PDF herunterladen
Pneumologie 2004; 58(2): 83-91
DOI: 10.1055/s-2003-812528
Übersicht
© Georg Thieme Verlag Stuttgart · New York

Parapneumonischer Erguss und Pleuraempyem - aktuelle Aspekte zu Einteilung, Diagnose und Therapie

Parapneumonic Effusion and Pleural Empyema - Topical Aspects of Classification, Diagnosis and TreatmentM.  Kolditz1 , M.  Halank1 , G.  Höffken1
  • 1Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Dresden
Weitere Informationen

Publikationsverlauf

Eingang: 31. Juli 2003

Nach Revision angenommen: 31. Oktober 2003

Publikationsdatum:
12. Februar 2004 (online)

Auch verfügbar auf
   Lizenzen und Reprints

Zusammenfassung

Parapneumonische Pleuraergüsse sind nicht selten und können bei Patienten mit bakteriellen Pneumonien in ca. 40 - 50 % der Fälle beobachtet werden. Dennoch sind Diagnostik und therapeutisches Vorgehen ausgesprochen variabel und bis jetzt kaum durch evidenzbasierte Daten gesichert. Die Einteilung der parapneumonischen Pleuraergüsse kann nach morphologischen, chemischen und bakteriologischen Kriterien erfolgen. In Abhängigkeit vom Schweregrad reichen differenzialtherapeutische Verfahren vom Verlauf ohne Intervention über Entlastungspunktion und Drainageanlage mit oder ohne lokale Fibrinolyse bis zu den chirurgischen Verfahren VATS und offene Exploration. In der vorliegenden Übersicht wird versucht, die aktuellen Aspekte der Einteilung, Diagnostik und Therapie zusammenzufassen und Schlussfolgerungen für die tägliche Praxis zu ziehen.

Abstract

Parapneumonic effusions can be diagnosed in about 40 - 50 % of patients with bacterial pneumonia, and therefore should be considered as a frequent condition. Despite their prevalence, there is limited consensus about diagnostic pathways and therapeutic procedures due to the lack of evidence-based data available. The classification of parapneumonic effusions is based on morphological, chemical and bacteriological criteria. Dependent on the complexity of the effusion, available management approaches include observation without intervention, thoracentesis, chest tube drainage with or without local fibrinolysis and the surgical options VATS and thoracotomy. This overview summarizes the actual aspects of classification, diagnosis and treatment of the parapneumonic effusion and draws conclusions for the daily management of this condition.

