Difficult Decisions in Thoracic Surgery - part 9 potx

416 J.B. Putnam, Jr. less than 150 mL/day (median chest tube dura- tion, 7 days). The recommended approach would be the one which would minimize hospitalization. 22 In summary, drainage of MPE using small bore catheter drainage and rapid pleurodesis achieves results similar to prolonged drainage prior to pleurodesis (level of evidence 1b to 3; recommendation grade B). may cause adverse reactions such as microemboli and granulomatous tissue reactions. 26 Although many agents have been evaluated for pleurodesis, talc is the most common agent used today. It is generally considered the most effective agent for pleurodesis. A systematic review through 1992 27 and another organized review 28 confi rmed the clinical and cost effectiveness of talc (level of evidence 1a; recommendation grade A). Talc has been studied in comparison with tetracycline and bleomycin. Tetracycline is no longer on the market and has been replaced with doxycycline. Talc has been found to be the better agent when- ever compared with an alternative sclerosing agent and is much cheaper (level of evidence level 1b). 29–31 More recent studies suggest that both thoracoscopic pleurodesis (in the operating room) and bedside instillation of talc slurry were equivalent in effectiveness (level of evidence level 1b; recommendation grade A). 32 Bedside drainage and talc slurry installation provide good resolution of symptoms, and are a cost-effective solution to the expensive alternatives of general anesthesia, thoracoscopy or thoracotomy, and inpatient hospitalization (level of evidence level 3). 16 Drainage of MPE using small bore catheter drainage and rapid pleurodesis achieves results similar to prolonged drainage prior to pleurodesis (level of evidence 1b to 3; recommendation grade B). 51.5. Pleurodesis/Sclerosis Pleurodesis: [pleuro + Greek desis, binding together (from dein, to bind).] Pleurodesis is generally considered standard treatment for recurrent MPE. Many agents have been used with variable success. Additional factors that impact on the success of pleurodesis include initial drainage time, chest drain diameter, management of the chest drain (suction, no suction), etc. Pleurodesis is performed to infl ame the visceral and parietal pleura, and to fuse the pleura together obliterating the potential pleural space. A sclerosing agent instilled within the ipsi- lateral thorax induces an infl ammatory reaction. With pleurodesis, the pleural fl uid cannot accu- mulate, or compress the functioning lung or (at the extreme) the mediastinum. 23 51.5.1. Sclerosing Agents Almost all sclerosing agents can produce fever, tachycardia, chest pain, and nausea. 24 As sclerosing agents may cause pain (talc, doxycycline, tetracycline, etc.), the patient should be premedicated with pain medication (usually narcotics) prior to instillation of the sclerosing agent. Talc is a common, inexpensive, and effective sclerosing agent. 25 With complete expansion of the lung and apposition of the visceral and parietal pleura, pleural symphysis can occur. Talc Talc is the agent of choice for pleurodesis (level of evidence 1a to 1b; recommendation grade A). Bedside instillations of talc slurry and thoracoscopic talc insuffl ation in the operating room have similar effectiveness (level of evidence 1b; recommendation grade A). 51.5.2. Talc Instillation Various techniques are used to instill talc within the pleural cavity. Three randomized, controlled trials have evaluated video-assisted thoracic surgery (VATS) with talc insuffl ation and bedside chest tube with installation of talc slurry, and the results suggested that either method was effective. 32–34 Talc slurry is commonly used following placement of a chest tube at the bedside. One 51. Management of Malignant Pleural Effusion: Sclerosis or Chronic Tube Drainage 417 study suggested fewer recurrences in patients with talc insuffl ation 33 following talc insuffl ation, but no such difference was noted in the other two studies in which bedside application of talc slurry appeared to be more effective. An additional benefi t of thoracoscopy is that tissue diagnosis, pleural biopsy, printable biopsy, breakdown of adhesions, etc., can be achieved. If a tissue diagnosis has been obtained, bedside drainage and instillation of talc slurry appears to be a clinically effective and cost-effective method of achieving pleurodesis. Although the bedside application of talc slurry can be easily done, the distribution of this talc slurry may not be completely uniform. Two randomized, controlled studies identifi ed that physical maneuvers of turning the patient for various periods of time in various positions (typically lateral decubitus, prone, opposite lateral decubitus, supine) do not enhance distribution of agents. 