U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

28-10-2011

Sintomas: dor “abdominal” no flanco direito, febre (37,8)

Investigação:•Ecografia abdominal: negativa•Rx tórax: •negativo

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

1-11-2011

Sintomas: • dor toracica• febre (38°)• Dispneia

Laboratorio:GB: 7.81 (N=78%)VHS: 96D-Dimero: 3150

Rx Torax:Pequeno derrame pleural a D.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

2-11-2011

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

4-11-2011

Drenagem Toracica (pig tail)

700 ml de liquido pleurico corpuscolado e amarelado

pH: 6,56!!!

Proteinas: 4,1 (no soro 5,5)

Glicose: 19

LDH: 10955!

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

P.te Indiano (Singh): 43 anni

• Pleurite parapneumônica– pleurite simples– Derrame parapneumônico complicado e empiema

• Derrame pleurico tubercular.– pleurite– empiema (raro)

• Pleurite atípica (Em pacientes imunodeprimidos é frequente a infecção oportunista.)– fungos

• candida, aspergillo, criptococco, coccidioides, histoplasma, blastomyces, sporotrichose

– bactérias incomuns• Actinomicosi, nocardiosi, chlamidia, rickettsiae

– parasitas• Amebiase, echinococcose, paragonimiase, trichominiase

– virus (não se conhece a real epidemiologia!)• Adenovirus, hantavirus, cytomegalovirus, herpes virus, hepatite, mononucleose,

dengue

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

• Dificil isolar os agentes patogênicos– Dificuldades com os métodos atuais. Identificação do agente patogênico em

menos de 40% dos casos com os métodos tradicionais.– Frequentemente não vem procurados!!!– A pleurite viral, em particular no adulto, é uma realidade, um “mito” ou um

diagnóstico “refúgio”???• Derrames parapneumônicos: mesma etiologia das pneumonias?

– Poucos estudos, com indicações de seleção, retrospectivo e com poucos casos, porém, orientam para etiologias diferentes.

• Empiema:– Toracocentese precoce e tratamento correto (drenagem): muitas vezes

inexplicavelmente retardados– Mortalidade em 12 meses de 22%; 35% no P.te imunodepresso.– Diferença entre adquiridas na comunidade e hospitalar? etiologia.. mortalidade.

• Derrame pleural tubercular:– Acredita-se de se tratar de uma patologia muito rara.– Se dá muita importancia a procura do BK no liquido pleurico– Descuida-se da importancia fundamental da biopsia pleurica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

454 Pts

Bacterial identification: 74%

streptococcus

staphylococcus

enterococcus

Gram negatives

anaerobes

Myc tuberc

actinomyces

others

Bacteriology of community acquired pleural infection

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

• The group Streptococcus milleri (SM) includes several species of pathogenic streptococci associated with pyogenic infections: at least three well-differentiated species:

– S. constellatus, S. intermedius and S. anginosus– The SM group is part of the usual flora of the mouth, it is also found among

normal faecal flora in 16–67% of healthy adults

• The most important clinical feature of these micro-organisms is their tendency to cause suppurative infections at various sites, ranging from dental abscesses to deep visceral abscesses

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Conclusions

community-acquired pleural infection is caused by penicillin-sensitive streptococci in about 50% of cases, with the other 50% being due to organisms that are usually penicillin resistant, including staphylococci and Enterobacteriaceae.

About 25% of community-acquired pleural infections include anaerobic bacteria.

Appropriate empiric antibiotic choices for these patients should therefore cover streptococci, penicillin-resistant staphylococci, and Enterobacteriaceae and should usually also include anaerobic bacterial therapy.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

One year Mortality

•53/304 (17%) in community-acquired infection

•17/36 (47%) in hospital ac inf

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Approximately 60% of hospital-acquired infections included bacteria frequently

resistant to antibiotics

•Mortality in different bacterial subsets:

•23/137 (17%): streptococcal inf.

•10/49 (20%): anaerobic-mixed inf.

•15/34 (44%) S. aureus inf.

•10/22 (45%) gram-negative inf.

•13/28 (46%) mixed aerobic inf.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

•Long delays in diagnosis

•long hospital stays

•recovery with surgery

•The mean delay in diagnosis was 44.2 days

•On average each patient:

• underwent CT 10.1 times

•had 2.6 percutaneous drainage procedures

•The mean time from the first percutaneous chest drainage to the date of diagnosis was 29.8 days

•the mean delay until thoracic surgery referral was 47.4 day

•The mean length of hospital stay postoperatively was 15.2 days

Ultrasonography and CT scanning, however, have greater sensitivity for fluid detection and provide additional information for determining the extent and nature of pleural infection.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

empyema

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

• Exudative stage: pleural fluid culture is negative, pH > 7.20, LDH <1000: 5 to 7 days

• fibrino-purulent stage: pleural fluid becomes purulent, early loculations, positive microbial culture. pH <7.20, LDH > 1000: 7 days up to 2 weeks

• organizing stage: fibroblasts grow into the pleural space; this results in a thik pleural peel: generally occurs within 2 to 4 weeks of onset of the pleural effusion.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica G.F. Tassi, G.P. Marchetti. Il versamento parapneumonico e l’empiema. In Pneumologia

Interventistica. A.G. Casalini. Springer Italia. 2007

Clinical and pathological evolution

stage Pleural fluid Biochemical aspects

treatment

Simple parapneumonic pleural effusion

yellow •pH>7.20•LDH<1000•GRAM neg

antibiotics

Complicated parapneumonic effusion

Yellow/turbid

•pH<7.20•LDH>1000•GRAM pos

Chest tube drainage

empyema Purulent Chest tube drainage

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

The primary outcome of the review was treatment failure resulting in death and surgery.

Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

The primary outcome of the review was treatment failure resulting in death and surgery.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Conclusions: In patients with loculated, complex fibrinopurulent parapneumonic empyema thoracis, a primary treatment strategy of VATS is associated with a higher efficacy, shorter hospital duration, and less cost than a treatment strategy that utilizes catheter-directed fibrinolytic therapy.

october 30th

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Case Report G.P.A. 51 years old

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Case Report G.P.A. 51 years old

october 31st

november 5th: Thoracoscopy

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Case Report G.P.A. 51 years old

november 23th

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Case Report G.P.A. 51 years old

Conclusion

Although thoracoscopy has proved useful in the treatment ofinfected pleural space, in particular in multiloculated empyema where it allows recovery avoiding thoracotomy, even today its employment has not been justified by large controlled trials. Moreover there are no prospective, controlled studies on the role of medical thoracoscopy inparapneumonic effusions and empyema.

Medical thoracoscopy, as a drainage procedure intermedate between tube thoracostomy and VATS, is significantly lower in cost and can avoid surgical thoracoscopy under general anaesthesia. It is essential that it is performed early on in the course of empyema and it is particularly advisable for frail patients at high surgical risk.

U.O. di Pneumologia - Endoscopia Toracica U.O. di Pneumologia - Endoscopia Toracica

Conclusion

Although thoracoscopy has proved useful in the treatment ofinfected pleural space, in particular in multiloculated empyema where it allows recovery avoiding thoracotomy, even today its employment has not been justified by large controlled trials. Moreover there are no prospective, controlled studies on the role of medical thoracoscopy inparapneumonic effusions and empyema.

Medical thoracoscopy, as a drainage procedure intermedate between tube thoracostomy and VATS, is significantly lower in cost and can avoid surgical thoracoscopy under general anaesthesia. It is essential that it is performed early on in the course of empyema and it is particularly advisable for frail patients at high surgical risk.