Tuesday, November 10, 1998 Pleural Disease, continued OPEN TUBE THORACOSCOPY IN THE TREATMENT OF COMPLICATED PLEURAL EMPYEMA Rui Haddad*; T D Ferreira. M C Reis. F D Teixeira. C H Boasquevisque. Department of Surgery, Faculdade de Medicina - Universidade Federal Rio de Janeiro, Rio de Janeiro, RJ, BRASIL and General Thoracic Surgery, Hospital Universitario Clementino Fraga Filho - UFRJ, Rio de Janeiro, RJ, BRASIL. Purpose: The proper timing and the selection of appropriate treatment are the most valuable prognostic factors in the management of pleural empyema. In this study patients (pts) \vith complicated pleural empyema were prospectively evaluated to determine the effectiveness of open tube thoracoscopy as their definite treatment. Methods: 100 consecutive pts in exudative (phase I) and fibrinous (phase II) phases of pleural empyema were selected from Jan 1991 to Dec 1997, based in the failure of the initial treatment \vith antibiotics and tube thoracostomy (70%) and/or the presence of multiple loculations, as seen in CT-scan, even without previous drainage (30% of the cases). These pts undenvent thoracoscopic debridement of the empyema, under general anesthesia, \vith double lumen endotracheal tube. A 3cm costectomy was done to facilitate the instrumentation. Thoracoscopic debridement of the empyema \vith the use of conventional 17em mediastinoscope (open tube) was done in every case. Pts ranged from 14 to 82 years, 66% were male, and the most common ethiologic factors included post-pneumonic empyema in 74% and iatrogenic in 18% of the cases. Results: Most pts were in ctitical conditions related to the association of acute primary pulmonary disease in 74 ,heart diseases in 11, diabetes in 9 and major trauma in 6 cases. The most common organisms involved were Staphilococcus aureus in 50% of the positive cultures, Streptococcus sp. in 21% and intestinal gram negative in 18%. Open tube thoracoscopy was done in these pts and the results were considered excelent (70%) and good (17%), with resolution of 87% of the cases. Five pts needed decortication and in 3 an Eloesser procedure was necessary. One death related to the method (PO bleeding) occurred in a pt \vith severe sepsis after multiple pulmonary thrombo-embolic episodes and use of anticoagulants. Four other pts died of underlying diseases or sepsis not-related to the empyema. 52% of the survivors were discharged \vith tube thoracostomy \vich was \vithdrawn after 2-3 weeks. The remaining pts were discharged \vithout chest tube. Conclusions: Open-tube thoracoscopy is an effective method for treatment of complicated pleural empyema, phases I and II, \vith resolution of 87% of the cases. Clinical Implications: VATS is an important addition to the modern thoracic surgery, but unfortunately it is not always avaiable in every thoracic senice. So the use of VATS, although seems to be effective in almost all the cases of complicated pleural empyema, its only really necessary in selected patients.