35,36 These two radiographic studies used a -labeled suspension and demonstrated no improvement in distribution or outcome with rotation (level of evidence 1b; recommendation grade A). tory failure was noted in 4% of patients undergoing bedside instillation of talc slurry compared to 8% in patients undergoing thoracoscopic talc insuffl ation. 32 Respiratory problems have been noted in a small fraction of patients in other studies. 39 51.5.4. Alternatives to Talc Tetracycline has been commonly used in the past in association with tube thoracostomy. 40 Instilla- tion of the tetracycline solution provides a faster pleurodesis and pleural symphysis than chest tube drainage alone; however, it may cause signifi cant pain. Doxycycline is an available alternative to tetracycline and is felt to have roughly equal effectiveness. 4,41,42 Bleomycin (60 units) has been shown useful and may be of equivalent effectiveness to tetracycline; however, it is expensive and can have systemic toxicity. 43,44 Talc was shown to be much cheaper than bleomycin in one study: $12 for talc compared to almost $1000 for bleomycin. 38 Talc was recommended as the fi rst choice in two small randomized studies evaluat- ing alternatives to talc including silver nitrate 45 and quinaquin. 30 51.6. Thoracoscopy and Sclerosis Thoracoscopy may also be considered as a means for obtaining pleural sclerosis in the management of MPE. After drainage and biopsy, the sclerosing agent is placed under direct visualization onto the pleural surface. Complications with this procedure include requirements for intubation and general anesthesia, and a small risk for bleeding and infection. A pneumothorax is uniformly present and requires a chest tube for a short time after the procedure. Proponents of this procedure believe the sclerosing agent can be more effi - ciently applied to the pleura. However, there are no studies showing one method to be superior to the other. Several agents can be used for pleurodesis, including talc, bleomycin, and doxycycline. 46,47 Surgical techniques, such as thoracoscopy, drainage, and talc poudrage, may not carry any Rotation of the patient’s body to enhance dis- persal of the sclerosing agent it not recommended (level of evidence 1b; recommendation grade B). 51.5.3. Talc Dose Talc administered as slurry through a chest tube or pleural catheter may be as effective as direct insuffl ation of talc via thoracoscopy. 37,38 Typi- cally, a slurry of 5 g in a solution of 50 to 100 mL saline (with or without lidocaine) is instilled. 39 Single institutional studies suggest that either 5 g or 2 g of talc can be used with similar results. There may be relationship between the size of talc particles or specifi c contaminants and complications of talc use. In addition, a higher incidence of respiratory failure in may be related to the use of 10 g of talc. Complications of talc sclerosis for MPE must be considered. In one study, respira- 418 J.B. Putnam, Jr. objective advantages over simple drainage and instillation of talc slurry. Mechanical abrasion of the parietal pleura using gauze, or other techniques (such as laser or argon beam coagula- tor) can be applied by thoracoscopic or open techniques. One single-institution study noted that mechanical pleurodesis (abrasion of the parietal pleura under thoracoscopic guidance) appeared to be more effective (less complications, shorter hospitalization) than talc pleurodesis. 48 Pleurectomy carries excessive risk of mortality and cannot be generally recommended. Unintended benefi ts of a thoracoscopic approach include inspection of the pleura, lysis/division of adhesions, and obliteration of loculations. Directed or random pleural biopsy should also be considered. Thoracoscopy has high accuracy in diagnosis of pleural disease, greater than 90%. 49 In patients in whom a diagnosis must be obtained for treatment considerations, drainage, multiple pleural biopsies, and treatment may all be performed under a single anesthetic. Surgical exploration or thoracoscopy in most patients carries risk of anesthesia and thoracic manipula- tion. Thoracoscopy or open exploration is war- ranted only in highly selected patients. The value of this technique to the end-stage patient may be very limited and more simple strategies may be considered. 