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EMPYEMA NEW MEDİCAL THERAPY MODALİTİES

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

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EMPYEMA NEW MEDİCAL THERAPY MODALİTİES

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  1. EMPYEMANEW MEDİCAL THERAPY MODALİTİES Dr.Hüseyin YILDIRIM Eskişehir Osmangazi University MedicalFaculty Department of ChestDisease

  2. PRESENTATION • Definition • Etiology • Microbiology • Radiology • Classification • Medicaltherapy

  3. DEFINITION • Pneumonia, • Bronchiectasis • Lungabscesses secondarypleuralfluid • refersto frank “pus” in the pleural space

  4. 2-7 days 2-5 days 5-10 days 10-21 days ENTRAPMENT ClinInfecDis 2007; 45: 1480-6

  5. ETIOLOGY • Community-acquiredandhealth-care-associatedpneumonia • Bronchialobstructionfromtumororforeign body • Rupturedlungabscess • Bronchiectasis • Thoracicandabdominalsurgery • Chestandabdominaltrauma • Thoracicinterventionalprocedures, such as thoracentesisandesophagoscopy • Primarypleuralinfectionfromhematogenous spread • Extension of infectionfromneck, abdomen, ormediastinum

  6. Risk factors for the development of pleural infection include; • Chroniclungdisease, • Rheumatoidartritis, • Diabetesmellitus, • Immunsuppresion, • HIV infection, • Alcoholism, • GORD, poordentalhygiene • Malnutrition • Substanceabuse • Neuromusculardisorders, seizures, mentalretardation

  7. Microbiology • The bacteriology of empyema is varied and significant differences are observed between community- and hospital-acquiredinfections. • Using the conventional methods achieves a bacterial diagnosis in approximately 60% ofpleural-fluidsamples. • Anaerobes play an important role in pleuralspaceinfection. CurrOpinPulmMed 2007; 13: 319-323

  8. Toplum kökenli enfeksiyöz ajanlar (MIST1 trial data) Bacteriology of complicated parapneumonic effusions. Foster, Sarah; Maskell, Nick Current Opinion in Pulmonary Medicine. 13(4):319-323, July 2007.

  9. Hastane kaynaklı enfeksiyon ajanları Bacteriology of complicated parapneumonic effusions. Foster, Sarah; Maskell, Nick Current Opinion in Pulmonary Medicine. 13(4):319-323, July 2007.

  10. Classification of PPE andempyema Chest 2000; 118: 1158-1171

  11. Theaim of therapy; Treatment of thoracicempyemaincludes four basic principles: • elimination of the pleuropulmonary infection withantimicrobialagents • drainage of complicatedparapneumonic effusion, • full expansion of the underlyinglung, and • prevention of thecomplication

  12. Methods for treatment of complicated parapneumonic effusions and pleuralempyema PulmPharmacolTher 2007; 20: 616-626

  13. Observation • Observation is an acceptable option for category I pleural effusionsbecause the risk of a poor outcome without drainage isverylow. • In patients with other categories of parapneumonic effusion,observation without examination of the pleural fluid is not acceptable. • It is important not todelaydrainage Proc Am Thorac Soc. 2006;3(1):75-80

  14. Antibiotherapy • All patients with pleural infection should be treated • with antibiotics. • Intravenous antibiotics are recommended as initialtherapy. • Thechoice of antibioticshould be based on the results of blood and pleuralfluidculturesandsensitivities

  15. Chest 2000; 117: 1734-1739

  16. Levofloxacin Moxifloxacin 22 EurRespir J 2004; 24: 466-470

  17. +

  18. TubeThoracostomy

  19. TubeThoracostomy • The optimal duration of drainage is unknown, • Successfulclosed-tubedrainage of empyema is evidencedbyimprovement in theclinicalandradiologicalstatuswithin 24h. • Ifthepatient has not demonstratedsignificantimprovementwithin 24 h of initiatingtubethoracostomy, eitherthepleuraldrainage is unsatisfactoryorthepatient is receivingthewrongantibiotic. • Drain removal may be consideredwhen the output falls to less than 150 mL dailyfor 2 days in the setting of clinical and radiographiimprovement.

