Background Pleural infection is associated with a high morbidity and mortality. Development of a validated clinical risk score at presentation to identify those at high risk of dying would enable ...patient triage and may help formulate early management strategies. Methods A clinical risk score was derived based on data from patients entering the multicenter UK pleural infection trial (first Multicenter Intrapleural Sepsis Trial MIST1, n = 411). From 22 baseline clinical characteristics, model selection was undertaken to find variables predictive of poor clinical outcome. Outcomes were mortality at 3 months (primary), need for surgical intervention at 3 months, and time from randomization to discharge. The derived scoring system RAPID (renal, age, purulence, infection source, and dietary factors) was validated using patients enrolled in the subsequent MIST2 trial (n = 191). Results Age, urea, albumin, hospital-acquired infection, and nonpurulence predicted poor outcome. Patients were stratified into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. Using the low-risk group as a reference, a RAPID score of 3 to 4 and > 4 was associated with an OR of 24.4 (95% CI, 3.1-186.7; P = .002) and 192.4 (95% CI, 25.0-1480.4; P < .001), respectively, for death at 3 months. In the validation cohort (MIST2), a medium-risk RAPID score was nonsignificantly associated with mortality (OR, 3.2; 95% CI, 0.8-13.2; P = .11), and a high-risk score was associated with increased mortality (OR, 14.1; 95% CI, 3.5-56.8; P < .001). Hospitalization duration was associated with increasing RAPID score (score 0-2: median duration = 7, interquartile range 6-13; score > 5: median duration = 15, interquartile range 9-28, P = .08). Conclusions The RAPID score may permit risk stratification of patients with pleural infection at presentation.
Primary spontaneous pneumothorax (PSP) affects young healthy people with a significant recurrence rate. Recent advances in treatment have been variably implemented in clinical practice. This ...statement reviews the latest developments and concepts to improve clinical management and stimulate further research.The European Respiratory Society's Scientific Committee established a multidisciplinary team of pulmonologists and surgeons to produce a comprehensive review of available scientific evidence.Smoking remains the main risk factor of PSP. Routine smoking cessation is advised. More prospective data are required to better define the PSP population and incidence of recurrence. In first episodes of PSP, treatment approach is driven by symptoms rather than PSP size. The role of bullae rupture as the cause of air leakage remains unclear, implying that any treatment of PSP recurrence includes pleurodesis. Talc poudrage pleurodesis by thoracoscopy is safe, provided calibrated talc is available. Video-assisted thoracic surgery is preferred to thoracotomy as a surgical approach.In first episodes of PSP, aspiration is required only in symptomatic patients. After a persistent or recurrent PSP, definitive treatment including pleurodesis is undertaken. Future randomised controlled trials comparing different strategies are required.
The minimal important difference (MID) is essential for interpreting the results of randomised controlled trials (RCTs). Despite a number of RCTs in patients with malignant pleural effusions (MPEs) ...which use the visual analogue scale for dyspnea (VASD) as an outcome measure, the MID has not been established.
Patients with suspected MPE undergoing a pleural procedure recorded their baseline VASD and their post-procedure VASD (24 hours after the pleural drainage), and in parallel assessed their breathlessness on a 7 point Likert scale.
The mean decrease in VASD in patients with a MPE reporting a 'small but just worthwhile decrease' in their dyspnea (i.e. equivalent to the MID) was 19mm (95% CI 14-24mm). The mean drainage volume required to produce a change in VASD of 19mm was 760ml.
The mean MID for the VASD in patients with a MPE undergoing a pleural procedure is 19mm (95% CI 14-24mm). Thus choosing an improvement of 19mm in the VASD would be justifiable in the design and analysis of future MPE studies.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Parapneumonic effusions have a wide clinical spectrum. The majority settle with conservative management but some progress to complex collections requiring intervention. For decades, physicians have ...relied on pleural fluid pH to determine the need for chest tube drainage despite a lack of prospective validation and no ability to predict the requirement for fibrinolytics or thoracic surgery.
To study the ability of suPAR (soluble urokinase plasminogen activator receptor), a potential biomarker of pleural fluid loculation, to predict the need for invasive management compared with conventional fluid biomarkers (pH, glucose, and lactate dehydrogenase) in parapneumonic effusions.
Patients presenting with pleural effusions were prospectively recruited to an observational study with biological samples stored at presentation. Pleural fluid and serum suPAR levels were measured using the suPARnostic double-monoclonal antibody sandwich ELISA on 93 patients with parapneumonic effusions and 47 control subjects (benign and malignant effusions).
Pleural suPAR levels were significantly higher in effusions that were loculated versus nonloculated parapneumonic effusions (median, 132 ng/ml vs. 22 ng/ml;
< 0.001). Pleural suPAR could more accurately predict the subsequent insertion of a chest tube with an area under the curve (AUC) of 0.93 (95% confidence interval, 0.89-0.98) compared with pleural pH (AUC 0.82; 95% confidence interval, 0.73-0.90). suPAR was superior to the combination of conventional pleural biomarkers (pH, glucose, and lactate dehydrogenase) when predicting the referral for intrapleural fibrinolysis or thoracic surgery (AUC 0.92 vs. 0.76).
