Studies on Continuous Intrapleural Drugs Instillation for Thoracic Diseases
Date Issued
2014
Date
2014
Author(s)
Huang, Pei-Ming
Abstract
The pleural cavity has unique dynamic drainage pathways. Intrapleural instillation was previously used to treat several diseases, such as pneumothorax, empyema, and malignant pleural effusion. We attempted to establish a new therapeutic method with continuous intrapleural instillation for diseases that are difficult to treat, such as acute respiratory distress syndrome, post-operative chylothorax, and hemothorax. This study yielded favorable results, and therefore, can be used as an effective treatment modality.
Intrapleural steroid instillation for acute lung injury after esophagectomy or multiple organ failure with acute respiratory distress syndrome
Currently, esophageal cancer therapy is an important area in medicine. In general, esophageal surgery is a complex pathophysiological process, and post-operative management plays an important role owing to the complexity of the procedure and patient malnutrition. The available therapies for pulmonary complications of esophagectomy include conservative treatments such as chest physiotherapy and mucolytic agents and invasive procedures such as bronchial toilet and tracheostomy. However, current therapies do not improve the survival rate in patients with severe acute respiratory failure (ARF). On the basis of the findings of this study, we aim to establish a new therapeutic technique with continuous intrapleural instillation for treatment of ARF after esophagectomy and acute respiratory distress syndrome combined with multiple organ failure.
The result and conclusion of the first part of study was as the followings:
Results
In the first two patients with esophageal cancer who underwent esophagectomy, we recommended intrapleural steroid instillation for ARF when the condition of the patients deteriorated despite treatment with other modalities, such as intravenous antibiotic administration and nutrition support. Improved clinical outcomes and pulmonary function were observed in both patients, and their oxygen demand also decreased from 100% concentration.
In the 30 consecutive extracorporeal membrane oxygenation adults who met the criteria of severe acute respiratory distress syndrome in combination with multiple organ dysfunction syndrome, the infiltrative shadows on plain chest radiographs were markedly improved on the third day of intrapleural treatment (p = 0.008) and significantly higher PaO2/FiO2 ratios than those treated with conventional method for 5 days (p = 0.028).
Conclusion
Intrapleural steroid instillation seems to be an easily and useful implemented treatment modality for patients with acute respiratory distress syndrome and multiple organ dysfunction syndrome that allows efficient recovery of lung function at a relatively low cost, especially when initiated early in the course of the disease.
Continuous intrapleural instillation with minocycline administration for refractory postoperative chylothorax
Chylothorax, characterized by accumulation of milky chyle in the pleural space due to disturbance of flow in the thoracic duct or its tributaries, is a rare and serious complication of thoracic surgery. The complication can lead to respiratory insufficiency, fluid imbalance, and nutrition deficiency. Although multiple approaches have been reported for the treatment of chyle leakage, there is lack of a clear consensus on its optimal management technique. We described a novel technique of continuous irrigation to enhance the pleurodesis effect of conventional intermittent minocycline infusion.
The result and conclusion of the second part of study was as the followings:
Results
Herein, we report cases of 3 patients with chylothorax in whom pleurodesis was successfully performed via continuous intrapleural irrigation with minocycline (800mg of minocycline and 800mg of 2% lidocaine hydrochloride in 1000ml of normal saline, set 100ml per hour) instead of the conventional intermittent pleurodesis. The main disadvantage of minocycline is post-instillation chest pain, which can be relieved by intrapleural lidocaine as the pretreatment and this technique of continuous low dose administration.
Conclusion
Post-operative chylothorax is rare and can lead to serious consequences. Continuous intrapleural irrigation with minocycline was a convenient and effective alternative to open surgical or thoracoscopic drainage in these cases.
Continuous intrapleural instillation with epinephrine administration for hemothorax
Although hemothorax has been recognized as a clinical entity for centuries, the surgical strategies for its management, especially when complicating ECMO, were rarely mentioned in detail in the medical literature. We also developed intrapleural epinephrine irrigation for hemothorax, which stimulates vascular contraction and further improves hemostasis. It can be further applied to hemothorax related to other disease.
The result and conclusion of the third part of study was as the followings:
Results
All hemothoraces were unilateral. With coagulopathic correction, control of bleeding was obtained in two patients after decompression of the pleural cavity, four patients after pleural epinephrine irrigation, and eight of 14 patients required surgical intervention for blood clot evacuation. Four extracorporeal membrane oxygenation patients with hemothorax had hemostasis without surgery after pleural epinephrine irrigation through the chest tube. Pleural epinephrine irrigation caused a mild increase of systolic blood pressure in these patients.
Conclusion
Furthermore, before definitive surgical treatment for hemothorax, we recommend that pleural lavaged streams of epinephrine should be used firstly. However, some hemothoraces (in patients with great vessel rupture, organ rupture, or massive postoperative hemothorax) require indispensably immediate, definitive surgical intervention. So the pleural epinephrine irrigation would not be used continuously if bleeding did not stop or decrease.
Summary
Continuous intrapleural instillation is a simple, safe, and definitive technique that can be used to treat several thoracic diseases such as acute respiratory distress syndrome, post-operative chylothorax, and hemothorax. However, future studies are warranted to demonstrate the efficacy and survival benefits of this technique.
Subjects
肋膜腔輸注
急性呼吸窘迫症
乳糜胸
血胸
SDGs
Type
thesis
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