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Management des parapneumonischen Ergusses und des Pleuraempyems

Management of parapneumonic effusion and pleural empyema

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Zusammenfassung

Etwa 50.000 Patienten entwickeln jährlich in Deutschland einen parapneumonischen Pleuraerguss. Die Prognose der Pneumonien wird dadurch ungünstig beeinflusst. Eine rasche Diagnose mittels bildgebender Verfahren und diagnostischer Pleurapunktion ist daher erforderlich. Basierend auf diagnostischen Kriterien lässt sich der parapneumonische Erguss in eine unkomplizierte und eine komplizierte Verlaufsform sowie das Pleuraempyem unterteilen. Therapeutische Strategien umfassen die parallele Einleitung einer empirischen antimikrobiellen Therapie unter Einschluss grampositiver, gramnegativer und anaerober Erreger und die rasche und vollständige Entfernung der infizierten Pleuraflüssigkeit. Adäquate Verfahren zur Ergussentfernung schließen die (wiederholte) Pleurapunktion, die Saugdrainage, die intrapleurale Fibrinolyse und thoraxchirurgische Verfahren ein. Ihre Anwendung erfolgt nach individueller Risikostratifizierung unter Berücksichtigung diagnostischer Kriterien wie Ausdehnung und Aussehen des Ergusses, mikrobiologischem Erregernachweis und biochemischer Parameter.

Abstract

Approximately 50,000 patients annually develop parapneumonic effusions in Germany. These effusions are of prognostic significance in pneumonia. Thus urgent diagnosis by imaging procedures and diagnostic thoracentesis is indicated. Based on diagnostic criteria, parapneumonic effusions can be classified as uncomplicated and complicated effusions and finally pleural empyema. Management strategies include the administration of broad-spectrum antimicrobial therapy covering gram-positive, gram-negative and anaerobic bacteria and the sufficient drainage of the infected pleural fluid. Adequate drainage procedures include thoracentesis, chest tube insertion, application of local fibrinolytics and thoracic surgery. Their application should be selected after individual risk stratification including the assessment of the pleural space anatomy and appearance as well as microbiological and biochemical analysis of the pleural fluid.

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Literatur

  1. Sahn SA (2007) Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis 45: 1480–1486

    Article  PubMed  CAS  Google Scholar 

  2. Hasley PB, Albaum MN, Li Y-H, Fuhrman C et al. (1996) Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia? Arch Intern Med 156: 2206–2212

    Article  PubMed  CAS  Google Scholar 

  3. Krueger S, Pauls S, Marre R et al. (2007) Correlation of accompanying pleural effusion with patient characteristics and mortality in patients with community acquired pneumonia. Eur Respir J 30 (Suppl 51): Abstract E3945

    Google Scholar 

  4. Ferguson AD, Prescott RJ, Selkon JB et al. (1996) The clinical course and management of thoracic empyema. QJM 89: 285–289

    PubMed  CAS  Google Scholar 

  5. Maskell NA, Davies CWH, Nunn AJ et al. (2005) U.K. controlled trial of intrapleural streptokinase for pleural infection. N Eng J Med 352: 865–874

    Article  CAS  Google Scholar 

  6. Light RW (2006) Parapneumonic effusions and empyema. Proc Am Thorac Soc 3: 75–80

    Article  PubMed  CAS  Google Scholar 

  7. Welte T, Marre R, Suttorp N (2006) What is new in the treatment of community-acquired pneumonia? Med Klin 101: 313–320

    Article  Google Scholar 

  8. Bryant RE, Salmon CJ (1996) Pleural empyema. Clin Infect Dis 22: 747–764

    PubMed  CAS  Google Scholar 

  9. Fine NL, Smith LR, Sheedy PF (1970) Frequency of pleural effusion in mycoplasma and viral pneumonias. N Eng J Med 283: 790–793

    CAS  Google Scholar 

  10. Kolditz M, Halank M, Höffken G (2004) Parapneumonischer Erguss und Pleuraempyem – aktuelle Aspekte zu Einteilung, Diagnose und Therapie. Pneumologie 58: 83–91

    Article  PubMed  CAS  Google Scholar 

  11. Maskell NA, Batt S, Hedley EL et al. (2006) The bacteriology of pleural infection by genetic and standard methods and its mortality significance. Am J Respir Crit Care Med 174: 817–823

    Article  PubMed  Google Scholar 

  12. Höffken G, Lorenz J, Kern W et al. (2005) Epidemiologie, Diagnostik, antimikrobielle Therapie und Management von erwachsenen Patienten mit ambulant erworbenen tiefen Atemwegsinfektionen sowie ambulant erworbener Pneumonie. S3-Leitlinie der Paul-Ehrlich-Gesellschaft für Chemotherapie e.V., der Deutschen Gesellschaft für Pneumologie, der Deutschen Gesellschaft für Infektiologie und vom Kompetenznetzwerk CAPNETZ. Chemother J 4: 97–155

