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Disorders of the Pleura |

“Ubi Pus, Ibi Evacua.” A Case of Complex Pleuroparenchymal Disease and Late Onset Empyema After Severe ARDS and Prolonged Mechanical Ventilation

Nazir Lone, MD; Yuji Oba, MD; Troy Whitacret, RRT; William Parker, DO; Harbaksh Sangha, MD; Ying Wang, MD; Hunter Hofmann, MD
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University of Missouri, Columbia, MO


Chest. 2013;144(4_MeetingAbstracts):490A. doi:10.1378/chest.1699697
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Abstract

SESSION TITLE: Pleural Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Complex pleuro-parenchymal disease and late onset empyema carries high mortality and morbidity. It is difficult to manage with prolonged antibiotics and chest tube drainage alone.1 We describe a case of severe ARDS complicated by nonresolving pleuro-parenchymal pathology that necessitated open wound thoracostomy (OWT) and vacuum-assisted closure (VAC).

CASE PRESENTATION: 35-years old female, never smoker, was admitted with acute hypoxemic respiratory failure. Prior to admission patient was treated for urinary tract infection with bactrim. Patient presented with fever, sob, pleuritic chest pain and dry cough. Patient had tachypnea, tachycardia and decreased bilateral breath sounds. ABG on 15 liters o2 showed Ph 7.42, Pco2 41.4 mmhg, po2 54.7 mmhg and sao2 of 86.5. Admission CXR is shown (Fig1a). Initial chest CT scan showed bilateral upper lobe diffuse ground-glass opacities and no pulmonary embolism. Intravenous antibiotics were started for presumed community acquired pneumonia. Patient was mechanically ventilated with TV <6ml/kg IBW and required peep of 25 cms to keep Spo2 goal of > 88%. Further diagnostic work up is shown (tab1). Patient had open lung biopsy (Fig1b). Systemic steroids were started. Respiratory failure and desaturation gradually progressed. Repeat CT scan of chest is shown (Fig2a). Nontraditional modalities for refractory ARDS (NMBD, iNo, HFO, Swan ganz) were attempted. Patient remained in respiratory failure for few weeks until profound volutrauma ensued (Fig2b). Later hospital course was complicated by recurrent pneumonia and drainage of pus from right pleural space. Despite prolonged antibiotics and multiple chest tubes, patient’s clinical condition deteriotated. Patient underwent open wound thoracostomy and VAC (Fig 3ab). Few weeks later patient was discharged home on 2 liters of nasal cannula with no chest tubes.

DISCUSSION: Complex pleuro- parenchymal disease can be a sequela of severe ARDS, lung resections, ventilator induced lung injury and repeated infections. Our patient had organizing diffuse alveolar damage of unknown etiology complicated by severe ARDS and empyema that triggered a nonresolving pleuro-parenchymal disease. Failure of multiple chest tube drainage and prolonged antibiotics necessitated an OWT with VAC. While the basic rule of “Ubi pus, ibi evacua” remains true; the key question is- how to do it? Early radical thoracic surgical procedure and less invasive techniques have been described but there is no universal approach for treating these patients.2

CONCLUSIONS: Further studies are needed for pattern recognition and epidemiological risk factors for complex pleuro-parenchymal disease in critically ill patients. Early use of VAC may be beneficial in this condition.

Reference #1: Davies etal . Predictors of outcome and long-term survival in patients with pleural infection. AJRCCM 1999;160:1682-7

Reference #2: Meindert et al: OWT Treatment of Empyema Is Accelerated by Vacuum-Assisted Closure. Ann Thorac Surg 2009;88:1131-7

DISCLOSURE: The following authors have nothing to disclose: Nazir Lone, Yuji Oba, Troy Whitacret, William Parker, Harbaksh Sangha, Ying Wang, Hunter Hofmann

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