Non-steroidal anti-inflammatory drugs reduce pleural adhesion in human: evidence from redo surgery.

Non-steroidal anti-inflammatory drugs (NSAIDs) reduced pleural adhesion in animal studies, but its effect on human had not been studied. A retrospective study was carried out for patients with solitary pulmonary nodules without a pre-operative tissue diagnosis positive for malignancy. The impact of the use of NSAIDs after stage one wedge resection was assessed by the degree of pleural adhesions encountered during second-stage, redo completion lobectomy. From April 2016 to March 2022, 50 consecutive patients meeting the inclusion criteria were included, and 44 patients were selected for analysis after exclusion (Treatment group with NSAID: N = 27; Control group without NSAID: N = 17). The preoperative characteristics and the final tumor pathologies were similar between the groups. The use of NSAID was significantly associated with lower risk of severe pleural adhesions and complete pleural symphysis (risk difference = -29%, p = 0.03). After controlling the effect of tumor size and chest drain duration, only the use of NSAID was statistically associated with the lowered risk of severe pleural adhesions and complete pleural symphysis. No statistically significant effects of NSAID on operative time (p = 0.86), blood loss (p = 0.72), and post-operative length of stay (p = 0.72) were demonstrated. In human, NSAIDs attenuated the formation of pleural adhesions after pleural disruptions. Physicians and surgeons should avoid the use of NSAIDs when pleural adhesion formation is the intended treatment outcome.

Association between intrapleural urokinase monotherapy and treatment failure in patients with pleural infection: a retrospective cohort study.

BACKGROUND: Pleural infection, an infection of the pleural space, is frequently treated with antibiotics and thoracic tube drainage. In case of insufficient drainage, an intrapleural fibrinolytic agent is considered before surgical intervention. However, the effectiveness of fibrinolytic monotherapy is still controversial. Therefore, we aimed to examine the association between urokinase monotherapy and treatment failure in patients with pleural infection. METHODS: In this retrospective observational study, patients with pleural infection underwent chest tube insertion were divided into two groups including patients treated with or without intrapleural instillation of urokinase. The propensity score overlap weighting was used to balance the baseline characteristics between the groups. Treatment failure was defined by the composite primary outcome of in-hospital death and referral for surgery. RESULTS: Among the 94 patients, 67 and 27 patients were in the urokinase and non-urokinase groups, respectively. Urokinase monotherapy improved the composite outcome between the groups (19.4% vs. 48.1%, p = 0.01). After adjusting using propensity score overlap weighting, urokinase monotherapy improved the composite outcome compared to the non-urokinase group (19.0% vs. 59.5%, p = 0.003). CONCLUSIONS: Urokinase monotherapy can be an important nonsurgical treatment option for patients with pleural infection. TRIAL REGISTRATION: The participants were retrospectively registered.

Surfactant for a Patient with Refractory Pyopneumothorax and Acute Respiratory Distress Syndrome Due to Pneumococcal Necrotizing Pneumonia Complicated by a Bronchopleural Fistula.

Background: Necrotizing pneumonia rarely occurs in children, but when it does it can be complicated by bronchopleural fistula, empyema, pneumothorax, sepsis, and acute respiratory distress syndrome (ARDS). Antimicrobial therapy is the cornerstone of its management; however, surgery is necessary in some cases. Ideally, surgical interventions are kept to a minimum, but this is not always possible if there is a mass effect from air and fluid in the pleural space, pulmonary necrosis leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Case Presentation: Herein we present a patient with refractory pyopneumothorax and ARDS due to pneumococcal necrotizing pneumonia complicated by a bronchopleural fistula. The patient's clinical condition deteriorated despite antibiotics, surgical drainage, and assisted ventilation. Owing to pneumothorax with a high percentage of air leakage, bilateral diffuse collapse of the lungs, and insufficient oxygenation, surgical treatment was considered, but because of the patient's lack of tolerance for surgery due to hemodynamic reasons and the complications associated with surgery, medical treatment was determined to be more appropriate. Surfactant treatment was administered to the patient, resulting in significant clinical improvement. Conclusion: To the best of our knowledge, this is the first report of the use of surfactant to treat ARDS due to necrotizing pneumonia. Based on the presented case, we think surfactant can be considered as a salvage treatment for such patients.

