Combined intrapleural therapy in infectious pleural effusion
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Nascimento, T. Gomes, A. Fernandes, A. Afonso" "autores" => array:4 [ 0 => array:2 [ "Iniciales" => "L.M." "apellidos" => "Nascimento" ] 1 => array:2 [ "Iniciales" => "T." "apellidos" => "Gomes" ] 2 => array:2 [ "Iniciales" => "A." "apellidos" => "Fernandes" ] 3 => array:2 [ "Iniciales" => "A." "apellidos" => "Afonso" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0873215915933123?idApp=UINPBA00004E" "url" => "/08732159/0000002100000002/v0_201604141148/X0873215915933123/v0_201604141148/en/main.assets" ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Combined intrapleural therapy in infectious pleural effusion" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "105" "paginaFinal" => "106" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "H. Dabó, L. Meira, I. Neves, A. Marinho, I. Gomes" "autores" => array:5 [ 0 => array:4 [ "Iniciales" => "H." "apellidos" => "Dabó" "email" => array:1 [ 0 => "hansdabo@yahoo.com.br" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "Iniciales" => "L." "apellidos" => "Meira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "I." "apellidos" => "Neves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "A." "apellidos" => "Marinho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 4 => array:3 [ "Iniciales" => "I." "apellidos" => "Gomes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => "Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "<span class="elsevierStyleSup">*</span>" "correspondencia" => "Corresponding author. hansdabo@yahoo.com.br" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n02-90393313fig1.jpg" "Alto" => 1551 "Ancho" => 1757 "Tamanyo" => 930811 ] ] "descripcion" => array:1 [ "en" => "Case 1 (A ¿ anterior¿posterior chest radiograph before the CIT; B ¿ anterior¿posterior chest radiograph after the CIT). Case 2 (C ¿ posterior¿anterior chest radiograph before the CIT; D ¿ posterior¿anterior chest radiograph after the CIT)." ] ] ] "textoCompleto" => "<p class="elsevierStylePara">To the Editor,</p><p class="elsevierStylePara">Pleural infection often complicates pneumonia, with a mortality rate of approximately 20%.<a href="#bib8" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">, </span><a href="#bib9" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">2</span></a><span class="elsevierStyleSup">, </span><a href="#bib10" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">3</span></a> It can also occur as a complication of pleural management (e.g., surgical procedures) or spontaneously. Surgery is often required in cases that are not resolved by medical therapy and the risks and costs are not negligible. Recent data indicate the effectiveness of intrapleural combined therapy, in which deoxyribonuclease is used in conjunction with a fibrinolytic.<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> The authors report two cases of patients with pleural infection who received this treatment, with excellent results.</p><a name="sec0005" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Case 1</span><p class="elsevierStylePara">A 54-year-old man with a history of cervical spinal cord injury 28 years ago, with tetraparesis and chronic hypercapnic respiratory failure under nocturnal non-invasive ventilation (NIV), was hospitalized for sympathectomy due hyperhidrosis. The procedure was complicated by a left pneumothorax, and a chest tube was placed. Approximately 24 h after chest tube removal, systemic inflammation was documented, and the chest radiograph showed a left pleural effusion, which thoracic ultrasound proved to be multiloculated (pleural fluid characteristics after thoracentesis were indicative of pleural infection). Despite antibiotics and the insertion of a new chest tube (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>A), the patient continued to present with fever, and pleural fluid drainage was very limited during subsequent days. Given the high patient surgical risks inherent to his comorbidities, combined intrapleural therapy (CIT) was started using a protocol similar to that explained by Rahman et al.,<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> with 5 mg dornase alfa (DNase) diluted in 45 ml NaCl 0.9% and 10 mg alteplase (fibrinolytic), diluted in 40 ml NaCl 0.9% (both administered sequentially twice a day, for 3 consecutive days), clamping the drain for 1 h following administration of each drug, allowing them to act. This resulted in a significant increase in pleural fluid drainage, and rapid clinical and radiological improvement (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>B). There were no complications associated with this treatment, and the patient was discharged 10 days after beginning CIT, without the need for any additional interventions.