SEVERE OVARIAN HYPERSTIMULATION SYNDROME AS A CAUSE OF PLEURAL EFFUSIONS Zoran Arsovski*; S Popovska. T Stefanovski. B Kaeva. G Balaban. D Dokic. M Gavrilovski. A Arsovska. Clinic of Pulmonology and Allergy, Medical Faculty Skopje, Skopje, Macedonia; Clinic of Gynecology, Medical Faculty Skopje, Skopje, Macedonia and Clinic of Neurology, Medical Faculty Skopje, Skopje, Macedonia. Purpose: To consider the pleural effusions developed as a consequence of severe ovarian hyperstimulation syndrome (OHSS). Methods: Ultrasound examination of the pleura, biochemical analyses of the pleural effusions, blood and mine control measurements, thoracocentesis and ascites evacuation. Results: During 5 years period we have followed 310 patients who were stimulated with human menopausal gonadotrophin - HMG. In only four women (1,29%) treated for infertility, aged 27-33 years, severe OHSS occurred. Main symptoms were dyspnoea, cough, weight gain, abdominal heaviness. All of them were pregnant, one had t\vins. The symptoms occurred after 10-16 days from administration of HMG. Three of them were \vith clinically apparent ascites and with bilateral pleural effusion (gr. IV) and one was in life-threatening situation (ascites, pleural effusions, changes in blood volume, protein disbalance, haemoconcentration-gr. V). Aldough supportive treatment was initially used (resting in bed, discontinuation of hormonal treatment, correction of the blood volume, correction of protein and electrolytes disbalance) toracocentesis was performed in all cases and acsites evacuation only in life-threatening patient. Two of them experienced one toracocentesis (x 3 liters), one experienced two
toracocentesis (2x2 liters) and one experienced three thoracocentesis ( lO liters) and ten acites evacuations (30 liters), respectively. In all cases pleural fluid was exudative, and paracentesis was followed \vith administration of human albumin solution. Pulmonary function test improved markedly in the three patients, right after toracocentesis. Hospitalization lasted between 25-38 days. Three of them ( gr.IV) delivered healthy children but one, \vith life-threatening situation, had a miscarriage. Conclusions: Although rarely found, severe OHSS have to be considered as a possible cause of a exudative pleural effusions in young women. Clinical Implications: Pleural effusions, due to an excessive use of HMG is a rare situation but difficult to predict and requires proper coordination between pulmologist and gynecologist.
THE UTILITY OF SOLUBLE L-SELECTIN MEASUREMENTS IN THE DIAGNOSTIC EVALUATION OF PLEURAL EFFUSIONS Roger A Gallup, MAJ, MC*; M J Morris, MAJ, MC. M B Bradley, CPT, MC. G Merrill, PhD. Pulmonary/Critical Care, Brooke Army Medical Center, Ft. Sam Houston, TX, USA. Purpose: The analysis of pleural fluid is instrumental in the diagnostic evaluation of pleural effusions. Several parameters have been evaluated and diagnostic algorithms devised. Soluble L-selectin (sL-selectin) is a component in the regulation of leukocyte migration. As such, monitoring of these levels may improve our diagnostic abilities. This data \vill help to characterize sL-selectin in pleural fTuid and to determine if the measurement of levels is of benefit in the separation of transudates and exudates. Methods: All patients undergoing diagnostic thoracentesis were eligible for study entry. Samples of pleural fluid and serum were obtained at the time of diagnostic thoracentesis. All labs, except sL-selectin assays, were done in the main hospital laboratory. The latter samples were processed separately and simultaneously run, via a quantitative sand\vich enzyme immunoassay technique (R&D Systems, Minneapolis, MN, USA). Values were then statistically analyzed to learn if any significant differences existed between groups, i.e., transudates[mdit] vs. exudates. Results: Mean sL-selectin values :t standard deviation (nglml) Conclusions: This data displays a significant difference in the pleural fluid sL-selectin values when comparing translates to exudates, both by clinical and Light's criteria. Also, no difference between serum values for any group were found. Clinical Implications: Measurement of sL-selectin values may facilitate the classification of pleural effusions. (n = 40)
Clinical - Pleural Clinical - Serum Light's - Pleural Light's - Serum
269.2+/-114.6 811.7+/-10.9 258.9+/-96.3 789.7+/-309.8
409.1 +/-156.8* 736.8+/-35.9 396.4+/-171.0* 793.0+/-358.4