Alteplase Dose Assessment for Pleural infection Therapy (ADAPT) Study-2: Use of 2.5 mg alteplase as a starting intrapleural dose.

BACKGROUND AND OBJECTIVE: Intrapleural tissue plasminogen activator/deoxyribonuclease (tPA/DNase) therapy is increasingly used in pleural infection. Bleeding risks and costs associated with tPA remain the clinical concerns. Our dose de-escalation series aims to establish the lowest effective dosing regimen for tPA/DNase. This study assesses the intrapleural use of 2.5 mg tPA/5 mg DNase for pleural infection. METHODS: Consecutive patients with pleural infection treated with a starting regime of 2.5 mg tPA/5 mg DNase were included from two centres in Australia and UK. Escalation of tPA dose was permitted if clinical response was inadequate. RESULTS: Sixty-nine patients (mean age 61.0 years) received intrapleural 2.5 mg tPA/5 mg DNase. Most (88.4%) were treated successfully and discharged from hospital without surgery by 90 days. Patients received a median of 5 [interquartile range [IQR] = 3-6] doses of tPA/DNase. Total amount of tPA used per patient was 12.5 mg [median, IQR = 7.5-15.0]. Seventeen patients required dose escalation of tPA; most (n = 12) for attempted drainage of distant non-communicating locule(s). Treatment success was corroborated by clearance of pleural opacities on radiographs (from median 27.0% [IQR = 17.1-44.5] to 11.0% [IQR = 6.4-23.3] of hemithorax, p < 0.0001), increased pleural fluid drainage (1.98 L [median, IQR = 1.38-2.68] over 72 h following commencement of tPA/DNase) and reduction of serum C-reactive protein level (by 45.0% [IQR = 39.3-77.0] from baseline at day 5, p < 0.0001). Two patients required surgery. Six patients with significant comorbidities (e.g., advanced cancer) had ongoing infection when palliated and died. Two patients experienced self-limiting pleural bleeding and received blood transfusion. CONCLUSION: A starting intrapleural regime of 2.5 mg tPA/5 mg DNase, with up-titration if needed, can be effective and deserves further exploration.

A Large Central Bronchopleural Fistula Closed by Bronchoscopic Administration of Recombinant Bovine Basic Fibroblast Growth Factor: A Case Report.

A large central bronchopleural fistula (BPF) surrounded by mediastinal tissue was successfully closed by local administration of recombinant bovine basic fibroblast growth factor (rbFGF) using the bronchoscope. No complications were observed during and after this bronchoscopic treatment. This is the first report of the bronchoscopic treatment of a large central BPF by the local spray of rbFGF. The bronchoscopic treatment with rbFGF is a potentially cost-effective method for central BPF surrounded by mediastinal tissue.

Intrapleural Fibrinolytics and Deoxyribonuclease for Treatment of Indwelling Pleural Catheter-Related Pleural Infection: A Multi-Center Observational Study.

BACKGROUND: Indwelling pleural catheters (IPC) are increasingly used for management of recurrent (especially malignant) effusions. Pleural infection associated with IPC use remains a concern. Intrapleural therapy with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) significantly reduces surgical referrals in non-IPC pleural infection, but data on its use in IPC-related pleural infection are scarce. OBJECTIVE: To assess the safety and efficacy of intrapleural tPA and DNase in IPC-related pleural infection. METHODS: Patients with IPC-related pleural infection who received intrapleural tPA/DNase in five Australian and UK centers were identified from prospective databases. Outcomes on feasibility of intrapleural tPA/DNase delivery, its efficacy and safety were recorded. RESULTS: Thirty-nine IPC-related pleural infections (predominantly Staphylococcus aureus and gram-negative organisms) were treated in 38 patients; 87% had malignant effusions. In total, 195 doses (median 6 [IQR = 3-6]/patient) of tPA (2.5 mg-10 mg) and DNase (5 mg) were instilled. Most (94%) doses were delivered via IPCs using local protocols for non-IPC pleural infections. The mean volume of pleural fluid drained during the first 72 h of treatment was 3,073 (SD = 1,685) mL. Most (82%) patients were successfully treated and survived to hospital discharge without surgery; 7 required additional chest tubes or therapeutic aspiration. Three patients required thoracoscopic surgery. Pleurodesis developed post-infection in 23/32 of successfully treated patients. No major morbidity/mortality was associated with tPA/DNase. Four patients received blood transfusions; none had systemic or significant pleural bleeding. CONCLUSION: Treatment of IPC-related pleural infection with intrapleural tPA/DNase instillations via the IPC appears feasible and safe, usually without additional drainage procedures or surgery. Pleurodesis post-infection is common.