Literatur

  • 1 Davies C WH, Gleeson F V, Davies R JO. BTS guidelines for the management of pleural infection.  Thorax. 2003;  58 (Suppl II) ii18-ii28
    PubMedGoogle Scholar
  • 2 Hoyos A de, Sundaresan S. Thoracic empyema.  Surg Clin N Am. 2002;  82 643-671
    PubMedGoogle Scholar
  • 3 Light R W. Pleural effusion.  N Engl J Med. 2002;  346 1971-1977
    CrossrefPubMedGoogle Scholar
  • 4 Sahn S A. Management of complicated parapneumonic effusions.  Am Rev Respir Dis. 1993;  148 813-817
    CrossrefPubMedGoogle Scholar
  • 5 Bryant R E, Salmon C J. Pleural empyema.  Clin Infect Dis. 1996;  22 747-764
    PubMedGoogle Scholar
  • 6 Teixeira L R, Villarino M A. Antibiotic treatment of patients with pneumonia and pleural effusion.  Curr Opin Pulm Med. 1998;  4 230-234
    CrossrefPubMedGoogle Scholar
  • 7 Davies C WH, Kearney S E, Gleeson F V. et al . Predictors of outcome and long-term survival in patients with pleural infection.  Am J Respir Crit Care Med. 1999;  160 1682-1687
    CrossrefPubMedGoogle Scholar
  • 8 Light R W. A new classification of parapneumonic effusions and empyema.  Chest. 1995;  108 299-301
    CrossrefPubMedGoogle Scholar
  • 9 Heffner J E, Brown L K, Barbieri C. et al . Pleural fluid chemical analysis in parapneumonic effusions.  Am J Respir Crit Care Med. 1995;  151 1700-1708
    CrossrefPubMedGoogle Scholar
  • 10 Colice G L, Curtis A, Deslauriers J. et al . ACCP consensus statement: Medical and surgical treatment of parapneumonic effusions. An evidence-based guideline.  Chest. 2000;  18 1158-1171
    PubMedGoogle Scholar
  • 11 Cheng D, Rodriguez R M, Rogers J. et al . Comparision of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip.  Chest. 1998;  114 1368-1372
    CrossrefPubMedGoogle Scholar
  • 12 Kelbel C, Lorenz J. Ultraschalldiagnostik in der Pneumologie.  Internist. 1993;  34 1012-1019
    PubMedGoogle Scholar
  • 13 Aoe K, Hiraki A, Murakami T. et al . Diagnostic significance of Interferon-γ in tuberculous pleural effusions.  Chest. 2003;  123 740-744
    CrossrefPubMedGoogle Scholar
  • 14 Lee Y CG, Rogers J T, Rodriguez R M. et al . Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions.  Chest. 2001;  120 356-361
    CrossrefPubMedGoogle Scholar
  • 15 Greco S, Girardi E, Masciangelo R. et al . Adenosine deaminase and interferon gamma measurements for the diagnosis of tuberculous pleurisy: a meta-analysis.  Int J Tuberc Lung Dis. 2003;  7 777-786
    PubMedGoogle Scholar
  • 16 Loddenkemper R. Diagnostik der Pleuraergüsse.  Dtsch Med Wochenschr. 1992;  117 1487-1491
    PubMedGoogle Scholar
  • 17 Yilmaz Turay U, Yildirim Z, Turkoz Y. et al . Use of pleural fluid C-reactive protein in diagnosis of pleural effusions.  Respir Med. 2000;  94 432-435
    PubMedGoogle Scholar
  • 18 Wang P S, Chen Y M, Hsieh Y L. et al . Pleural effusion and serum soluble Fas-ligand levels are elevated in different clinical conditions.  Lung. 2002;  180 25-32
    CrossrefPubMedGoogle Scholar
  • 19 Vives M, Porcel J M, Gazques I. et al . Pleural SC5b-9: A test for identifying complicated parapneumonic effusions.  Respiration. 2000;  67 433-438
    CrossrefPubMedGoogle Scholar
  • 20 Schaberg T. Pleuraerguss bei Pneumonie.  Ther Umsch. 2001;  58 604-608
    PubMedGoogle Scholar
  • 21 Bartlett J G, Gorbach S L, Thadepalli H. et al . Bacteriology of empyema.  Lancet. 1974;  1 338-340
    PubMedGoogle Scholar
  • 22 Mandal A K, Thadepalli H, Mandal A K. et al . Outcome of primary empyema thoracis: Therapeutic and microbiologic aspects.  Ann Thorac Surg. 1998;  66 1782-1786
    CrossrefPubMedGoogle Scholar
  • 23 Chen K Y, Hsueh P R, Liaw Y S. et al . A 10-year experience with bacteriology of acute thoracic empyema: Emphasis on Klebsiella pneumoniae in patients with diabetes mellitus.  Chest. 2000;  117 1685-1689
    CrossrefPubMedGoogle Scholar
  • 24 Lim T K, Chin N K. Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis.  Eur Respir J. 1999;  13 514-518
    CrossrefPubMedGoogle Scholar
  • 25 Davies R JO, Traill Z C, Gleeson F V. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection.  Thorax. 1997;  52 416-421
    CrossrefPubMedGoogle Scholar
  • 26 Bouros D, Schiza S, Patsourakis G. et al . Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: A prospective, double-blind study.  Am J Respir Crit Care Med. 1997;  155 291-295
    PubMedGoogle Scholar
  • 27 Bouros D, Schiza S, Tzanakis N. et al . Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema.  Am Respir Crit Care Med. 1999;  159 37-42
    CrossrefPubMedGoogle Scholar
  • 28 Bouros D, Antoniou K M, Chalkiadakis G. et al . The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics.  Surg Endosc. 2002;  16 151-154
    CrossrefPubMedGoogle Scholar
  • 29 Huang H, Chang H, Chen C. et al . Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusions or empyema.  Chest. 1999;  115 751-756
    CrossrefPubMedGoogle Scholar
  • 30 Morgenroth A, Pfeuffer H P, Seelmann R. et al . Pleural penetration of ciprofloxacin in patients with empyema thoracis.  Chest. 1991;  100 406-409
    PubMedGoogle Scholar
  • 31 Vaughan J J, Basran G S. Penetration of intravenous and oral ciprofloxacin into sterile and empyemic human pleural fluid.  Ann Pharmacother. 1994;  28 313-315
    PubMedGoogle Scholar