51.7. Tube Drainage and Sclerosis Versus Thoracoscopy and Sclerosis A recent prospective, randomized trial was performed by cancer and leukemia group B (CALGB) to evaluate the effi cacy, safety, and instillation technique for talc for pleurodesis for treatment of MPE. 32 The trial evaluated 501 patients who were randomized to thoracoscopy with talc insuffl a- tion talc poudrage (TTI, n = 242) or thoracostomy and talc slurry (TS, n = 240). The primary end point was 30-day freedom from radiographic MPE recurrence among surviving patients whose lungs initially re-expanded more than 90%. Mor- bidity, mortality, and quality of life were also assessed. Patient demographics and primary malignan- cies were similar between study arms. A signifi - cant portion of patients died within 30 days (13% TS; 9.4% TTI). In evaluable patients who survived at least 30 days, the freedom from recurrence was 70% (TS) and 79% (TTI), somewhat lower than the expected 90% to 100% effectiveness antici- pated. Overall, there was no difference between patients with successful 30-day outcomes based upon the instillation technique (TTI, 78%; TS, 71%). Subgroup analysis suggested that patients with primary lung or breast cancer had better success with TTI than with TS (82% vs. 67%). Treatment-related mortality occurred in nine TTI patients and seven TS patients. Common morbidity included fever, dyspnea, and pain. Respiratory complications were more common following TTI than TS (14% vs. 6%) including respiratory failure (TS = 4%; TTI = 8%), and toxic deaths (TS = 5; TTI = 6). The authors suggested that the etiology and incidence of respiratory complications from talc need further exploration. Based on this single study, outcomes of chest tube placement and sclerosis and thoracoscopy with talc insuffl ation for management of MPE are similar (level of evidence 1b; recommendation grade B). There may be an advantage to performing a thoracoscopy approach in patients with MPE related to lung cancer or breast cancer. Outcomes of chest tube placement and sclerosis and thoracoscopy with talc insuffl ation for management of MPE are similar (level of evidence 1b; recommendation grade B). There may be an advantage to performing a thoracoscopy approach in patients with MPE related to lung cancer or breast cancer. 51.8. Chronic Indwelling Pleural Catheter The Pleurx® catheter (Denver Biomedical Inc.) is a chronic indwelling Silastic catheter com- municating within the pleural space. The patient or caregiver connects the catheter to a dispos- 51. Management of Malignant Pleural Effusion: Sclerosis or Chronic Tube Drainage 419 able vacuum bottle every other day to drain the pleural fl uid, provide relief of dyspnea, and potentially achieve spontaneous pleurodesis. 5,50 The technique of insertion of a chronic indwelling pleural catheter has been described elsewhere. 5,9 Between 1994 and 1999, a prospective, multi- center, randomized clinical trial was conducted to compare the effectiveness and safety of an indwelling pleural catheter with the effectiveness and safety of a chest tube and doxycycline sclerosis for treatment of cancer patients with symptomatic recurrent MPE. 5 The anti- cipated benefi ts of catheter-based treatment were outpatient management, improved quality of life, reduced medical costs, and improved function. A total of 144 patients were randomly assigned to either an indwelling pleural catheter or a chest tube and doxycycline sclerosis (talc was not available at all centers at the time of the study.) Chest tubes were placed in a standard fashion. A modifi ed Borg scale, the dyspnea component of the Guyatt chronic respiratory questionnaire, and Karnofsky performance status score were assessed and used for making comparisons between groups. Outcomes measured included control of pleural effusion, length of hospitalization, morbidity, and survival. There was no difference between the two groups in initial (pretreatment) performance status or initial dyspnea scores. Median survival was 90 days in both the chest tube and pleural catheter groups. Patients with lung or breast cancer had a 90-day survival rate of approxi- mately 70%; patients with other cancer types (as a group) had a 90-day survival rate of less than 40%. After treatment, both the chest tube and pleural catheter groups showed similar