Margaret Winter ppt 2014 [Microsoft PowerPoint]
BLOOD PLEURODESIS IN A GREAT
DANE WITH A PERSISTENT,
SPONTANEOUS PNEUMOTHORAX
Maggie Winter
4/23/13
Advisors: Dr. DiFazio, Dr. Flanders
The Patient
• 7yr, FS, Great Dane
• 3 day history of tachypnea and dyspnea while at boarding facility
• rDVM took radiographs and found…
Pneumothorax
What is a pneumothorax?
Accumulation of air in the pleural space
Pneumothorax- review
Open vs. Closed vs. Both
Traumatic Iatrogenic
HBC, high rise syndrome, bite wounds
Thoracocentesis, ET cuff,
PEEP barotrauma
Excellent Prognosis Good Prognosis
Spontaneou s
1°- no lung dz
2°- lung dz
Etiology
Bullae/bleb rupture (bullous emphysema )
Parasites
Dirofilaria immitis (heart worm)
Paragonimus spp. cysts (lung fluke)
Migrating FB
Grass awns, porcupine quills
Severe pneumonia
Feline asthma
Neoplasia
Prognosis: variable dependent upon etiology and treatment modality
Risk Factors
Siberian Huskies
Bullous emphysema
Medium/Large breeds
No age or sex predilection
Diagnosis
Decreased BV sounds
Diagnostic/therapeutic thoracocentesis
Thoracic radiographs
Often no evidence of etiology
Thoracic CT
Determine etiology
Surgical planning
Treatment
Stabilization- thoracocentesis/thoracostomy tubes + O
2 supplementation + antacid
Risk of regurgitation 2° to aerophagia
Exploratory median sternotomy
UNLESS there is non-surgical dz identified preoperatively
Parasites
Diffuse pulmonary dz
Significantly lower recurrence & mortality in patients treated surgically
Let’s return to our patientrDVM (9/10/13)
Radiographs
Bilateral pneumothorax
Diffuse interstitial pattern
Thoracocentesis
>1 liter of air from each hemithorax
Bilateral Mila chest tubes
Continuous suction
Referred to CUHA the next morning
CUHA Emergency Service (9/11/13):
PE:
Tachycardic (HR=180 bpm)
Tachypneic (RR=60 brpm)
Decreased BV sounds dorsally
Under conditioned (BCS 3/9) + muscle atrophy
Short strided gait
Severe medial buttress (L > R)
Claws scuffed down to P3 x 4
Severe pododermatitis
Initial diagnostics & treatments
QATs = normal
Venous blood gas = mild respiratory alkalosis
SpO
2
= 97% (on room air)
Stabilization: O
2 supplementation via intranasal cannulas, tapped chest via tubes, analgesia
Overnight: continuous suction, antibiotics, IV fluids, gastroprotectant
Transferred to the soft tissue surgery service the next day
Problem List
Spontaneous pneumothorax
DDX: ruptured bullae, neoplasia, infectious
Diffuse interstitial pattern
DDX: atelectasis, lung lobe torsion, pneumonia, neoplasia, immune mediated dz, hemorrhage
Severe generalized muscle wasting
DDX: paraneoplastic, malabsorption/maldigestion, nutritional, orthopedic disease
Abnormal gait (with scuffed claws)
DDX: OA, disc disease, wobbler’s, poor muscle tone
Pododermatitis
DDX: allergies, pain, peripheral neuropathy, behavioral
Surgery Service Plan:
Stifle radiographs
R/O: neoplasia
Results: Osteoarthritis
Thoracic CT
Etiology
± Exploratory Thoracotomy
Bullae
Treatment Plan:
REMEMBER:
Spontaneous pneumothorax is a surgical disease!
Our patient:
Median sternotomy
Multiple partial lung lobectomies + Histopathology
5 days post-op supportive care in the ICU with persistent pneumothorax!
Owner wanted to bring patient home
What happens if surgery fails or isn’t an option?
