A 60-year-old man comes to the clinic due to a 3-week history of fatigue, shortness of breath, and fever. The patient has a 35-pack-year history of cigarette smoking but has no other significant medical history. Temperature is 38.6 C (101.5 F), blood pressure is 140/92 mm Hg, pulse is 110/min, and respirations are 24/min. There is dullness to percussion at the right lung base. Chest radiograph shows a moderate-sized loculated pleural effusion on the right side. Ultrasonography reveals multiple separate fluid pockets within the pleural space. Chest tube placement produces only a small amount of thick pus. Intrapleural administration of a medication with which of the following effects would most likely improve chest tube drainage in this patient?

Question

A 60-year-old man comes to the clinic due to a 3-week history of fatigue, shortness of breath, and fever.  The patient has a 35-pack-year history of cigarette smoking but has no other significant medical history.  Temperature is 38.6 C (101.5 F), blood pressure is 140/92 mm Hg, pulse is 110/min, and respirations are 24/min.  There is dullness to percussion at the right lung base.  Chest radiograph shows a moderate-sized loculated pleural effusion on the right side.  Ultrasonography reveals multiple separate fluid pockets within the pleural space.  Chest tube placement produces only a small amount of thick pus.  Intrapleural administration of a medication with which of the following effects would most likely improve chest tube drainage in this patient?

Quizplus · Accepted Answer

11ec160b_3c63_6235_9249_a350450d9c80_MD0001_00 This patient's several weeks of fever, shortness of breath, and fatigue with imaging showing a loculated pleural effusion with complex septations represents a classic presentation of empyema. Empyema is an advanced form of complicated parapneumonic effusion in which bacterial invasion into the pleural space is followed by progressive inflammation with pus accumulation and organized fibrosis. Treatment requires prompt drainage of the infected fluid via a chest tube, but such effusions are often difficult to drain due to numerous loculations (ie, separated fluid pockets) and high fluid viscosity. In some cases, intrapleural administration of a fibrinolytic agent (eg, tissue plasminogen activator [tPA], streptokinase) in combination with deoxyribonuclease (DNase) can improve drainage of a loculated empyema and help resolve the effusion via chest tube drainage. The tPA activates fibrin-bound plasminogen to break down organized fibrin, and the DNase enzyme may assist by cleaving nucleic acids that increase fluid viscosity after being deposited by lysed leukocytes (eg, neutrophil extracellular traps). A complicated parapneumonic effusion or empyema that cannot be successfully drained following the administration of tPA and DNase typically requires surgical drainage via video-assisted thoracoscopic surgery. (Choice B) Interstitial edema formation occurs early in the development of pleural effusion, causing increased fluid to pass into the pleural space. Once organized fibrosis and empyema develop, reducing interstitial edema formation is of no significant benefit. (Choices C and D) Factor Xa inhibitors (eg, rivaroxaban, apixaban) are given systemically for the treatment of venous thromboembolic disease, and medications that inhibit platelet activity (eg, aspirin, P2Y12 inhibitors) are used systemically to lower the risk of intra-arterial thrombosis. However, none of these medications target fibrin (the major contributor to development of loculated empyema), and they are therefore not helpful in the management of empyema. (Choice E) Pleurodesis involves the instillation of a chemical irritant (eg, talc) into the pleural space to fuse the visceral and parietal pleural layers together. It is used to prevent reaccumulation of pleural fluid in patients with recurrent pleural effusion, but it does not assist in drainage of an empyema. Educational objective: Empyema involves bacterial invasion of the intrapleural space with progressive inflammation, pus accumulation, and organized fibrosis. Drainage with a chest tube is often difficult due to loculations and high fluid viscosity, but it can be aided by the intrapleural administration of a fibrinolytic agent (eg, tissue plasminogen activator) in combination with a nucleic acid cleaving enzyme (ie, deoxyribonuclease). __________ References: Intrapleural use of tissue plasminogen activator and DNase in pleural infection. (http://www.ncbi.nlm.nih.gov/pubmed/21830966)

A 60-Year-Old Man Comes to the Clinic Due to a 3-Week