A case of pancreatic-pleural fistula of Type 1 autoimmune pancreatitis successfully treated with pancreatic drainage and steroid.

Pancreatic-pleural fistula is a rare but severe complication with pancreatitis. A 50-year old man with heavy alcoholic history was transferred to our hospital due to pancreatic pleural effusion with diffuse pancreatic swelling. MRCP revealed two stenotic parts of main pancreatic duct. We inserted a pancreatic stent, and pleural effusion was improved. However, diffuse pancreatic swelling still remained for 3 months. Autoimmune pancreatitis was suspected because of morphologic appearance and high serum levels of IgG4. We confirmed his illness as Type 1 autoimmune pancreatitis pathologically by EUS-FNA and started steroid administration. Diffuse pancreatic swelling was improved immediately. Pancreatic-pleural fistula did not relapse after removing the pancreatic stent and tapering steroid. This is a first report for pancreatic-pleural fistula caused by autoimmune pancreatitis and successfully treated with pancreatic drainage and steroid.

Pleural Thickening after Pleural Effusion: How can we Follow-Up in Children?

INTRODUCTION: No clear information exists about the factors affecting pleural thickening following parapneumonic effusion in children. We aimed to investigate factors that affect the resolving time of pleural thickening after parapneumonic effusion. METHODS: Between the years of 2007-18, 91 patients, which were followed due to diagnosis of pleural thickening after parapneumonic effusion, were assessed. Ages, complaints, physical examination findings, laboratory results, chest x-ray and ultrasonography findings, treatments, duration of treatment and recovery time of the patients were examined terms in of pleural thickening resolving time. RESULTS: The mean age of patients was 7.5 ± 5.0 years. Pleural thickening resolving time was 151 ± 6.8 days. The resolving time for pleural thickening was delayed with older ages, longer duration of complaints, fever before hospital admission and treatment, lower oxygen saturation at the time of admission, crackles in the physical examination, higher white blood cell count and pleural fluid density (p = 0.018, p = 0.001, p = 0.021, p = 0.020, p = 0.024, p = 0.025, p = 0.021, p = 0.019). In addition, the amount of effusion measured by thorax ultrasonography, fibrinolytic usage, and complications had a role in the delayed resolving time (p = 0.034, p = 0.001, p = 0.034). Pleural thickening resolved in 80% of the patients. CONCLUSION: In this report, 80% of pleural thickening, following parapneumonic effusion resolved within 5 months. Patients who do not have a complication during follow-up are not required to monitor with frequent chest x-ray. Patients with a higher amount of pleural effusion, complications and need for fibrinolytic treatment should be followed more carefully.

Combined intrapleural and intrabronchial injection of fibrin glue for closing alveolar pleural fistula: a case report.

BACKGROUND: The treatment of persistent air leak is a challenge. Herein, we reported the combined intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy to seal off an alveolar pleura fistula developed following necrotizing pneumonia in high-risk patient. CASE PRESENTATION: A 74-year-old man was intubated in emergency for acute ischemic stroke. Percutaneous dilatational tracheostomy was then performed, and 15 days later patient returned to spontaneous breathing. However, he developed alveolar pleural fistula following necrotizing pneumonia with persistent air leaks. The intrabronchial and intrapleural injection of fibrin glue using fiber bronchoscopy sealed off the alveolar pleura fistula after that other endoscopic treatments as bronchial valve and intrabronchial fibrin glue application had failed. CONCLUSIONS: Our strategy is safe and easy to reproduce. It represents an additional method in the armamentarium of the physicians for the management of PAL when all standard strategies are unfeasible or fail.

Lower-lobe predominant pleuroparenchymal fibroelastosis.

