Empiema Pleural - Simpósio Brasil-Itália

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Aula apresentada no I Simpósio Brasil-Itália pelo Dr Angelo Casalini - Universitá di Parma

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  • Questa classificazione inizialmente presentata dall’ACCP e ripresa da Light che l’ha paragonata ad una classificazione TNM ha una valenza diagnostica e terapeutica. Importante sottolineare l’importanza della misurazione del ph misurato con uno strumento da emogasanalisi.
  • Empiema Pleural - Simpósio Brasil-Itália

    1. 1. U.O. di Pneumologia - Endoscopia Toracica
    2. 2. P.te Indiano (Singh): 43 anniSintomas: dor “abdominal”no flanco direito, febre (37,8)Investigação:•Ecografia abdominal:negativa•Rx tórax:•negativo 28-10-2011 U.O. di Pneumologia - Endoscopia Toracica
    3. 3. P.te Indiano (Singh): 43 anniSintomas: • dor toracica • febre (38°) • DispneiaLaboratorio:GB: 7.81 (N=78%)VHS: 96D-Dimero: 3150Rx Torax:Pequeno derrame pleural a D. 1-11-2011 U.O. di Pneumologia - Endoscopia Toracica
    4. 4. P.te Indiano (Singh): 43 anni 2-11-2011 U.O. di Pneumologia - Endoscopia Toracica
    5. 5. P.te Indiano (Singh): 43 anni Drenagem Toracica (pig tail)700 ml de liquido pleurico corpuscolado eamareladopH: 6,56!!!Proteinas: 4,1 (no soro 5,5)Glicose: 19LDH: 10955! 4-11-2011 U.O. di Pneumologia - Endoscopia Toracica
    6. 6. P.te Indiano (Singh): 43 anni U.O. di Pneumologia - Endoscopia Toracica
    7. 7. P.te Indiano (Singh): 43 anni U.O. di Pneumologia - Endoscopia Toracica
    8. 8. • Pleurite parapneumônica – pleurite simples – Derrame parapneumônico complicado e empiema• Derrame pleurico tubercular. – pleurite – empiema (raro)• Pleurite atípica (Em pacientes imunodeprimidos é frequente a infecção oportunista.) – fungos • candida, aspergillo, criptococco, coccidioides, histoplasma, blastomyces, sporotrichose – bactérias incomuns • Actinomicosi, nocardiosi, chlamidia, rickettsiae – parasitas • Amebiase, echinococcose, paragonimiase, trichominiase – virus (não se conhece a real epidemiologia!) • Adenovirus, hantavirus, cytomegalovirus, herpes virus, hepatite, mononucleose, dengue U.O. di Pneumologia - Endoscopia Toracica
    9. 9. • Dificil isolar os agentes patogênicos – Dificuldades com os métodos atuais. Identificação do agente patogênico em menos de 40% dos casos com os métodos tradicionais. – Frequentemente não vem procurados!!! – A pleurite viral, em particular no adulto, é uma realidade, um “mito” ou um diagnóstico “refúgio”???• Derrames parapneumônicos: mesma etiologia das pneumonias? – Poucos estudos, com indicações de seleção, retrospectivo e com poucos casos, porém, orientam para etiologias diferentes.• Empiema: – Toracocentese precoce e tratamento correto (drenagem): muitas vezes inexplicavelmente retardados – Mortalidade em 12 meses de 22%; 35% no P.te imunodepresso. – Diferença entre adquiridas na comunidade e hospitalar? etiologia.. mortalidade.• Derrame pleural tubercular: – Acredita-se de se tratar de uma patologia muito rara. – Se dá muita importancia a procura do BK no liquido pleurico – Descuida-se da importancia fundamental da biopsia pleurica U.O. di Pneumologia - Endoscopia Toracica
    10. 10. U.O. di Pneumologia - Endoscopia Toracica
    11. 11. U.O. di Pneumologia - Endoscopia Toracica
    12. 12. U.O. di Pneumologia - Endoscopia Toracica
    13. 13. 454 PtsBacterial identification: 74% U.O. di Pneumologia - Endoscopia Toracica
    14. 14. Bacteriology of community acquired pleural infection streptococcus staphylococcus enterococcus Gram negatives anaerobes Myc tuberc actinomyces others U.O. di Pneumologia - Endoscopia Toracica
    15. 15. • The group Streptococcus milleri (SM) includes several species of pathogenic streptococci associated with pyogenic infections: at least three well-differentiated species: – S. constellatus, S. intermedius and S. anginosus – The SM group is part of the usual flora of the mouth, it is also found among normal faecal flora in 16–67% of healthy adults• The most important clinical feature of these micro-organisms is their tendency to cause suppurative infections at various sites, ranging from dental abscesses to deep visceral abscesses U.O. di Pneumologia - Endoscopia Toracica
    16. 16. Conclusionscommunity-acquired pleural infection is caused by penicillin-sensitivestreptococci in about 50% of cases, with the other 50% being due toorganisms that are usually penicillin resistant, including staphylococci andEnterobacteriaceae.About 25% of community-acquired pleural infections include anaerobicbacteria.Appropriate empiric antibiotic choices for these patients should thereforecover streptococci, penicillin-resistant staphylococci, and Enterobacteriaceaeand should usually also include anaerobic bacterial therapy. U.O. di Pneumologia - Endoscopia Toracica