</p><a name="f0005" class="elsevierStyleCrossRefs"></a><p class="elsevierStylePara"><img src="320v21n02-90393313fig1.jpg" alt="Case 1 (A – anterior–posterior chest radiograph before the CIT; B – anterior–posterior chest radiograph after the CIT). Case 2 (C – posterior–anterior chest radiograph before the CIT; D – posterior–anterior chest radiograph after the CIT)."></img></p><p class="elsevierStylePara">Figure 1. Case 1 (A – anterior–posterior chest radiograph before the CIT; B – anterior–posterior chest radiograph after the CIT). Case 2 (C – posterior–anterior chest radiograph before the CIT; D – posterior–anterior chest radiograph after the CIT).</p><a name="sec0010" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Case 2</span><p class="elsevierStylePara">A 41-year-old woman with no relevant past medical history, presented with right pleuritic pain, systemic inflammatory syndrome and evidence of loculated right pleural effusion in thoracic ultrasound. Thoracentesis was indicative of pleural infection, so she was given antibiotics, and a chest tube was placed (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>C). On subsequent days, pleural fluid drainage remained vestigial, and analytic inflammatory markers remained elevated. Thoracic surgery was not found to be emergent; consequently, CIT was undertaken, following a similar protocol as in Case 1, with comparable results (<a href="#f0005" class="elsevierStyleCrossRefs">Figure 1</a>D). The patient was discharged 12 days after beginning intrapleural treatment, and no further drainage was needed. As a complication, she reported intense local pain during the instillation of the drugs, which was suitably controlled with systemic analgesia administered before subsequent procedures.</p><p class="elsevierStylePara">The efficacy of fibrinolytic therapy in the pleural infection is controversial, as the results obtained in several studies are not consistent.<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> Case reports and small observational studies suggest its effectiveness, but it has not been confirmed in larger studies.<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">, </span><a href="#bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a> In the largest randomized, controlled and double-blind trial, Markell et al. concluded that streptokinase was not superior to placebo in reducing mortality or the need for surgery.<a href="#bib13" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">6</span></a> In a Cochrane meta-analysis,<a href="#bib14" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">7</span></a> which included the previous study, Cameron and Davies concluded that there is a potential benefit of fibrinolytics, although this result should be interpreted with caution. More recently, in another randomized, controlled and double-blind trial, Rahman et al. found that only the combination of alteplase and dornase alfa was effective in increasing drainage, and reducing the length of stay and the need for surgery.<a href="#bib11" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">4</span></a> In a more recent meta-analysis,<a href="#bib12" class="elsevierStyleCrossRefs"><span class="elsevierStyleSup">5</span></a> Janda and Swiston concluded that fibrinolytics are potentially beneficial in pleural infection in adults, and that they should be considered in loculated pleural effusion, as they may reduce the need for surgery.