Upper-lobe predominance of elastofibrosis is agreed upon for the diagnosis of clinical pleuroparenchymal fibroelastosis (PPFE). We herein describe a patient with dermatomyositis-related interstitial pneumonia with a histology of lower-lobe predominant PPFE. A 71-year-old woman who had been diagnosed with dermatomyositis-related interstitial pneumonia died of respiratory failure. The computed tomography patterns of the lower lobes showed reticular and ground-glass opacities with traction bronchiectasis. An autopsy revealed that the bilateral lower lobes were sclerotic with decreased air volume. A microscopic examination of the lower lobes showed pleural fibrosis and subpleural elastofibrosis without the structural destruction, indicative of histological PPFE. PPFE histology was also evident in the upper lobes but relatively modest compared to that of the lower lobes. In addition, because the computed tomography images of the patient were suggestive of non-PPFE-type fibrosis, lower-lobe dominant PPFE might be overlooked in daily practice.

The first use of combination of Intrapleural Fibrinolytics (Alteplase & DNAse) for pleural infection in Malaysia.

The use of a combination of intrapleural fibrinolytics or tissue plasminogen activator(tPA) Alteplase and deoxyribonuclease (Dnase) has been increasing for cases of complicated pleural infection/parapneumonic effusion worldwide. Its efficacy and success rate in selected cases of complicated parapneumonic effusion unresponsive to antibiotics and chest drainage are well documented. This case report demonstrates the first use of combination intrapleural fibrinolytic (Alteplase) and DNAse (Pulmozyme) in Malaysia for a case of pleural infection/parapneumonic effusion.

Thoracic Hyper-IgG4-Related Disease Mimicking Malignant Pleural Mesothelioma.

We report a rare case of a IgG4-related disease presenting with recurrent pleural effusion, pleural thickness and multiple mediastinal lymphadenopathies and no involvement of other extrathoracic organs. A 65-year-old man with a previous asbestos exposure presented with cough and pain discomfort. A large right pleural effusion was detected and evacuated (siero-haematic liquid). With the suspicious of a pleural mesothelioma, a CT-scan before and a 18F-FDG PET/CT-scan later were performed revealing multiple pleural thickenings and multiple mediastinal lymphadenopathies with radiotracer uptake. EBUS-TBNA EBUS-TBNA did not result in a formal pathological diagnosis; thus, multiple pleural biopsy were performed via right thoracoscopy. At pathology the pleura was markedly thickened by a chronic fibroinflammatory process with scattered lymphoid follicles and a large number of mature plasma cells. Immunohistochemistry shows a mixed B (CD20+) and T (CD3+) population of lymphocytes, without light chain restriction and an increased number of IgG4-positive plasma cells. A presumptive diagnosis of IgG4-related disease was formulated. Total body CT-scan excluded other organ involvement. Blood test showed elevated serum IgG4 concentrations (253 mg/dL) and mild elevation of acute-phase reactants (C-reactive protein 10.7 mg/L). Autoimmune profile was negative. A diagnosis of definite IgG4-related disease was made, and treatment with prednisone 50 mg/day was started.

Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics.

INTRODUCTION: Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms 'pleural infection', 'empyema' and 'parapneumonic'. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.

Restrictive lung defects: parenchymal, chest wall and neuromuscular.

Sarcoidosis is a multisystem condition which may affect a number of organs and, within the cardiopulmonary system, most commonly manifests as parenchymal, airway-centred, nodal, vascular or cardiac disease. Pleural involvement is rare, but well described, and often presents as pleural effusions or pleural thickening. Here, we present the first case of active sarcoidosis manifesting as bilateral pleural calcification. We highlight the importance of a nuanced understanding of pulmonary physiology when dissecting coexistent extrathoracic and intrathoracic pulmonary restriction. We demonstrate the value of positron emission tomography scanning for identification of sites of sarcoid activity, in this case the pleura, to ensure tissue confirmation of this rare but functionally important manifestation of disease. Sarcoidosis should be considered within the differential diagnosis for patients with pleural calcification, not explained by more common causes.

