Timothy A. Galbraith

Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas

Acute multiloculated thoracic empyemas incompletely drained by tube thoracostomy alone usually require operation. To avoid a thoracotomy yet treat this difficult problem, intrapleural fibrinolytic agents were employed. Between April 1, 1990, and April 1, 1993, 13 consecutive patients presenting with a fibrinopurulent empyema were demonstrated to have incomplete drainage. To facilitate drainage, streptokinase, 250,000 units in 100 mL 0.9% saline solution (3 patients), or urokinase, 100,000 units in 100 mL 0.9% saline solution (10 patients), was instilled daily into the chest tube, and the tube was clamped for 6 to 12 hours followed by suction. This routine was continued daily for a mean of 6.8 +/- 3.7 days (range, 1 to 14 days) until resolution of the pleural fluid collection was demonstrated by computed chest tomography and clinical indications. This regimen was completely successful in 10 of 13 patients (77%), who had resolution of the empyema, eventual withdrawal of chest tubes, and no recurrence. Two patients, both pediatric liver transplant patients, had an initial good response but eventually required decortication. One patient with a good radiographic response became increasingly febrile during streptokinase therapy and underwent a thoracotomy, but no significant undrained fluid was found. This patients continued fever was believed to be a streptokinase reaction. Urokinase was used subsequently. No treatment-related mortalities or complications occurred. Intrapleural fibrinolytic agents, especially urokinase, are safe, cost-effective means of facilitating complete chest tube drainage, thereby avoiding the morbidity of a major thoracotomy for 77% of a group of multiloculated empyema patients who traditionally would have required open surgical therapy.

Pulmonary resection for invasive Aspergillus infections in immunocompromised patients.

Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.

Intrapleural doxycycline control of malignant pleural effusions

The intrapleural instillation of agents for pleural sclerosis has proved effective in preventing the reaccumulation of symptomatic malignant pleural effusions. Because manufacture of the most popular agent, tetracycline, was recently discontinued, a preliminary study was undertaken to evaluate an alternative agent, doxycycline, for treating symptomatic malignant pleural effusions. From November 1991 to September 1992, 21 patients with symptomatic malignant pleural effusions have undergone overnight chest tube drainage followed by intrapleural instillation of 10 mL 1% lidocaine and then doxycycline, 500 mg in 30 mL 0.9% saline solution. The chest tube was clamped 2 hours with patient repositioning every 15 minutes. Tubes were removed when drainage was less than 50 mL/8 h. Of surviving patients, a complete objective response at 1 month was obtained in 88% (15/17), who were free of a symptomatic or radiographic recurrence of the effusion. Complications included mild pain in 23% (5/21), moderate pain requiring analgesics in 19% (4/21), and mild fever in 5% (1/21). There were no treatment-related deaths. The mean time for chest tube removal was 1.7 +/- 0.7 days after the last treatment. Based on this preliminary study, we conclude that doxycycline is a highly effective agent for the palliative treatment of symptomatic malignant pleural effusions. Its safety profile and efficacy compare favorably with those of tetracycline and other agents used for pleural sclerosis.

Cystic adenomatoid malformation involving an entire lung in a 22-year-old woman

Congenital cystic adenomatoid malformation is an uncommon cause of respiratory distress in infants and is a rare entity in adults. Presentation in older patients is that of recurrent pulmonary infections. Usually a single lobe is involved. This report describes congenital cystic adenomatoid malformation involving the entire right lung in a 22-year-old woman presenting with gastrointestinal bleeding due to cavernous transformation of the portal and splenic veins.

Clinical evaluation of a new generation membrane oxygenator: a prospective randomized study

A new generation hollow-fibre membrane oxygenator (Spiral Gold™) has been introduced by Baxter Healthcare (Irvine, CA, USA). The purpose of this study was to evaluate the operational performance of this device under clinical conditions and to compare it to the Univox® Gold™ membrane oxygenator. Following institutional review board approval, and the obtainment of informed consent, 26 patients undergoing coronary artery bypass grafting were randomly assigned to either a Spiral Gold™ (Spiral) (n = 13) or Univox® Gold™ (Univox) (n = 13) group. Study parameters were grouped into the following categories: haematological, haemodynamic, oxygenator performance and perioperative outcomes. All patients received identical surgical, anaesthesia and postoperative care. There were no statistically significant differences in either preoperative or operative parameters between groups. During cardiopulmonary bypass, the Spiral group had a significantly lower pressure drop (26.9 ± 8.2 vs 46.7 ± 16.2 mmHg, p < 0.001). The Spiral group had significantly lower plasma free haemoglobin levels during all time periods of CPB compared to the Univox group. Heat exchange coefficients were higher during the rewarming period in the Spiral patients (0.59 ± 0.28) compared to the Univox group (0.36 ± 0.19), p = 0.06. There were no differences in oxygen transfer between groups, but ventilation gas sweep rates and FiO2 levels were statistically lower in the Spiral group at two of the three sampling time periods. The ratio of ventilating gas sweep rate to blood flow rate was lower in the Spiral group (0.56 ± 0.12) compared to the Univox group (0.74 ± 0.23), p < 0.03. The Spiral Gold™ oxygenator had superior oxygen transfer efficiency and lower haemolysis rates than the Univox® Gold™ oxygenator.

Tracheoesophageal fistula developing during chemotherapy for non‐Hodgkins lymphoma

Lymphoma is an unusual cause of tracheoesophageal fistula (TEF). Most fistulas develop after radiation therapy and are a rare occurrence in patients treated with chemotherapy alone. The presence of a TEF is usually indicative of active lymphoma. This report describes a tracheoesophageal fistula that developed during chemotherapy for diffuse large cell lymphoma.