signifi - cant improvements in the Guyatt chronic respiratory questionnaire scores and had similar morbidity rates. There were no treatment-related deaths. Initial treatment success rates (pleurodesis achieved in the chest tube group; drainage of effusion and relief of dyspnea in the pleural catheter group) were 64% in the patients treated with a chest tube and sclerosis, compared to 92% of those treated with a chronic indwelling catheter. Seventy percent of patients treated with a pleural catheter experienced spontaneous pleurodesis. Seventy-one percent of patients with a chest tube had pleurodesis, although 28% of these patients developed a recurrence of their pleural effusion after treatment. The hospitalization was shorter in the pleural catheter patients: 1 day versus 6.5 days. An overnight hospitalization stay was standard protocol treatment for the patients receiving a pleural catheter. On the basis of initial treatment outcomes, both chest tube and sclerosis and chronic pleural drainage have similar success rates (level of evidence 1b; recommendation grade B). Whether there is a signifi cantly higher rate of recurrent pleural effusion long term after using the chest tube/sclerosis technique remains to be seen. On the basis of the successful multi-institutional experience with indwelling pleural catheters, an analysis of the results of outpatient management of patients with MPE and an indwelling pleural catheter was conducted. 51 Hospitalization and early charges between patients treated with pleural catheters were compared to those treated with chest tube drainage and sclerosis. One hundred consecutive patients treated with the pleural catheter (40 inpatients, 60 outpatients) and 68 consecutive patients treated with chest tube drainage and sclerosis (all inpatients) were analyzed. Outcomes evaluated were control of pleural effusion, length of hospitalization, morbidity, and survival. There were no pretreatment or post-treatment differences in physical performance status or symptoms between the two groups. Mean hospitalization time was 8 days for inpatients whether they were treated with a chest tube or a pleural catheter. Overall survival was 50% at 90 days. Survival did not differ by treatment among the groups. In patients treated with pleural catheters, there were no catheter-related deaths, no emergency operations, and no major bleeding. Eighty- one percent of patients treated with pleural catheters experienced no side effects. The eco- nomic impact of pleural catheters was signifi cant. For patients treated in hospital, mean charges ranged from $7000 to $11,000. Patients treated as outpatients (60 pleural catheter patients) had mean charges of $3400. Outpatient pleural catheter drainage was safe, cost effi cient, and successful, and was associated with minimal morbidity. 420 J.B. Putnam, Jr. 51.9. Special Circumstances: Trapped Lung Patients with a trapped lung represent another diffi cult clinical challenge. 52 After drainage of a pleural effusion, the underlying lung may remain collapsed from adhesions or pleural carcinomatosis. To the inexperienced physician, this may mimic a pneumothorax. A chest tube may be placed, but the trapped lung will not expand. Long-term use of the chest tube in an attempt to re-expand the lung may increase the risk of pleural empyema. Standard techniques of thoracotomy and decortication may be considered to remove the pleural peel. Decortication is usually performed in patients with benign diseases in whom the pleural peel restricts ventila- tion with progressive and refractory dyspnea. Expansion of the normal underlying lung can improve symptoms of dyspnea. However, this intervention is sometimes drastic and may be contraindicated in patients with extensive malignancy. The Pleurx® catheter and the pleuro-peritoneal shunt (Denver Biomedical, Inc.) have been used in selected patients with a trapped lung. The pleuro-peritoneal shunt has two fenestrated limbs that are placed into the pleural cavity and into the peritoneum, respectively. A one-way valve within a subcutaneous or external pumping chamber allows the patient or caregiver to pump and drain the fl uid (from the pleural cavity to the peritoneal cavity) on a daily basis. The Pleurx® catheter may be used to drain fl uid from a trapped lung if symptoms of dyspnea occur. Use of the catheter allows the patient and/ or his or her caregiver to relieve the dyspnea while draining the pleural fl uid at home. In this manner the patient and caregiver can intervene directly against symptoms of dyspnea that the patient experiences as a result of the recurring pleural effusion. Drainage is typically performed every other day. Patients tolerate this well and are able to maintain an independent and functional life outside hospital. 