Intrapleural fibrinolytic therapy in complicated parapneumonic effusion and empyema: present status.

Pneumonia remains one of the commonest community- and hospital-acquired infection despite the advent of potent antimicrobial agents. A significant number of patients with pneumonia develop parapneumonic effusions. The parapneumonic effusion may be "simple" consisting of free-flowing, clear exudative fluid which almost resolves completely with antibiotics alone. In case of delayed or inappropriate treatment, some of these simple effusions progress to complicated parapneumonic effusions and empyema. The management of these types of effusions with intercostal tube drainage and antibiotics fails most of the time due to the presence of thick viscous fluid and multiple pleural space loculations. The various therapeutic options available at this stage include intrapleural instillation of fibrinolytic agents, breaking down of loculations or decortication either by video-assisted thoracosopic surgery (VATS) or thoracotomy and open drainage procedures. Video-assisted thoracic surgery is a better option but it is neither easily available nor affordable by majority of patients in developing countries, like India. Intrapleural instillation of fibrinolytic agents has been found to be a useful adjunctive therapy in various small uncontrolled and randomised trials. After a recent and first large multicentre trial which showed that this therapy does not have any significant effect in reducing mortality and need for surgery in patients with pleural infection, the role of intrapleural fibrinolytics has become more controversial. In view of this, there is a need to re-define its role especially in the developing countries.

An unusual endobronchial foreign body.

A 24-year-old male presented with features of pneumonia of right lower lobe. Chest radiograph after treatment showed cystic opacities in the right lower zone along with a radio-opaque foreign body at the right cardiophrenic angle. The foreign body was successfully removed via the fibreoptic bronchoscope. It was a very unusual type of foreign body with an equally unusual mode of aspiration.

Status of inhalation therapy in bronchial asthma in adults above twelve years of age in armed forces.

OBJECTIVE: The aim of this study was to evaluate the status of inhalation therapy in bronchial asthma in terms of frequency of its use, role of general physicians and general practitioners in prescribing inhalation therapy, role of inhaled steroids and B2 agonists, concurrent use of oral drugs, technique of using inhaler devices, use of spacer devices and peak flow monitoring. MATERIAL AND METHODS: 150 patients (76 males, 74 females) of bronchial asthma over 12 years of age referred to chest clinic of a tertiary care hospital for inadequate control were interviewed on the basis of a questionnaire and screening of prescription and case records wherever available. RESULTS: 127 (84.6%) patients were on inhalation therapy and maximum number of prescriptions was by general physicians (81%). The dosages of inhaled steroids were less than 400 mg in 60 (83.3%) cases and 26 (36%) patients discontinued it after some time. All patients were on beta-2 agonist inhalers and 74 (58.3%) patients were using these on regular basis. The concurrent use of oral short acting B2 agonist and oral steroids was seen in 107 (84%) and 41 (32.2%) patients respectively. Metered dose inhalers (MDIs) were most frequently used inhaler devices in 100 (78.7%) cases followed by rotahalers in 27 (21%) cases. The technique of using MDI and rotahalers was incorrect in 64 (64%) and 7 (25.9%) cases respectively. Spacer devices were used rarely and none of the patients were monitored by peak flow rates. CONCLUSIONS: Although inhalation therapy was being prescribed in large number of patients, more so by general physicians, yet the therapy was not being effective considering the fact that the referral to chest clinic in all the cases was for uncontrolled asthma. The main reasons for ineffective inhalation therapy were, underuse of inhaled steroids, overuse of B2 agonists and incorrect use of inhaler devices. There is an urgent need to educate general physicians especially in regards to usefulness of inhaled steroids, as on demand use of B2 agonists, demonstration of correct inhalation technique to patients, use of spaces devices and peak flow monitoring.

Endobronchial non-Hodgkin's lymphoma.

A 23-year-old male presented with clinical and radiological features of left lung collapse. Fibre-optic bronchoscopy revealed a smooth globular mass almost completely occluding the left main bronchus. Needle aspiration and endobronchial biopsy from the mass revealed it to be a case of anaplastic large cell lymphoma, a subtype of non-Hodgkin's lymphoma. This report documents the rare presentation of non-Hodgkin's lymphoma as an endobronchial mass.

Intrapleural streptokinase in complicated parapneumonic effusions and empyema.

BACKGROUND: The management of complicated parapneumonic effusions (CPE) and empyema by chest tube drainage usually fails because of thick viscous fluid and multiple pleural space loculations. The use of intrapleural fibrinolytic agents facilitates pleural drainage and can obviate the need for more invasive surgical interventions in these types of effusions. OBJECTIVE: To evaluate the role of intrapleural fibrinolytic therapy with streptokinase (STK) as an adjunctive therapy in the management of CPE and empyema. MATERIAL AND METHODS: Thirty patients of CPE and empyema were considered for intrapleural fibrinolytic therapy when the chest tubes/catheter drainage became insignificant (i.e., less than 50 ml a day) and the tube was adequately positioned and patent. Intrapleural STK was administered eight hourly in the dosage of 2,50,000 IU in 50 ml of saline. The end points were volume of fluid drained and radiological resolution. RRESULTS:There were 24 (80%) patients with CPE and six (20%) with empyema, with a mean age of 35 years. The median of STK doses used were three in 26 (87%) cases and two in four (13%) cases. There was significant drainage (mean +/- SD) 1094 ml +/- 116 and radiological resolution in 26 (87%) cases. The only complication observed was transient chest pain in one and fever in two patients. CCONCLUSION:Intrapleural fibrinolytic therapy with STK is a safe and effective adjunctive therapy in the management of CPE and empyema.

Analysis of arterial blood gases--a comprehensive approach.

The arterial blood gases is one of the most important investigation for assessment of clinical oxygenation and acid-base status in critically ill patients. It provides us with information about ventilation, oxygenation and acid-base status, the three closely interrelated physiology parameters, which maintain the pH homeostasis. Its correct interpretation and application necessitates the knowledge of basic applied physiology in relation to these parameters. Through this review article an attempt has been made to formulate a comprehensive approach by first describing the basic physiology in relation to these parameters followed by stepwise approach to analyse arterial blood gases.

Tracheobronchopathia osteochondroplastica.

Tracheobronchopathia osteochondroplastica (TO) is a rare and benign disorder characterized by cartilagenous and/or osseous submucosal deposits projecting into the laryngotracheobronchial lumen. The disorder is usually asymptomatic and most of the cases have been diagnosed incidentally at autopsy or during bronchoscopy. A case of TO in association with bronchogenic carcinoma is being reported for its rarity.

Intrapleural streptokinase in a two-year-old child with a parapneumonic effusion.

A two-year-old child was hospitalised with features of parapneumonic effusion. He was initially managed with parenteral antibiotics and chest tube drainage. After three days drainage became insignificant inspite of chest tube being patent and appropriately positioned. CT scan of chest showed multiloculated effusion. In view of multiloculated effusion it was decided to try intrapleural fibrinolysis with streptokinase. Streptokinase in a dose of 1,25000 IU dissolved in 50 ml of normal saline was instilled through the chest tube daily. After instilling three doses, there was a significant increase in the drainage followed by almost complete radiological resolution. There were no side effects. Intrapleural streptokinase is a useful adjunctive threapeutic modality in the management of complicated parapneumonic effusion or empyema in paediatric patients.