    Google Scholar 

  13. Metersky ML (2003) Is the lateral decubitus radiograph necessary for the management of a parapneumonic pleural effusion? Chest 124: 1129–1132

    Article  PubMed  Google Scholar 

  14. Heffner JE, Brown LK, Barbieri C, de Leo JM (1995) Pleural fluid chemical analysis in parapneumonic effusions. Am J Respir Crit Care Med 151: 1700–1708

    PubMed  CAS  Google Scholar 

  15. Cheng D, Rodriguez RM, Rogers J et al. (1998) Comparision of pleural fluid pH values obtained using blood gas machine, pH meter, and pH indicator strip. Chest 114: 1368–1372

    Article  PubMed  CAS  Google Scholar 

  16. Jiménez D, Díaz G, García-Rull S et al. (2006) Routine use of pleural fluid cultures. Are they indicated? Limited yield, minimal impact on treatment decisions. Respir Med 100: 2048–2052

    Article  PubMed  Google Scholar 

  17. Porcel JM, Ruiz-González A, Falguera M et al. (2007) Contribution of a pleural antigen assay (Binax NOW) to the diagnosis of pneumococcal pneumonia. Chest 131: 1442–1447

    Article  PubMed  Google Scholar 

  18. Thys JP, Vanderhoeft P, Herchuelz A et al. (1988) Penetration of aminoglycosides in uninfected pleural exudates and in pleural empyemas. Chest 93: 530–532

    Article  PubMed  CAS  Google Scholar 

  19. Frey DJM, Klapa J, Kaiser D (1999) Spül-Drainage und Fibrinolyse zur Behandlung des metapneumonischen Pleuraempyems. Pneumologie 53: 596–604

    Article  PubMed  CAS  Google Scholar 

  20. Colice GL, Curtis A, Deslauriers J et al. (2000) ACCP consensus statement: medical and surgical treatment of parapneumonic effusions. An evidence-based guideline. Chest 18: 1158–1171

    Article  Google Scholar 

  21. Maskell N, Nunn A, Davies RJO (2006) Intrapleural streptokinase for pleural infection. BMJ 332: 552

    Article  PubMed  Google Scholar 

  22. Davies RJO, Traill ZC, Gleeson FV (1997) Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 52: 416–421

    Article  PubMed  CAS  Google Scholar 

  23. Bouros D, Schiza S, Patsourakis G et al. (1997) Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: A prospective, double-blind study. Am J Respir Crit Care Med 155: 291–295

    PubMed  CAS  Google Scholar 

  24. Tuncozgur B, Ustunsoy H, Sivrikoz MC et al. (2001) Intrapleural urokinase in the management of parapneumonic empyema: a randomised clinical trial. Int J Clin Pract 55: 658–660

    PubMed  CAS  Google Scholar 

  25. Diacon AH, Theron J, Schuurmans MN et al. (2004) Intrapleural streptokinase for empyema in complicated parapneumonic effusions. Am J Respir Crit Care Med 170: 49–53

    Article  PubMed  Google Scholar 

  26. Tokuda Y, Matsushima D, Stein GH, Miyagi S (2006) Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest 129: 783–790

    Article  PubMed  CAS  Google Scholar 

  27. Bouros D, Schiza S, Patsourakis G et al. (1997) Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double-blind study. Am J Respir Crit Care Med 155: 291–295

    PubMed  CAS  Google Scholar 

  28. Luh SP, Chou MC, Wang LS et al. (2005) Video-assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients. Chest 127: 427–432

    Article  Google Scholar 

  29. Loddenkemper R (1998) Thoracoscopy – state of the art. Eur Respir J 11: 213–221

    Article  PubMed  CAS  Google Scholar 

  30. Brutsche MH, Tassi GL, Györik S et al. (2005) Treatment of sonographically stratified multiloculated thoracic empyema by medical thoracoscopy. Chest 128: 3303–3309

    Article  PubMed  Google Scholar 

  31. Bouros D, Antoniou KM, Chalkiadakis G et al. (2002) The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics. Surg Endosc 16: 151–154

    Article  PubMed  CAS  Google Scholar 

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  1. Abteilung für Pneumologie, Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus, Fetscherstraße 74, 01307, Dresden, Deutschland

    M. Kolditz & G. Höffken

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  1. M. Kolditz
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  2. G. Höffken
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Correspondence to M. Kolditz.

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Kolditz, M., Höffken, G. Management des parapneumonischen Ergusses und des Pleuraempyems. Pneumologe 5, 219–228 (2008). https://doi.org/10.1007/s10405-008-0248-2

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