AMPYEM MEDKAL TEDAVDEK YENLKLERDr.Hüseyin YILDIRIM
3
3
4
Pneumonia
EXUDATIVE
Ruptured lung abscess
Primary pleural infection from hematogenous spread
Extension of infection from neck, abdomen, or mediastinum
5
Chronic lung disease,
6
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.
7
8
Bacteriology of complicated parapneumonic effusions.
Foster, Sarah; Maskell, Nick
9
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
18
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
19
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
20
21
22
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.
25
25
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.
27
28
The pathogenesis of fibrin deposition in exudative pleural effusions includes alterations in the balance of procoagulant and fibrinolytic activity.
Streptokinase
Urokinase
29
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
32
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.
33
The usual regimens for tPA are 25 mg /1-5 day
34
35
36
36
Chest 2006; 129: 783-790
Contraindications for fibrinolytic therapy
40
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
41
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
42
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
45
46
47
48
49
50
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