51.10. Conclusions The management of recurrent MPE requires selection among treatment options based on a careful assessment of the benefi ts of the therapy and the associated risks. Patients with MPE have limited life expectancy. Therefore, efforts to palliate or eliminate dyspnea help to optimize function, eliminate hospitalization, and reduce excessive end-of-life medical care costs, and may be achieved w ith both pleurodesis and an indwelling pleural catheter. Pleurodesis is an effective means of treating patients with MPE. The approach consisting of tube thoracostomy, drainage, and sclerosis with talc slurry is more cost effective than thoracoscopy with drainage and talc poudrage. Completeness of drainage appears to be advantageous for patients with MPE. Most patients currently have a large chest tube placed rather than a small-bore 12F to16F pigtail catheter, although the small-bore catheter appears to be equally effective and more com- fortable. Further prospective studies are necessary to clarify this potential advantage for the small-bore catheters. Careful decisions by the cli- nician in coordination with the patient and his/ her family are necessary to select the optimal therapy for the patient (Figure 51.1). Various effective solutions exist that can be individually tailored to the patient with malignant pleural effusion. Chest tube/sclerosis and chronic pleural drainage have similar success rates (level of evidence 1b; recommendation grade B). Outpatient management of MPE can be considered a standard of care for patients undergoing chronic pleural drainage (level of evidence 3; recommendation grade C). No hospitalization was required for patients initially evaluated as outpatients. Outpatient management of MPE can be considered a standard of care (level of evidence 3; recommendation grade C). 51. Management of Malignant Pleural Effusion: Sclerosis or Chronic Tube Drainage 421 References 1. Light RW. Management of pleural effusions. J For- mosan Med Assoc 2000;99:523–531. 2. Light RW. Useful tests on the pleural fl uid in the management of patients with pleural effusions [editorial]. Curr Opin Pulm Med 1999;5:245–249. 3. Sanchez-Armengol A, Rodriguez-Panadero F. Survival and talc pleurodesis in metastatic pleural carcinoma, revisited. Report of 125 cases. Chest 1993;104:1482–1485. 4. Patz EF, Jr. Malignant pleural effusions: recent advances and ambulatory sclerotherapy. Chest 1998;113(suppl 1):74S–77S. 5. Putnam JB Jr, Light RW, Rodriguez RM, et al. A randomized comparison of indwelling pleural catheter and doxycycline pleurodesis in the management of malignant pleural effusions. Cancer 1999;86:1992–1999. 6. American Thoracic Society. Management of malignant pleural effusions. Am J Respir Crit Care Med 2000;162:1987–2001. A patient with cancer and dyspnea. A CXR demonstrates a pleural effusion Is this a malignant pleural effusion? Was dyspnea relieved? No No No Ye s Ye s Ye s Evaluate CXR or CT Chest Did lung completely expand? Follow patient until pleural effusion-related dyspnea recurrs Chest drainage tube and talc slurry Thoracoscopy and talc poudrage Pleurx catheter (chronic indwelling pleural catheter) Repeat thoracentesis Therapeutic options Repeat thoracentesis as needed or Pleurx catheter Consider other causes of dyspnea or loculated effusion Consider other causes of effusion Perform diagnostic and therapeutic thoracentesis (to dryness, cough, and/or pleuritic pain) FIGURE 51.1. Clinical algorithm for management of malignant pleural effusion. 422 J.B. Putnam, Jr. 7. Antunes G, Neville E, Duffy J, Ali N, and the Pleural Diseases Group SoCCBTS. BTS guidelines for the management of malignant pleural effusions. 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Prevost A, Nazeyrollas P, Milosevic D, Fernan dez- Valoni A. Malignant pleural effusions treated with high dose intrapleural doxycycline: clinical effi cacy and tolerance. Oncol Rep 1998;5:363– 366. 42. Herrington JD, Gora-Harper ML, Salley RK. Chemical pleurodesis with doxycycline 1 g. Phar- macotherapy 1996;16:280–285. 43. Ong KC, Indumathi V, Raghuram J, Ong YY. A comparative study of pleurodesis using talc slurry and bleomycin in the management of malignant pleural effusions. Respirology 2000;5:99–103. 