Clinical and microbiologic characteristics of pleuro-pulmonary infection due to Streptococcus intermedius / Características clínicas y microbiológicas de la infección pulmonar causada por Streptococcus intermedius

The clinical and microbiological characteristics of pleuro-pulmonary infection (PPI) caused by Streptococcus intermedius is described, including 6 cases in the literature and 9 cases handled at the present centre. Out of the 15 patients, 12 were male; mean age at diagnosis was 62.06 ± 15 years. Twelve had risk factors for S. intermedius infection such as alcoholism in 5 (35.7%) patients, periodontal disease in 3 (24.6%) cases, chronic obstructive pulmonary disease in 3 (24.6%), and diabetes mellitus in 2 (14.2%). Cough was present in 12 (80%) patients and chest pain and dyspnea in 9 (60%). The mean diagnosis interval was 34 days. The diagnosis was obtained from pleural fluid aspirate in 13 (86.6%) cases and from biopsy/tissue samples in 2. The most frequently antimicrobials used for treatment were ceftriaxone + levofloxacin. Ten patients cured with a combination of medical and surgical treatment and 2 patients died as a consequence of infection. The incidence of PPI caused by S. intermedius is increasing in our health area; drainage along with antibiotic therapy is recommended for treatment

Se describen las características clínicas y microbiológicas de la infección pleuro-pulmonar producida por Streptococcus intermedius , incluyendo 6 casos de la literatura y 9 casos diagnosticados en nuestro centro. De los 15 pacientes, 12 eran varones; la media de edad al diagnóstico fue de 62,02 ± 15 años. Doce tenían factores de riesgo para la infección por S. intermedius , tales como alcoholismo en 5 (35,7%) pacientes, enfermedad periodontal en 3 (24,6%) casos, enfermedad pulmonar obstructiva crónica en 3 (24,6%), y diabetes mellitus en 2 (14,2%). Se presentó tos en 12 (80%) pacientes y dolor torácico y disnea en 9 (60%). La media del intervalo diagnóstico fue de 34 días. El diagnóstico se obtuvo de aspirado de líquido pleural en 13 (86,6%) casos y de muestras de biopsia/tejido en 2. Los antimicrobianos más frecuentemente utilizados fueron ceftriaxona + levofloxacino. Diez pacientes curaron con una combinación de tratamiento médico y quirúrgico y dos pacientes fallecieron como consecuencia de la infección. La incidencia de infección pleuro-pulmonar causada por S. intermedius se ha incrementado en nuestra área de salud; el tratamiento recomendado es el drenaje junto con la terapia antibiótica

Clinical and microbiologic characteristics of pleuro-pulmonary infection due to Streptococcus intermedius.

The clinical and microbiological characteristics of pleuro-pulmonary infection (PPI) caused by Streptococcus intermedius is described, including 6 cases in the literature and 9 cases handled at the present centre. Out of the 15 patients, 12 were male; mean age at diagnosis was 62.06 ± 15 years. Twelve had risk factors for S. intermedius infection such as alcoholism in 5 (35.7%) patients, periodontal disease in 3 (24.6%) cases, chronic obstructive pulmonary disease in 3 (24.6%), and diabetes mellitus in 2 (14.2%). Cough was present in 12 (80%) patients and chest pain and dyspnea in 9 (60%). The mean diagnosis interval was 34 days. The diagnosis was obtained from pleural fluid aspirate in 13 (86.6%) cases and from biopsy/tissue samples in 2. The most frequently antimicrobials used for treatment were ceftriaxone + levofloxacin. Ten patients cured with a combination of medical and surgical treatment and 2 patients died as a consequence of infection. The incidence of PPI caused by S. intermedius is increasing in our health area; drainage along with antibiotic therapy is recommended for treatment.

A Pilot Feasibility Study in Establishing the Role of Ultrasound-Guided Pleural Biopsies in Pleural Infection (The AUDIO Study).

BACKGROUND: Pleural infection is a common complication of pneumonia associated with high mortality and poor clinical outcome. Treatment of pleural infection relies on the use of broad-spectrum antibiotics because reliable pathogen identification occurs infrequently. We performed a feasibility interventional clinical study assessing the safety and significance of ultrasound (US)-guided pleural biopsy culture to increase microbiological yield. In an exploratory investigation, the 16S ribosomal RNA technique was applied to assess its utility on increasing speed and accuracy vs standard microbiological diagnosis. METHODS: Twenty patients with clinically established pleural infection were recruited. Participants underwent a detailed US scan and US-guided pleural biopsies before chest drain insertion, alongside standard clinical management. Pleural biopsies and routine clinical samples (pleural fluid and blood) were submitted for microbiological analysis. RESULTS: US-guided pleural biopsies were safe with no adverse events. US-guided pleural biopsies increased microbiological yield by 25% in addition to pleural fluid and blood samples. The technique provided a substantially higher microbiological yield compared with pleural fluid and blood culture samples (45% compared with 20% and 10%, respectively). The 16S ribosomal RNA technique was successfully applied to pleural biopsy samples, demonstrating high sensitivity (93%) and specificity (89.5%). CONCLUSIONS: Our findings demonstrate the safety of US-guided pleural biopsies in patients with pleural infection and a substantial increase in microbiological diagnosis, suggesting potential niche of infection in this disease. Quantitative polymerase chain reaction primer assessment of pleural fluid and biopsy appears to have excellent sensitivity and specificity.

