (48%). MEASUREMENTS: In each case, symptoms, chest studies, culture results, procedure timing, length of hospitalization, and outcome were reviewed. RESULTS: Twenty-one patients (91%) had developed an empyema secondary to community-acquired pneumonia. The cultures of pleural fluid were positive in 19 cases (83%). Anaerobes were isolated from 6 patients and aerobes from 13. A single bacteria was isolated from 10 (52%), and multiple organisms (average 2.66 per case) grew in the remaining 9 positive cultures. The most common organism culture growths were Staphylococcus aureus (23%) and Gram-negative bacilli (36%). Length of hospitalization averaged 25.6 days (+/-15). Intercostal tube drainage was necessary in 18 patients and none required surgery. Patients with AIDS diagnosis needed a longer period of hospitalization, and the presence of bacteremia and bronchopleural fistula was more frequent. However, this did not influence a patient's final outcome. A follow-up was available in 18 cases, with 4 deaths recorded (average survival, 35 months; range, 4 to 84 months). CONCLUSIONS: In our series, TE associated with HIV infection was often the primary cause leading to hospital admission and later HIV diagnosis. IV drug abuse was the predominant factor for HIV infection and was also related to clinical presentation and microbiological findings. The best approach to treatment is--as with other patient groups--a prompt drainage and appropriate antibiotic treatment, since a favorable outcome is expected.     

Bacterial contamination of the pleural cavity during lung resection as one of the causes of development of postoperative empyema

Recovery of spatial resolving capacity (acuity) of central vision after temporary blindness induced by prolonged (1.5, 3, 6 min) light adaptation to a sun or incandescence lamp (20, 40, 80 thous. lux) illuminated white screen was studied. The recovery time increased exponentially with an increase in energy light stimulation (product of brightness of the deadapting source by the time of action). A general formula describing the relationship between the time of recovery of acuity and brightness of the test table and energy of light stimulus was derived.     

A case of ruptured descending thoracic aortic aneurysm into the right pleural cavity: importance of preoperative drainage of the right pleural cavity

We present an unusual case of a ruptured descending thoracic aortic aneurysm into the right pleural cavity of a patient with pectus carinatum. The presence of pectus carinatum played an important role in the development of the aneurysm at the atypical site and the rupture into the right pleural cavity. A small amount of right pleural bleeding on admission can increase and develop to massive hemothorax until emergency operation. Massive bleeding in the right pleural cavity where the dependent lung is located causes atelectasis and increased shunt fraction under one lung ventilation. Therefore, continuous drainage of the right pleural cavity is essential to prevent serious hypoxia during graft replacement in a case of ruptured descending thoracic aneurysm into the right hemithorax.