44. Noppen M, Degreve J, Mignolet M, Vincken W. A prospective, randomised study comparing the effi cacy of talc slurry and bleomycin in the treatment of malignant pleural effusions. Acta Clinica Belgica 1997;52:258–262. 45. Paschoalini MS, Vargas FS, Marchi E, et al. Pro- spective randomized trial of silver nitrate vs talc slurry in pleurodesis for symptomatic malignant pleural effusions. Chest 2005;128:684–689. 46. de Campos JR, Vargas FS, de Campos WE, et al. 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Outpa- tient management of malignant pleural effusion by a chronic indwelling pleural catheter. Ann Thorac Surg 2000;69:369–375. 52. Pien GW, Gant MJ, Washam CL, Sterman DH. Use of an implantable pleural catheter for trapped lung syndrome in patients with malignant pleural effusion. Chest 2001;119:1641–1646. 424 52 Initial Spontaneous Pneumothorax: Role of Thoracoscopic Therapy Faiz Y. Bhora and Joseph B. Shrager is diffi cult to accurately assess the size of a pneumothorax from a two-dimensional chest radiograph, the volume of a pneumothorax approximates the ratio of the cube of the lung diameter to the hemithorax diameter, and as a result the size is often underestimated. For example, a 1-cm pneumothorax on the posterior- anterior (PA) chest radiograph occupies about 27% of the hemithorax volume if the lung diameter is 9 cm and the hemithorax is 10 cm [(10 3 − 9 3 )/10 3 = 27%]. By the same principle, a 2-cm radiographic pneumothorax occupies 49% of the hemithorax. The British Thoracic Society (BTS) recommends intervention for any PSP greater than 2 cm regardless of symptoms, quantifying these as large pneumothoraces. 4 If more precise size estimates are required, computed tomogra- phy (CT) scanning is the most accurate approach. 5 However, CT scan is only required initially in cases where it is diffi cult to differentiate a pneumothorax from suspected bullae in cases of complex cystic lung disease. 6 Hence, at least one guideline recommends observation alone for small (<2 cm) minimally symptomatic PSP 7–9 and this is one reasonable approach. The mean rate of resolution/reabsorp- tion of pneumothoraces without an ongoing air leak is 1.8% per day and full re-expansion of a 15% pneumothorax occurs in 8 to 12 days. 9 Patients with these small PSPs do not require hospital admission, but all would agree that they should be observed in the emergency room for 4 to 6 h with a repeat chest radiograph showing no enlargement of the pneumothorax. They can then be discharged with clear advice to return in the The management of spontaneous pneumothorax (SP) is complicated by the many clinical settings in which it occurs and the lack of accepted guidelines for management. Primary spontaneous pneumothorax (PSP) occurs in persons without obvious underlying lung disease with a reported incidence of 7.4 to 18/100,000 per year for men and 1.2 to 6/100,000 per year for women. 1 Secondary spontaneous pneumothorax (SSP) complicates an underlying lung disease, most often chronic obstructive pulmonary disease (COPD), with a reported incidence similar to that of PSP. Because of the additional presence of the patient’s underlying lung disease, SSP is considered a potentially life-threatening event, while PSP is rarely life threatening. 2,3 In this chapter, we will focus on the possible role of video-assisted thoracic surgery (VATS) as fi rst-line therapy for patients presenting with their fi rst episode of PSP, in contrast to the traditional approach of initial nonoperative management with surgical therapy reserved only for recurrent PSP. We will also briefl y discuss the limited role of VATS as initial therapy for patients presenting with their fi rst episode of SSP. 52.1. Initial Decision: Observation Versus Intervention The initial questions to be answered when faced with a patient with SP are: When is simple observation suffi cient, and, on the other hand, when is intervention necessary? Size of pneumothorax is one criteria by which to choose between observa- tions and intervention strategies. Although it 52. Initial Spontaneous Pneumothorax: Role of Thoracoscopic Therapy 425 event of worsening breathlessness, and they should be seen in the outpatient clinic 1 to 2 weeks later to assure continued resolution. Obser- vation alone is inappropriate in more than minimally symptomatic patients regardless of the size of the pneumothorax on a chest radiograph. Unlike PSP, all patients with SSP require either inpatient observation or intervention. For SSP less than 1 cm with minimal symptoms, inpatient observation with serial fi lms is recommended by the BTS. All other cases should receive active intervention, most often in the form of intercostal tube drainage. It is our advice, on the basis of the lung volume reduction surgery experience, that no suction should be placed upon the chest tubes of patients with SSP unless the lung fails to expand initially, after which time the minimal amount of suction allowing near-complete re- expansion should be applied. 