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Role of Medical Interventions in Complicated Parapneumonic Pleural Effusion and Empyema
Amogh Dawadi1, Ashesh Dhungana1, Deepa Kumari Shrestha1
1Department of Pulmonary, critical care and sleep medicine National Academy of Medical Sciences, Bir Hospital, Kathmandu.
Background:
Complicated parapneumonic effusion (PPE) and empyema require intercostal drainage (ICD), failure of which usually leads to surgery. Intrapleural instillation of fibrinolytic agents (IFT) enhance pleural drainage and reduce the need for surgery. This study aimed to evaluate the role of medical interventions (ICD and IFT) in complicated PPE and empyema.
Methods:
In a prospective, cohort study conducted at National Academy of Medical Sciences, Bir Hospital. Patients aged >18 years with complicated PPE and empyema were included. ICD was placed in all. In those with significant residual effusion and loculations after ICD, intrapleural Streptokinase was instilled and daily drain output recorded. Outcomes were measured as complete, partial response and treatment failure. The duration of ICD tube in situ, length of hospital stay and need for surgical interventions was evaluated at three-month follow up.
Results:
A total of 51 patients were enrolled into the study. Commonest symptoms were dyspnea, cough, chest pain and fever with a median duration of 14 days (IQR = 7-28). The etiologies of effusions were presumed or proven bacterial infection in 36 (70.5%), tuberculosis in 8 (15.7%) and parasitic infection in 2 (3.9%). ICD was successful in achieving a complete drainage in 22 (43.1%) patients. In the remaining 29 (56.9%), intrapleural Streptokinase was instilled which led to increase in drain output by 760.34 ± 283.90 ml. Post Streptokinase instillation; 18 (62.1%), 4 (15.8%) and 7 (24.2%) patients met the predefined criteria of "complete" response, "partial" response and treatment failure respectively. The mean duration of ICD tube in situ and hospital stay was 10.98 ± 3.56 and 13.51 ± 3.92 days respectively.
Conclusions:
In patients with complicated parapneumonic effusion and empyema, intercostal drainage and intrapleural fibrinolytic have high success rates and a potential to significantly reduce the need for surgical interventions. These results are relevant to us as thoracic surgery and VATS services are limited and only available at few centers in Nepal.
Insights
Intercostal drainage combined with intrapleural fibrinolytic instillation effectively treats complicated parapneumonic effusion and empyema. This medical approach significantly reduces the need for surgical interventions in patients with these pleural infections.
Area of Science:
- Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Complicated parapneumonic effusion (PPE) and empyema are serious pleural infections.
- Standard treatment involves intercostal drainage (ICD), but failure often necessitates surgery.
- Intrapleural fibrinolytic instillation (IFT) can enhance drainage and potentially avoid surgery.
Purpose of the Study:
- To evaluate the effectiveness of medical interventions, specifically ICD and IFT, for complicated PPE and empyema.
- To assess the success rates and impact on surgical intervention needs.
Main Methods:
- A prospective cohort study included adult patients with complicated PPE or empyema.
- All patients received ICD; those with residual effusion or loculations received intrapleural Streptokinase.
- Outcomes included complete response, partial response, treatment failure, duration of ICD, hospital stay, and need for surgery.
Main Results:
- Of 51 patients, 43.1% achieved complete drainage with ICD alone.
- Intrapleural Streptokinase in 56.9% of patients increased drain output significantly.
- Following Streptokinase, 62.1% had a complete response, and the need for surgery was reduced.
Conclusions:
- Intercostal drainage combined with intrapleural fibrinolytic agents demonstrates high success rates in managing complicated PPE and empyema.
- This medical management strategy can substantially decrease the requirement for surgical procedures.
- These findings are particularly relevant in resource-limited settings where thoracic surgery services are scarce.
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