    17. 17. One year Mortality•53/304 (17%) in community-acquired infection•17/36 (47%) in hospital ac inf Approximately 60% of hospital-acquired infections included bacteria frequently resistant to antibioticsU.O. di Pneumologia - Endoscopia Toracica
    18. 18. •Mortality in different bacterial subsets: •23/137 (17%): streptococcal inf. •10/49 (20%): anaerobic-mixed inf. •15/34 (44%) S. aureus inf. •10/22 (45%) gram-negative inf. •13/28 (46%) mixed aerobic inf.U.O. di Pneumologia - Endoscopia Toracica
    19. 19. U.O. di Pneumologia - Endoscopia Toracica
    20. 20. •The mean delay in diagnosis was 44.2 days•Long delays in diagnosis •On average each patient:•long hospital stays • underwent CT 10.1 times•recovery with surgery •had 2.6 percutaneous drainage procedures •The mean time from the first percutaneous chest drainage to the date of diagnosis was 29.8 days •the mean delay until thoracic surgery referral was 47.4 day •The mean length of hospital stay postoperatively was 15.2 days U.O. di Pneumologia - Endoscopia Toracica
    21. 21. Ultrasonography and CT scanning, however,have greater sensitivity for fluid detection andprovide additional information for determiningthe extent and nature of pleural infection. U.O. di Pneumologia - Endoscopia Toracica
    22. 22. U.O. di Pneumologia - Endoscopia Toracica
    23. 23. empyema U.O. di Pneumologia - Endoscopia Toracica
    24. 24. U.O. di Pneumologia - Endoscopia Toracica
    25. 25. Clinical and pathological evolution • Exudative stage: pleural fluid culture is negative, pH > 7.20, LDH <1000: 5 to 7 days • fibrino-purulent stage: pleural fluid becomes purulent, early loculations, positive microbial culture. pH <7.20, LDH > 1000: 7 days up to 2 weeks • organizing stage: fibroblasts grow into the pleural space; this results in a thik pleural peel: generally occurs within 2 to 4 weeks of onset of the pleural effusion.G.F. Tassi, G.P. Marchetti. Il versamento parapneumonico e l’empiema. In Pneumologia Interventistica. A.G. Casalini. Springer Italia. 2007 U.O. di Pneumologia - Endoscopia Toracica
    26. 26. stage Pleural fluid Biochemical treatment aspectsSimple parapneumonic yellow •pH>7.20 antibioticspleural effusion •LDH<1000 •GRAM negComplicated Yellow/ •pH<7.20 Chest tubeparapneumonic effusion turbid •LDH>1000 drainage •GRAM posempyema Purulent Chest tube drainage U.O. di Pneumologia - Endoscopia Toracica
    27. 27. U.O. di Pneumologia - Endoscopia Toracica
    28. 28. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.The primary outcome of the review was treatment failure resulting in death and surgery. U.O. di Pneumologia - Endoscopia Toracica
    29. 29. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.:CD002312.The primary outcome of the review was treatment failure resulting in death and surgery. U.O. di Pneumologia - Endoscopia Toracica
    30. 30. U.O. di Pneumologia - Endoscopia Toracica
    31. 31. Conclusions: In patients with loculated, complex fibrinopurulent parapneumonicempyema thoracis, a primary treatment strategy of VATS is associated with a higherefficacy, shorter hospital duration, and less cost than a treatment strategy that utilizescatheter-directed fibrinolytic therapy.
    32. 32. Case ReportG.P.A. 51 years oldoctober 30th U.O. di Pneumologia - Endoscopia Toracica
    33. 33. Case ReportG.P.A. 51 years oldoctober 31st U.O. di Pneumologia - Endoscopia Toracica
    34. 34. Case Report G.P.A. 51 years oldnovember 5th: Thoracoscopy U.O. di Pneumologia - Endoscopia Toracica
    35. 35. Case ReportG.P.A. 51 years oldnovember 23th U.O. di Pneumologia - Endoscopia Toracica
    36. 36. ConclusionAlthough thoracoscopy has proved useful in the treatment ofinfected pleural space, in particular in multiloculated empyema where it allowsrecovery avoiding thoracotomy, even today its employment has not beenjustified by large controlled trials. Moreover there are no prospective,controlled studies on the role of medical thoracoscopy inparapneumonic effusions and empyema.Medical thoracoscopy, as a drainage procedure intermedate between tubethoracostomy and VATS, is significantly lower in cost and can avoid surgicalthoracoscopy under general anaesthesia. It is essential that it is performedearly on in the course of empyema and it is particularly advisable for frailpatients at high surgical risk. U.O. di Pneumologia - Endoscopia Toracica

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