52.2. Which Intervention? 52.2.1. Simple Aspiration Versus Tube Thoracostomy Once it has been determined that intervention is needed for PSP, there are three main options: simple aspiration; intercostal tube drainage with or without chemical pleurodesis; and surgical strategies. Both the BTS and an American College of Chest Physicians Delphi Consensus Statement 10 recommend simple aspiration as fi rst-line treatment for all PSP and most SSP needing intervention. This recommendation is based on the fact that successful initial re-expansion of the lung occurs in 59% to 83% of cases of PSP and 33% to 67% in SSP 11–13 and the fact that intercostal drainage with a tube can always be performed as second-line treatment should simple aspiration fail. Successful aspiration in these series depended on age (under 50 years, 70%–81% success; over 50 years, 19%–31% success); the presence of chronic lung disease (27%–67% success); and the size of the pneumothorax (<3 L aspirated, 89% success; >3 L aspirated, no success; >50% pneumothorax on chest fi lm, 62% success; <50% pneumothorax on chest fi lm, 77% success). Several prospective, randomized trials have shown no difference in initial success rates of lung re-expansion (59% vs. 63%) or recurrence of pneumothorax at 3 months (20% vs. 28%) between simple aspiration and chest tube thoracostomy 13,14 Touted advantages of needle or small-catheter– based simple aspiration are a reduction in total pain scores during hospitalization and shorter hospital stays in some series. 15 Although there may be some advantages of simple aspiration stemming from less invasiveness and perhaps lower cost compared to tube thoracostomy, small- bore chest tubes can be placed with minimal morbidity and provide greater versatility in cases of initial nonexpansion of the lung in the form of application of suction and if needed, pleurodesis. It is certainly reasonable, and in our opinion optimal, therefore, to move directly to small-bore chest tube placement in most patients with SP who fall into the intervention subset, especially those with larger pneumothoraces, the elderly, and those with underlying lung disease (SSP). It is our opinion that most SSP larger than 1 cm and all SSP larger than 2 cm should be treated by intercostal tube drainage. If simple aspiration is performed in patients with SSP, prompt progres- sion to intercostal tube drainage should be performed at the fi rst sign of incomplete drainage. Although some have even recommended that consideration be given to a second attempt at aspiration for SP, 11 this would seem unwise to us after an unsuccessful fi rst attempt under any circumstances. There is no published evidence to suggest that larger tubes (20F–24F) are any better than small tubes (10F–14F), 16 although the authors’ personal experience favors using at least a 20F tube in these circumstances, as this size tube is far less likely to become kinked or clogged with blood or tissue, thereby causing ineffective evacuation of the pleural space. Furthermore, if one opts to perform talc pleurodesis through the tube (as may be done for some cases of SSP), this can be diffi cult to perform through a very small tube. Whether or not to place suction upon an intercostal tube after tube insertion is controversial. We believe that for PSP, a brief period (1–2 h) of –20 cm suction should be applied after tube insertion to promote initial re-expansion, but that the tube should subsequently be placed to water seal regardless of the presence of air leak. For SSP, where underlying bullous disease may be [...]