Pneumonia SHOULD BLOOD CULTURES BE DONE ROUTINELY IN PATIENTS ADMITTED WITH PNEUMONIA? Vijo Poulose, MD*; M Gudi, MD, FCCP. N Anandarao, MD, FCCP. Dept. of Medicine, New York Methodist Hospital, Brooklyn, NY, USA. Purpose: The American Thoracic Society's 1993 guidelines for the management of community-acquired pneumonias (CAP) include obtaining blood cultures before antibiotics are started. Several studies have questioned the usefulness of such blood cultures. Also, there have been no similar studies on patients from nursing homes. Methods: We did a chart review of 208 patients who were admitted to the medicine service \vith a diagnosis of pneumonia during the 6 month period from March to August 1997. These charts were studied to see how many fit our study criteria which were 1) at least one clinical criteria which included fever, shortness of breath, pleuritic chest pain, cough, localized rales or bronchial breath sounds 2) new, focal infiltrate on the chest X' ray 3) at least one set of blood cultures drawn \vi thin 24 hours of admission. CHEST I 114/4 I OCTOBER, 1998 SUPPLEMENT
Tuesday, November 10, 1998 Pneumoni~conanued Sixty eight patients with CAP and 32 patien ts with nursing-home acquired pneumonia (NHAP) were identified in this manne r. Results: In the CAP group, 5 of the 68 patients (7.3%) had positive cultures ( o ne Strep. pneumoniae, one Staph. aureus and the other three were considered to be contaminants). The physician's choice of antibiotics was made prior to knowing the resu lts of the cultures and in all except one case, remained unchanged. In this particular case, the patient's antibiotic was changed from Cefuroxime to Vancomycin when th e initial culture report revealed Staphylococcal species. However, the final report confirmed it to be Staph. epidermidis and r epeat cultures drawn before Vancomycin was started were negative. In the NHAP group, 3 of the 32 patients (9.3 %) had positive cultures. Two grew Staph. epidermidis and the third grew Propionobacterium species, all of which were considered to be false positives. In all the 32 cases, the choice of antibiotics re mained unchanged. Conclusions: These results confirm that routine blood cultures are not useful in patients with CAP, and at least in one patient led to an inappropriate change of antibiotic. This study also suggests a similar conclusion for nursing home-acquired pneumonias. Clinical Implications: The American Thoracic Society needs to review its guidelines for the management of CAP. Larger studies need t o be done in the case of nursing hom e-acquired pneumonias before any definite conclusions can be drawn.
INCIDENCE OF PNEUMONIA IN PATIENTS AFTER STROKE Anita A Arsovska, MD*; A Popovski , PhD. Z S Arsovski , MD. Clinic of Neurology, Medical Faculty, Skopje, Macedonia and Clinic of Pulmology, Medical Faculty, Skopje, Macedonia. Purpose: To evaluate the frequency of pneumonia in patients after cerebro-vascular insult (CVI) . Methods: Retrospective analysis of 400 patients (211 male, 189 female) with stroke, confirmed with computer tomography (CT), average age 63, who developed pneumonia. Results: The incidence of pneumonia was analysed in 2 diferent groups of patients, who were clasified according to CT findings after stroke. First group -352 patients (88%), with involvement of a. carotis intema system. The second group - 48 patients (12%), \\~th involvement of a. vertebrobasilaris system. Criteria for diagnosis of pneumonia were: new pneumonic infiltration seen on a chest roentgenogram , physical chest findings, and one or more of the following simptoms: temperature higher then 37,5 (C, dyspnea, cough. Pneumonia was found in 45 patie nts (12,78%) in the first group, 22 patie nts (45,83%) in the second group. Aspiration pneumonia was mainly cause of pneumonia, 82%, and were developed due to post CVI swallo\\~ng disorders. 18 o/o of patients developed nosocomial pneumonia. Conclusions: Patients \vith stroke when a system of a. vertebrobasilaris is affected should be subjected t o develope pneumonia (statisticaly s ignificant difference p
microbiologic data (sputum I tracheal aspirate culture and sensitivity) including cross check of cultures \\~th clinical therapy evaluation to docum ent therapy of specifi c bacte1ia. Results: Trauma patients had a signiJlcan tly greater number of positive cultures than the community acquired pneumonia group or the MIC U patients \~th pneumonia. Pseudomonas, Staphylococcus, Streptococcus as well as miscellaneous gram negative were predominant in trauma patients. Mixed I oral flora were predominant in the community acquired pneumonia and MICU pneumonia patients. There was a notable paucity of Pseudomonas infections in the MI CU patients. Conclusions: Trauma patient have significantly g reater numbers of bacte ria identified from the tracheal aspirate I sputum culture as compared to MICU or community acquired pneumonia patients. The bacterial species seen in the trauma patient tend to be the bacteria that develop resistance (Pseudomonas , Staphylococcus, Streptococcus). Careful consideration needs to be given to obtain more specific cultures in trauma patients. Clinical Implications: Hospitalized patients 'vith bacterial pneumonia may have vastly diversified bacterial species. Therefore close assessment of patient population may yield better empiric therapy.