Raised pleural suPAR was predictive of patients receiving more invasive management of parapneumonic effusions and added value to conventional biomarkers. These results need validation in a prospective multicenter trial.
continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) provide enhanced oxygen delivery and respiratory support for patients with severe COVID-19. CPAP and HFNO are currently ...designated as aerosol-generating procedures despite limited high-quality experimental data. We aimed to characterise aerosol emission from HFNO and CPAP and compare with breathing, speaking and coughing.
Healthy volunteers were recruited to breathe, speak and cough in ultra-clean, laminar flow theatres followed by using CPAP and HFNO. Aerosol emission was measured using two discrete methodologies, simultaneously. Hospitalised patients with COVID-19 had cough recorded using the same methodology on the infectious diseases ward.
In healthy volunteers (n=25 subjects; 531 measures), CPAP (with exhalation port filter) produced less aerosol than breathing, speaking and coughing (even with large >50 L/min face mask leaks). Coughing was associated with the highest aerosol emissions of any recorded activity. HFNO was associated with aerosol emission, however, this was from the machine. Generated particles were small (<1 µm), passing from the machine through the patient and to the detector without coalescence with respiratory aerosol, thereby unlikely to carry viral particles. More aerosol was generated in cough from patients with COVID-19 (n=8) than volunteers.
In healthy volunteers, standard non-humidified CPAP is associated with less aerosol emission than breathing, speaking or coughing. Aerosol emission from the respiratory tract does not appear to be increased by HFNO. Although direct comparisons are complex, cough appears to be the main aerosol-generating risk out of all measured activities.
Slowly clearing infections in the pleural space are a source of substantial morbidity. This study showed that instillation of recombinant DNase and tissue plasminogen activator (t-PA) is more ...effective than placebo in clearing radiographic pleural effusions.
Pleural infection affects more than 65,000 patients each year in the United States and the United Kingdom,
1
and the incidence is increasing in both countries — in both children
2
–
4
and adults.
5
,
6
The mortality rate from pleural infection is between 10% and 20%,
5
,
7
–
9
and drainage through a chest tube and administration of antibiotics fail in approximately one third of patients, who then require surgical drainage.
5
,
9
The median duration of the hospital stay for these patients is 12 to 15 days,
5
,
6
,
8
,
9
with 25% hospitalized for more than a month. Care of each patient costs . . .
Background: The optimal choice of chest tube size for the treatment of pleural infection is unknown, with only small cohort studies reported
describing the efficacy and adverse events of different ...tube sizes.
Methods: A total of 405 patients with pleural infection were prospectively enrolled into a multicenter study investigating the utility
of fibrinolytic therapy. The combined frequency of death and surgery, and secondary outcomes (hospital stay, change in chest
radiograph, and lung function at 3 months) were compared in patients receiving chest tubes of differing size (Ï 2 , t test, and logistic regression analyses as appropriate). Pain was studied in detail in 128 patients.
Results: There was no significant difference in the frequency with which patients either died or required thoracic surgery in patients
receiving chest tubes of varying sizes ( < 10F, number dying or needing surgery 21/58 36%; size 10-14F, 75/208 36%; size
15-20F, 28/70 40%; size > 20F, 30/69 44%; Ï 2 trend, 1 degrees of freedom df = 1.21, P = .27), nor any difference in any secondary outcome. Pain scores were substantially higher in patients receiving (mainly
blunt dissection inserted) larger tubes ( < 10F, median pain score 6 range 4-7; 10-14F, 5 4-6; 15-20F, 6 5-7; > 20F,
6 6-8; Ï 2 , 3 df = 10.80, P = .013, Kruskal-Wallis; Ï 2 trend, 1 df = 6.3, P = .014).
Conclusions: Smaller, guide-wire-inserted chest tubes cause substantially less pain than blunt-dissection-inserted larger tubes, without
any impairment in clinical outcome in the treatment of pleural infection. These results suggest that smaller size tubes may
be the initial treatment of choice for pleural infection, and randomized studies are now required.
Trial registration: MIST1 trial ISRCTN number: 39138989.
In this randomized trial involving 454 patients with pleural infections that required antibiotic therapy and chest-tube drainage, there was no benefit from the use of intrapleural streptokinase in ...terms of survival, the need for surgery, the length of the hospital stay, or the resolution of radiographic abnormalities.
In this trial involving 454 patients with pleural infections, there was no benefit from the use of intrapleural streptokinase in terms of survival, the need for surgery, the length of the hospital stay, or the resolution of radiographic abnormalities.
Pleural infection develops in about 65,000 patients each year in the United States and the United Kingdom.
1
Approximately 15 percent of patients die,
2
which is similar to the death rate among patients hospitalized with pneumonia,
3
,
4
and 15 to 40 percent require surgical drainage of the infected pleural space.
2
,
5
The median duration of inpatient care is 15 days, with 20 percent of patients remaining in the hospital for a month or longer.
2
Apart from antibiotic therapy, treatment in patients with pleural infection consists mainly of drainage of the infected pleural fluid, and the intrapleural administration of fibrinolytic drugs is . . .
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