... patients involving fibrinolytics in adults Reference Level of evidence Design Bergh ( 197 7)30 4 Henke ( 199 2)31 4 Taylor ( 199 4)32 4 Laisaar ( 199 6)33 4 Roupie ( 199 6)34 4 Moulton ( 198 9)35 4 Park ( 199 6)36 4 Bouros ( 199 4)37 4 Jerjes-Sanches ( 199 6)38 4 Bouros ( 199 6) 39 4 Lim ( 199 9)21 3b Chin ( 199 7) 29 2b Case control Davies ( 199 7)28 2b Wait ( 199 7)20 1b Randomized, controlled trial Randomized series Bouros ( 199 9)26... infrequently result in torn visceral pleura, leading to a greater TABLE 52.1 Level of evidence of studies reporting results of VATS procedure in first-episode PSP Study Schramel, 199 6 Kim, 199 8 Hatz, 2000 Torresini, 2000 Margolis, 2003 Sawada, 2005 Reference Study period Level of evidence 27 28 33 36 34 35 198 5– 199 4 199 5– 199 7 199 1– 199 7 199 6– 199 9 199 2–2001 198 9–2001 2+ 3 3 2+ 3 2+ 430 F.Y Bhora and J.B Shrager... imaging in predicting resectability AJR Am J Roentgenol 199 2;1 59: 961 96 6 10 Gerbaudo VH, Sugarbaker DJ, Britz-Cunningham S, et al Assessment of malignant pleural mesothe- 16 17 18 19 20 21 22 23 24 4 49 lioma with (18)F-FDG dual-head gamma-camera coincidence imaging: comparison with histopathology J Nucl Med 2002;43:1144–11 49 Benard F, Sterman D, Smith RJ, et al Pro-gnostic value of FDG PET imaging in. .. of C-C (monocyte chemotactic peptide) and C-X-C (interleukin 8) chemokines Am J Respir Cell Mol Biol 199 5;12: 581–588 8 Philip-Joet F, Alessi MC, Philip-Joet C, et al Fibrinolytic and in ammatory processes in pleural effusions Eur Respir J 199 5;8:1352–1356 9 Idell S, Girard W, Koenig KB, et al Abnormalities of pathways of fibrin turnover in the human pleural space Am Rev Respir Dis 199 1;144: 187– 194 ... Porter J, Banning AP Intrapleural streptokinase Thorax 199 8;53:720 45 Temes RT, Follis F, Kessler RM, et al Intrapleural fibrinolytics in management of empyema thoracis Chest 199 6;110:102–106 46 Frye MD, Jarratt M, Sahn SA Acute hypoxemic respiratory failure following intrapleural thrombolytic therapy for hemothorax Chest 199 4;105: 1 595 –1 596 47 Idell S, Mazar A, Cines D, et al Single-chain urokinase alone... plasminogen, it activates plasminogen that can cleave fibrin strands, causing loculations instead of being utilized on free-floating fibrinogen Second, binding to plasminogen on fibrin strands may shield it from plasminogen activator inhibition and prolong its effects.47,48 Further study is needed to clarify the apparent advantage of single-chain urokinase compared to streptokinase and other urokinase... comparing 112 patients in group I (conservative therapy, 198 5– 198 9) to 97 patients in group II (VATS, 199 1– 199 4) In group II, 70 /97 patients were cases of first-time SP The groups were fairly well matched For group I, tube thoracostomy was only performed if the pneumothorax was over 15% or progressed during observation Of the 112 patients in group I, 97 underwent tube thoracostomy Follow-up was obtained in. .. Cochrane Database Syst Rev 2002:CD00 195 6 25 Ashbaugh DG Empyema thoracis Factors in uencing morbidity and mortality Chest 199 1 ;99 :1162– 1165 26 Bouros D, Schiza S, Tzanakis N, et al Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema A randomized, double-blind study Am J Respir Crit Care Med 199 9;1 59: 37–42 27 Weinstein M, Restrepo R, Chait PG, et... empyema in children References 1 Bernstein JM Treatment of community-acquired pneumonia – IDSA guidelines Infectious Diseases Society of America Chest 199 9;115:9S–13S 53 Intrapleural Fibrinolytics 2 Strange C, Sahn SA The defi nitions and epidemiology of pleural space infection Semin Respir Infect 199 9;14:3–8 3 Maskell NA, Davies CW, Nunn AJ, et al U.K controlled trial of intrapleural streptokinase for... to its receptor in tetracycline-induced pleuritis in rabbits Am J Respir Crit Care Med 2002;166 :92 0 92 6 48 Antony VB Fibrinolysis in the pleural space: breaking the bonds that bind Am J Respir Crit Care Med 2002;166 :90 9 91 0 49 Ray TL, Berkenbosch JW, Russo P, et al Tissue plasminogen activator as an adjuvant therapy for pleural empyema in pediatric patients J Intensive Care Med 2004; 19: 44–50 50 Walker . reporting results of VATS procedure in first-episode PSP. Study Reference Study period Level of evidence Schramel, 199 6 27 198 5– 199 4 2+ Kim, 199 8 28 199 5– 199 7 3 Hatz, 2000 33 199 1– 199 7 3 Torresini,. patients, comparing 112 patients in group I (conservative therapy, 198 5– 198 9) to 97 patients in group II (VATS, 199 1– 199 4). In group II, 70 /97 patients were cases of fi rst-time SP. The groups. Wilkins and Wilkins; 199 5:242–277. 24. Massard G, Thomas P, Wihlm JM. Minimally invasive management for fi rst and recurrent pneumothorax. Ann Thorac Surg 199 8;66: 592 – 599 . 25. Freixinet

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