  • 32 Panzer J D, Brown D C, Epstein W L. et al . Clindamycin levels in various body tissues and fluids.  J Clin Pharmacol New Drugs. 1972;  12 259-262
    PubMedGoogle Scholar
  • 33 Makino J, Yoshiyama Y, Kanke M. et al . Pharmacokinetic study of penetration of meropenem into pleural effusion in patients with pleurisy.  Jpn J Antibiot. 2002;  55 77-88
    PubMedGoogle Scholar
  • 34 Strahilevitz J, Lev A, Levi I. et al . Experimental pneumococcal pleural empyema model: The effect of moxifloxacin.  J Antimicrob Chemother. 2003;  51 665-669
    CrossrefPubMedGoogle Scholar
  • 35 Novick W J. Levels of cefotaxime in body fluids and tissues: A rewiev.  Rev Infect Dis. 1982;  4 (Suppl) S346-S353
    PubMedGoogle Scholar
  • 36 Benoni G, Arosio E, Cuzzolin L. et al . Penetration of ceftriaxone into human pleural fluid.  Antimicrob Agents Chemother. 1986;  29 906-908
    PubMedGoogle Scholar
  • 37 Walstad R A, Hellum K B, Blika S. et al . Pharmacokinetics and tissue penetration of ceftazidime: Studies on lymph, aqueous humour, skin blister, cerebrospinal and pleural fluid.  J Antimicrob Chemother. 1983;  12 (Suppl A) 275-282
    PubMedGoogle Scholar
  • 38 Goonetilleke A K, Dev D, Aziz I. et al . A comparative analysis of pharmacokinetics of ceftriaxone in serum and pleural fluid in humans: A study of once daily administration by intramuscular and intravenous routes.  J Antimicrob Chemother. 1996;  38 969-976
    PubMedGoogle Scholar
  • 39 Wildfeuer A, Ruhle K H, Bolcskei P L. et al . Concentrations of ampicillin and sulbactam in serum and in various compartments of the respiratory tract of patients.  Infection. 1994;  22 149-151
    CrossrefPubMedGoogle Scholar
  • 40 Thys J P, Vanderhoeft P, Herchuelz A. et al . Penetration of aminoglycosides in uninfected pleural exudates and in pleural empyemas.  Chest. 1988;  93 530-532
    CrossrefPubMedGoogle Scholar
  • 41 Hughes C E, Scoy R E van. Antibiotic therapy of pleural empyema.  Semin Respir Infect. 1991;  6 94-102
    PubMedGoogle Scholar
  • 42 Soman A, Honeybourne D, Andrews J. et al . Concentrations of moxifloxacin in serum and pulmonary compartments following a single 400 mg oral dose in patients undergoing fibre-optic bronchoscopy.  J Antimicrob Chemother. 1999;  44 835-838
    CrossrefPubMedGoogle Scholar
  • 43 Vogel F, Worth H, Adam D. et al . Rationale Therapie bakterieller Atemwegsinfektionen.  Chemotherapie Journal. 2000;  1 3-23
    PubMedGoogle Scholar
  • 44 Frey D JM, Klapa J, Kaiser D. Spül-Drainage und Fibrinolyse zur Behandlung des metapneumonischen Pleuraempyems.  Pneumologie. 1999;  53 596-604
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 45 Davies R JO, Gleeson F V. The diagnosis and management of pleural empyema.  Curr Opin Pulm Med. 1998;  4 185-190
    PubMedGoogle Scholar
  • 46 Cameron R J. Management of complicated parapneumonic effusions and thoracic empyema.  Intern Med J. 2002;  32 408-414
    CrossrefPubMedGoogle Scholar
  • 47 Chin N K, Lim T K. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions.  Chest. 1997;  111 275-279
    CrossrefPubMedGoogle Scholar
  • 48 Tuncozgur B, Ustunsoy H, Sivrikoz M C. et al . Intrapleural urokinase in the management of parapneumonic empyema: A randomised clinical trial.  Int J Clin Pract. 2001;  55 658-660
    PubMedGoogle Scholar
  • 49 Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions.  Chest. 2003;  123 432-435
    CrossrefPubMedGoogle Scholar
  • 50 Light R W, Nguyen T, Mulligan M E. et al . The in vitro efficacy of varidase versus streptokinase or urokinase for liquefying thick purulent exsudative material from loculated empyema.  Lung. 2000;  178 13-18
    CrossrefPubMedGoogle Scholar
  • 51 Simpson G, Roomes D, Reeves B. Successful treatment of empyema thoracis with human recombinant deoxyribonuclease.  Thorax. 2003;  58 365-366
    CrossrefPubMedGoogle Scholar
  • 52 Davies C WH, Lok S, Davies R JO. The systemic fibrinolytic activity of intrapleural streptokinase.  Am J Respir Crit Care Med. 1998;  157 328-330
    PubMedGoogle Scholar
  • 53 Waller D A. Thoracoscopy in management of postpneumonic pleural infections.  Curr Opin Pulm Med. 2002;  8 323-326
    CrossrefPubMedGoogle Scholar
  • 54 Wait M A, Sharma S, Hohn J. et al . A randomized trial of empyema therapy.  Chest. 1997;  111 1548-1551
    CrossrefPubMedGoogle Scholar
  • 55 Sahn S A. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas.  Thorax. 1998;  53 S65-S72
    PubMedGoogle Scholar
  • 56 Cassina P C, Hauser M, Hillejan L. et al . Video-assisted thoracoscopy in the treatment of pleural empyema: Stage-based management and outcome.  J Thorac Cardiovasc Surg. 1999;  117 234-238
    CrossrefPubMedGoogle Scholar
  • 57 Loddenkemper R. Thoracoscopy - state of the art.  Eur Respir J. 1998;  11 213-221
    CrossrefPubMedGoogle Scholar
  • 58 Solér M, Wyser C, Bolliger C T. et al . Treatment of eraly parapneumonic empyema by „medical” thoracoscopy.  Schweiz Med Wochenschr. 1997;  127 1748-1753
    PubMedGoogle Scholar
  • 59 Lim T K. Management of parapneumonic effusion.  Curr Opin Pulm Med. 2001;  7 193-197
    CrossrefPubMedGoogle Scholar

Martin Kolditz

Medizinische Klinik und Poliklinik I (Direktor: Prof. Dr. med. G. Ehninger) · Universitätsklinikum Carl Gustav Carus

Fetscherstr. 74

01307 Dresden