Talk:Pleural empyema

Empyema and Pyothorax

A pyothorax is a form of empyema, but an empyema is not necessarily a pyothorax - it can be an appendicitis, a pyometra, a septic arthritis etc. Please stop using "empyema" as a synonym for pyothorax - medically spoken, this is wrong. --69.91.167.69 (talk) 18:32, 30 July 2008 (UTC)

Thrombolytics

Ah, thrombolytics in empyema: a can of worms indeed. :-)

If I recall correctly, the MIST (MRC trial) data hasn't been published yet. In any case, the Cochrane database states: -

"The numbers of patients in the controlled trials are small. In meta-analysis of these trials, intrapleural fibrinolytic therapy confers significant benefit when compared with normal saline control. Although lesser levels of evidence suggest that intrapleural fibrinolysis can be considered as an important adjunctive therapy to intercostal tube drainage in these conditions, on the basis of RCT evidence alone, we cannot recommend the routine use of fibrinolysis in their management as the trial numbers are too small."

I deliberately didn't include thrombolytics in the article because the evidence still isn't clear-cut (although if you can find the MIST data I would be very interested). Axl 23:47, 8 Nov 2004 (UTC)

See, this is why we need you around. I just stuffed into the article something that I'd heard about... :-) JFW | T@lk 23:35, 9 Nov 2004 (UTC)

Thoracentesis removal

I agree the use of a chest tube and thoracentesis are not seen as the same. Nevertheless inserting the chest tube does represent a form of thoracentesis, that is removal of fluid/air from the intrathoracic space. --Nomen Nescio 22:38, August 30, 2005 (UTC)

In my opinion, your distinction between chest tube insertion and thoracentesis is too loose. The chest tube is a (usually plastic) tube that remains in the chest. Thoracentesis involves only a transient (usually metal) sharp needle, taken out straight away at the end of the procedure. The distinction between these is particularly important in the treatment of empyema. Chest tube insertion is required. Therapeutic thoracentesis is not appropriate. Axl 17:34, 1 September 2005 (UTC)

The word ....centesis comes from the Greek kentesis which means puncture. Therefore thoracentesis means to punctate the thorax. This is what I described and in essence it is the procedure of removing fluid/air from the thorax. The word does not say how this is done. Strictly speaking, by inserting a chest tube and thereby removing fluid/air that part of the procedure represents thoracentesis. --Nomen Nescio 18:05, September 1, 2005 (UTC)

Although most will use a chest tube in situ to treat empyema I have seen pulmonologists that punctated daily to remove the needle after the empyema was flushed. They would repeat this until the fluid became clear. --Nomen Nescio 23:21, September 1, 2005 (UTC)

The etymology of thoracentesis is interesting, but not directly relevant to the modern medical definition of the word. I object to this phrase: -

"A chest tube is inserted, a procedure known as thoracentesis..."

because chest tube insertion is not (and should not be) known as thoracentesis. Axl 08:32, 2 September 2005 (UTC)

Repeat daily thoracentesis is not indicated in empyema. The British Thoracic Society describes Grade B evidence recommending insertion of a chest drain. Four references are cited in the guidelines. Axl 08:32, 2 September 2005 (UTC)

You are correct to say that intermittent thoracentesis is not current protocol. As to its definition, please consider (emphasis added):

• "Thoracentesis: Puncture of the chest wall for extraction of pleural fluid." from the Merck Manual

I still think that thoracentesis means sticking a needle into the thorax to remove ...., but I do agree that most will not use the word to mean the initial part of thoracostomy. --Nomen Nescio 11:21, September 2, 2005 (UTC)

I know what thoracentesis is. I agree with the Merck definition. I draw your attention again to the quotation above: chest tube insertion is not known as thoracentesis. Axl 12:59, 2 September 2005 (UTC)

Thoracentesis is inappropriate - as the lumen of the catheter is about 6 fr. Also thoracentesis usually implies a time limited session.

 Ideally, I use a 36 fr. thoracostomy (chest) tube for continued drainage, usually over several days.  As to repeated thoracentesis - that is certainly not therapeutic for the patient, and possibly quite harmful.  —Preceding unsigned comment added by Kanai3 (talk • contribs) 12:23, 23 September 2007 (UTC) 

Source

PMID 20224409 seems useful and comprehensive. JFW | T@lk 12:20, 12 August 2010 (UTC)

As does doi:10.1183/09059180.00005610 JFW | T@lk 04:31, 26 November 2010 (UTC)

New BTS guidelines. doi:10.1136/thx.2010.137000. JFW | T@lk 12:22, 4 May 2011 (UTC)

Amoeba

I removed the following text from the article:-

"Pleural empyema is also seen in severe cases of amoebiasis where the entamoeba reaches the pleural cavity either by direct{through blood - rare} or primarily from liver to lung[plerual cavity]."

No reference was supplied. The only secondary source that I found was this one. However that source is inappropriate because it is explicitly about thoracic amoebiasis, not a general discussion of empyema. The only other source that I found was this case report. Axl ¤ [Talk] 08:23, 31 July 2013 (UTC)

Aminoglycosides

I have removed the following text from the article:-

"Aminoglycosides should be avoided as they have poor penetration into the pleural space (This sentence contradicts the previous one where it says clindamycin, vancomycin, gentamycin (which are aminoglycosides) should be used)."

Clindamycin and vancomycin are not aminoglycosides. I shall review the current literature regarding gentamicin/aminoglycosides. Axl ¤ [Talk] 01:23, 20 January 2016 (UTC)

From Light's Pleural Diseases (6th edition, 2013), chapter 12, page 225: "The degree to which the different antibiotics penetrated the infected pleural space was highly variable. Metronidazole penetrated most easily, followed by penicillin, clindamycin, vancomycin, ceftriaxone, and gentamicin. Subsequent studies demonstrated that the quinolones, clarithromycin, azithromycin, linezolid, and ertapenem penetrate the infected pleural space well. This variance in the penetrance of antibiotics into the pleural fluid should be considered when an antibiotic is selected for the treatment of patients with parapneumonic effusions." Axl ¤ [Talk] 01:40, 20 January 2016 (UTC)