An unusual presentation of pulmonary embolism leading to infarction, cavitation, abscess formation and bronchopleural fistulation.

We report an unusual presentation of pulmonary embolism (PE) where a 58-year-old man first developed symptoms of community-acquired pneumonia. Despite antibiotic therapy, he remained unwell with rising inflammatory markers, general malaise and persistent cough. He developed stony dull percussion and absent breath sounds to his left mid to lower zones. Serial chest x-rays showed progression from lobar consolidation to a large loculated left-sided pleural collection. CT chest showed left-sided lung abscess, empyema and bronchopleural fistulation. Incidentally, the scan revealed acute left-sided PE and its distribution corresponded with the location of the left lung abscess and empyema. The sequence of events likely started with PE leading to infarction, cavitation, abscess formation and bronchopleural fistulation. This patient was managed with a 6-month course of rivaroxaban. After completing 2 weeks of intravenous meropenem, he was converted to 4-week course of oral co-amoxiclav and metronidazole and attained full recovery.

Concurrent Versus Sequential Intrapleural Instillation of Tissue Plasminogen Activator and Deoxyribonuclease for Pleural Infection.

BACKGROUND: Treatment of pleural infection with instillation of sequential intrapleural tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) twice daily for a total of 6 doses has been shown to decrease surgical referral and improve radiographic imaging. This labor-intensive regimen was empirically chosen. Thus, it remains unclear whether the 2 drugs can be administered immediately one after the other (concurrent administration) instead of instilling them separately with a 1-hour to 2-hour interval in between (sequential administration). The aim of this study was to compare the efficacy and safety of sequential versus concurrent tPA/DNase therapy in patients with pleural infection. METHODS: This was a prospective observational study. Consecutive patients with pleural infection who received concurrent and sequential tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on the amount of pleural fluid drainage, clinical response and radiographic findings. RESULTS: A total of 38 patients with pleural infection received tPA/DNase treatment: 18 in the sequential group and 20 in the concurrent group. Treatment was successful in 77.7% in the sequential group and 75% in concurrent group (P=0.57). There was no statistically significant difference between the 2 treatment groups (sequential and concurrent) in median pleural fluid drainage (P=0.45), median volume of pleural effusion estimated on chest computed tomography scan (P=0.4) or median hemithorax occupied by effusion on chest radiography (P=0.83) following intrapleural therapy. One patient required a blood transfusion for gradual pleural blood loss in each treatment group. Pain needing escalation of analgesia affected 3 patients in each arm but none required cessation of therapy. CONCLUSION: A simpler regimen of concurrent administration of intrapleural tPA/DNase as compared with sequential intrapleural therapy is safe, effective, and represents a viable option for the management of pleural infection.

The Utility of Ultrasound to Diagnose Tunnel-Tract Infection Related to Indwelling Pleural Catheters.

Indwelling pleural catheter (IPC) infections lead to increased morbidity and treatment failure in patients with chronic recurrent pleural effusions. Ultrasonography is a readily available diagnostic tool used by pulmonologists on a daily basis. Ultrasonography has been used to identify the etiology of indwelling peritoneal catheter obstruction, including infection of the exit site and tunnel tract. The use of ultrasonography to identify tunnel-tract infection involving IPC has not been reported. We describe the ultrasonographic characteristics of 3 cases of confirmed tunnel-tract infection and compared them with noninfected chronic IPCs. Ultrasonographic evaluation of the soft tissue tunnel tract can accurately identify fluid collections around the catheter and cuff, which is highly suggestive of tunnel-tract infection.