  20. ChestTube Size Chest 2010; 137: 536-543

  21. Image-guideddrainage • US and CT are the most commonly used modality to guide drainages. • Entry site should be chosen close to the dependent portion of theeffusion. • TrocarorSeldingertechnique can be used for the catheter placement depending on operatorpreference. • The catheter size can be tailored according to the thickness of thefluid. • Contrastinjectionsunderfluoroscopy can also be used to evaluate the presence andonnection of residual collections with the catheter tip. Eur J Radiol 2005; 55: 311-320

  22. Eur J Radiol 2005; 55: 311-320

  23. FIBRINOLYTIC AGENTS • The pathogenesis of fibrin deposition inexudative pleural effusions includes alterations in thebalance of procoagulant and fibrinolytic activity. • Streptokinase • Urokinase • Tissueplamonogenactivator (Alteplase, t-PA)

  24. Respirology 2004; 9: 428-440

  25. FİBRİNOLİTİK TEDAVİ

  26. Streptokinase • Streptokinase is a non-enzymatic protein produced by 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 afterinstillation before water-seal or suction drainage

  27. Urokinase • Urokinase is a direct plasminogen activator, initially isolatedfromhumanurine. • It is manufacturedfromcultured human embryonic kidney cells. • In contrast to streptokinase, urokinase is not antigenic andits efficacy is not reduced by antibody production • The usual regimens for urokinase are 100,000 IU daily.

  28. TissuePlasminogenActivator (tPA); • Tissueplasminogenactivatorprovidesfibrinolyticactivitywithouttheantigenicity of streptokinase. • TheusualregimensfortPAare 25 mg /1-5 day

  29. N Engl J Med 2005; 352: 865-874

  30. RespMed 2008; 12: 1694-1700 36

  31. Chest 2006; 129: 783-790

  32. CochranDatabase 2009

  33. Respiration 2008; 75: 241-250

  34. Contraindicationsforfibrinolytictherapy PulmPharmacolTher 2007; 20: 616-626

  35. SIDE EFFECTS • Theobscuringeffects of systemicresponsestotheunderlyingdisease • Immunulugicreactiontostreptokinaserepresentthemostcommonlyreportedadverseeffects. • Theinitialuse of streptokinaseresulted in febrilereaction, general malaise, andleukocytosis. • Localorsystemichemorrhage • IV administration of streptokinasegenerates a systemicantibodyresponse; antistreptokinaseantibody

  36. Streptodornase • Theincreasedviscosity of pleural pus in patientwithempyema is attributabletohighconcentration of DNA resultingfromthebreakdown of phagocytes, bacteria, andotherintrapleuralcells. • Streptodornase is a mixture of fourDNAaseenzymesreleasedbystreptococcithatreducedtheviscosity of pus throughthedigestion of DNA. • Clinicaltrialareneededtoevaluatetheefficacy of streptodornase

  37. Deoxyribonuclease(humanrecombinantDNAase) • CommerciallyavailablehrDNAasedigests DNA andmaypotentiallydecreasetheviscosity of empyema pus withoutthe risk of allergicreactions. • Minimal sideeffects • No randomisedtrial

  38. Chest 2006; 129: 1577-1583

  39. Anti-growthfactorantibodies • Transforminggrowthfactor (TGF) • Vascularendothelialgrowthfactor (VEGF) İntrapleuralgeneration of theseagentspromotesthe formation of fibroticbandsleadingtopleuralloculations. • Anti-TGF ve anti-VEGF maypreventtheformation of loculations PulmPharmacolTher 2007; 20: 616-626

  40. MedicalThoracoscopy

  41. EurRespir J 2006; 28: 409-421

  42. Localanesthesia(premedication) 50

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