• Pleural port
• Blood pleurodesis
• Sclerosing agents
Pleural Port
Not recommended as first line of treatment
Case report:
2 patients with persistent pneumothrax despite thoracotomy
tapped on outpatient basis until resolution (≤ 2 weeks)
then went 17 & 23 months before euthanasia
How it works…
22g Huber needle
Placed SQ in the 7 th or 8 th ICS
Our Patient’s Pleural Port
Autologous Blood Pleurodesis
Infusing a patient’s own blood into their pleural space to treat pneumothorax or thoracic effusion
MOA: unknown
Elicits inflammatory rxn pleural adhesions obliterates space for air to accumulate
Sealing sites of air leakage with clots
Signs resolve rapidly- immediately to <24hrs
Autologous blood dose: none established
Rat study- 2-3 mL/kg
Case reports- up to 5mL/kg
Our patient- 4.2mL/kg (250mL)
Autologous Blood Pleurodesis
Minimal reported side effects in dogs
Humans- fever
Variable efficacy
Human studies show efficacy in 57%-100% Tx
Rabbit study showed ineffective Tx using 1mL/kg autologous blood
Conclusion:
Safe, simple, inexpensive Tx for persistent pneumothorax when surgery is not an option or fails
Sclerosing Agents
• Second line of treatment
• Lack of prospective randomized studies
1. Talc powder
2. Silver nitrate
3. Tetracycline
4. Doxycycline
Sclerosing Agents
Talc
Slurry vs. Poudrage – similar efficacy
ARDS reported rarely
~87% success rate (humans)
Widely used
Ineffective in rabbit study, effective in dog & pig studies
Species-dependent dosage?
Silver nitrate
Rabbits- more intense pleural reaction than talc in 1 st 6hrs
Hemothorax, atelectasis post treatment
Sclerosing Agents
Tetracycline
Historically used
Not available
Doxycycline
Proven to form adhesions/fibrosis
Associated with longer hospital stay and discomfort
Conclusion:
No single “best” sclerosing agent
Talc has high reported success
Need randomized prospective studies to determine efficacy and dosages
Our Patient
250mL autologous blood pleurodesis
Blood from jugular infused through chest tube
Alternated down side a few times distribute blood
Pulled thoracostomy tube and discharged from CUHA several hours later
rDVM Update 1 month later
No respiratory issues for 1 month
Presented to rDVM for:
Progressive weight loss, anorexia, lethargy
Recurrent urinary tract infection refractory to antibiotics
T = 103°F
Mature neutrophillia
Rads: scant pleural effusion
Cost
Exploratory thoracotomy + lung lobectomy = $1,856
Stifle rads + thoracic CT w/contrast = $552
Pleural port placement = $806
Huber needles (5) = $31
Blood pleurodesis = $115
Hospitalization + diagnostics + stabilization + care + meds = $3,983.36
Total = $7,343.36
References
Cahalane, Kosanovich A, Flanders J. Use of Pleural Access Ports for Treatment of Recurrent Pneumothorax in Two Dogs. J Am Vet Med Assoc 2012; 241.4:467-471.
Jerram R, Fossum T, Berridge B, Steinheimer D, Slater M. The Efficacy of Mechanical Abrasion and Talc
Slurry as Methods of Pleurodesis in Normal Dogs. Vet Surg 1999; 28.5:322-332.
Merbl Y, Kelmer E, Shipov A, et al. Resolution of persistent pneumothorax by use of blood pleurodesis in a dog after surgical correction of a diaphragmatic hernia. J Am Vet Med Assoc 2010; 237:299–303.
Mitchem R, Herndon B, Fiorella R, et al. Pleurodesis by Autologous Blood, Doxycycline, and Talc in a Rabbit
Model. Ann Thorac Surg 1999; 67:917-921.
Oliveira, Frederico H, Cataneo D, Ruiz R, Cataneo A. Persistent Pleuropulmonary Air Leak Treated with
Autologous Blood: Results from a University Hospital and Review of Literature. Respiration (2010);
79.4:302-306.
Ozpolat B, Gazyagci S, Gozubuyuk A, et al. Autologous Blood Pleurodesis in Rats to Elucidate the Amounts of Blood Required for Reliable and Reproducible Results. J Surg Res 2010; 161:228-232.
Puerto D, Brockman D, Lindquist C, et al. Surgical and non-surgical management of and selected risk factors for spontaneous pneumothorax in dogs: 64 cases (1986-1999). J Am Vet Med Assoc 2002;
220:1670–1674.
Smith S, Byers C. Spontaneous Pneumothorax Compendium 2009; 11.3:5-11.
Tschopp J, Rami-Porta R, Noppen M, Astoul P. Management of Spontaneous Pneumothorax: State of the
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