COMMUNITY-ACQUIRED PNEUMONIA (CAP): PROSPECTIVE EVALUATION OF ETIOLOGY, CLINICAL PRESENTATION. OUTCOME AND USE OF A GUIDELINE IN A TEACHING HOSPITAL A Famiglietti. R Absi. N Tiraboschi. R J L Carlos M. Luna*; M B asala. Gene. C Vay. G Griemberg. A Capdevila. A Videla. F N ogueira. B Schedro~tzky. C Casalnuovo. Hospital de Clinicas, Universidad de Buenos Aires, Argentina. Purpose: To evaluate etiology, clinical presentation, hospitalization decision, and outcome of CAP in relation with recommendations from a guideline. Methods: During 7 months, 260 patients full-filling the Fang crite ria for CAP, were evaluated. Thirty-eight were furth er excluded. Our University Hospital cares predomiri"antly old people. The guideline stratifies patients in 3 groups, and brings recommendations for hospitalization , admission into the ICU and antibiotic therapy. Results: 131 patients (59%) were older than 65, mortality and hospitalization rate were significantly higher in them. 40 patients (18%) were grQ!!p__l (< than 65 \~thout comorbidities); 164 (74%) (29 outpatients) group 2; and 18 (8%) roup 3 (ICU admission ). Mortality per group was 0%, 9%, and 44%. Pat o ens included: S. pneunwniae (20% of isolated) , Respiratory Viruses (10% , P aeruginosa (10%), M. pneunwniae (7%), S. aureus (7%), C. pneunwniae (6%), S. epidemddis (6% ), M. tuberculosis (5%), H. injluenzae (4%), Fungi (4%), and other Gram(-) (18%). In group 1 respiratory viruses were the commonest pathogens, followed by S. pneumoniae, M. pneumonine and H. injluenzae. In group 3 S. pneunwnine was the commonest pathogen, followed by S. aureus, P. aeruginosa, other Gram (-) and M. tuberculosis. Conclusions: Guideline was validated in hospitalization decision and outcome prediction. Some pathogens are probably unusual in this world area (Legionella sp. ). Other (M. pneumoniae, C. pneumoniae and P. aeruginosa), were common in this study. Clinical Implications: Guideline demonstrated its usefulness. Possible presence of "atypical" and Gram (-) organisms should beconsidered at the time of deciding the therapy.
Pulmonary Function Testing THE ROLE AND PREVALENCE OF SURREPTITIOUS CARBOXY HEMOGLOBIN IN THE OUTPATIENT MEASUREMENT OF DIFFUSING CAPACITY B Hoffmeyer. S Khan. M Nsour. A Siddiqui. B. Pichurko, MD , FCCP*; Dept. ofMedicine, Pro~dence Hospital and Medical Centers, Southfield and NoVJ, MI. Purpose: The assessment of pulmonary gas exchange by the commonly employed single breath carbon monoxide (CO) urtake method (DLC0 513 ) often yields poorly reproducible measurements o uncertain accuracy. The complex interrelationship b etween multiple gas analyzers, patient posiAbstracts of Original Investigations, CHEST 1996-Poster Presentations