</p><p class="elsevierStylePara">In the cases discussed above, CIT using dornase alfa and alteplase contributed to the resolution of the pleural infection and prevented surgery, which presented a very high risk in Case 1, even if the considered approach was a less invasive option than video-assisted thoracoscopic surgery, which would involve perioperative lung collapse. Although the formal criteria for intra-pleural therapy or the most effective protocol has not yet been defined, the therapy should be considered in patients with contraindication or high risk for surgery, as it appears to have advantages related to costs and associated risks.</p><a name="sec0015" class="elsevierStyleCrossRefs"></a><span class="elsevierStyleSectionTitle">Conflict of interest</span><p class="elsevierStylePara">The authors declare no conflict of interest.</p><p class="elsevierStylePara">Corresponding author. hansdabo@yahoo.com.br</p>" "pdfFichero" => "320v21n02a90393313pdf001.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "320v21n02-90393313fig1.jpg" "Alto" => 1551 "Ancho" => 1757 "Tamanyo" => 930811 ] ] "descripcion" => array:1 [ "en" => "Case 1 (A ¿ anterior¿posterior chest radiograph before the CIT; B ¿ anterior¿posterior chest radiograph after the CIT). Case 2 (C ¿ posterior¿anterior chest radiograph before the CIT; D ¿ posterior¿anterior chest radiograph after the CIT)." ] ] 1 => array:6 [ "identificador" => "fig2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "descripcion" => array:1 [ "en" => "Case 1 (A – anterior–posterior chest radiograph before the CIT; B – anterior–posterior chest radiograph after the CIT). Case 2 (C – posterior–anterior chest radiograph before the CIT; D – posterior–anterior chest radiograph after the CIT)." ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib8" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax. 2010; 65(Suppl. 2):ii41-53." 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| 2021 September | 49 | 42 | 91 |
| 2021 August | 53 | 35 | 88 |
| 2021 July | 53 | 23 | 76 |
| 2021 June | 48 | 26 | 74 |
| 2021 May | 84 | 27 | 111 |
| 2021 April | 252 | 98 | 350 |
| 2021 March | 177 | 39 | 216 |
| 2021 February | 120 | 20 | 140 |
| 2021 January | 81 | 15 | 96 |
| 2020 December | 71 | 13 | 84 |
| 2020 November | 68 | 20 | 88 |
| 2020 October | 67 | 26 | 93 |
| 2020 September | 64 | 20 | 84 |
| 2020 August | 76 | 21 | 97 |
| 2020 July | 71 | 20 | 91 |
| 2020 June | 76 | 15 | 91 |
| 2020 May | 57 | 15 | 72 |
| 2020 April | 75 | 17 | 92 |
| 2020 March | 57 | 8 | 65 |
| 2020 February | 69 | 25 | 94 |
| 2020 January | 75 | 18 | 93 |
| 2019 December | 64 | 26 | 90 |
| 2019 November | 82 | 10 | 92 |
| 2019 October | 67 | 21 | 88 |
| 2019 September | 54 | 21 | 75 |
| 2019 August | 115 | 16 | 131 |
| 2019 July | 99 | 19 | 118 |
| 2019 June | 84 | 16 | 100 |
| 2019 May | 104 | 17 | 121 |
| 2019 April | 95 | 32 | 127 |
| 2019 March | 123 | 18 | 141 |
| 2019 February | 102 | 10 | 112 |
| 2019 January | 107 | 25 | 132 |
| 2018 December | 35 | 3 | 38 |
| 2018 November | 9 | 1 | 10 |
| 2018 October | 7 | 8 | 15 |
| 2018 September | 22 | 9 | 31 |
| 2018 August | 33 | 24 | 57 |
| 2018 July | 27 | 21 | 48 |
| 2018 June | 23 | 11 | 34 |
| 2018 May | 26 | 16 | 42 |
| 2018 April | 41 | 15 | 56 |
| 2018 March | 34 | 14 | 48 |
| 2018 February | 8 | 8 | 16 |
| 2018 January | 15 | 9 | 24 |
| 2017 December | 20 | 18 | 38 |
| 2017 November | 19 | 20 | 39 |
| 2017 October | 14 | 14 | 28 |
| 2017 September | 10 | 7 | 17 |
| 2017 August | 14 | 10 | 24 |
| 2017 July | 8 | 8 | 16 |
| 2017 June | 13 | 9 | 22 |
| 2017 May | 15 | 11 | 26 |
| 2017 April | 5 | 0 | 5 |
| 2017 March | 7 | 3 | 10 |
| 2017 February | 5 | 4 | 9 |
| 2017 January | 5 | 3 | 8 |
| 2016 December | 4 | 3 | 7 |
| 2016 November | 4 | 4 | 8 |
| 2016 October | 2 | 10 | 12 |
| 2016 September | 2 | 1 | 3 |
| 2016 August | 4 | 3 | 7 |
| 2016 July | 3 | 9 | 12 |
| 2016 June | 0 | 9 | 9 |
| 2016 May | 1 | 11 | 12 |
| 2016 April | 76 | 2 | 78 |
| 2016 March | 117 | 42 | 159 |
| 2016 February | 83 | 46 | 129 |
| 2016 January | 70 | 34 | 104 |
| 2015 December | 100 | 34 | 134 |
| 2015 November | 51 | 22 | 73 |
| 2015 October | 66 | 34 | 100 |
| 2015 September | 59 | 24 | 83 |
| 2015 August | 39 | 12 | 51 |
| 2015 July | 42 | 12 | 54 |
| 2015 June | 40 | 18 | 58 |
| 2015 May | 49 | 23 | 72 |
| 2015 April | 120 | 68 | 188 |
| 2015 March | 112 | 69 | 181 |
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