Lung-function trajectories leading to chronic obstructive pulmonary disease

Pleural irrigation with normal saline for empyemaPleural infection remains a serious condition that has significant morbidity and mortality.[1] In wellresourced countries the mortality is estimated to be approximately 20% in the 6 months following the initial presentation.[2] Despite this alarming mortality, controversy remains regarding the management and specifically the role of fibrinolytic therapy.[3] The impact of pleural infections is likely to be greater in resource-limited countries like South Africa where there is a high prevalence of infectious diseases.Medical management with intravenous antibiotics and intercostal drainage is the mainstay of treatment, but this fails in a proportion of patients, mandating surgical intervention.Pre-emptive surgical management is of unproven benefit and may be costly.In 2011, The Multi-centre Intra-pleural Sepsis Trial (MIST 2) suggested that a combination of tissue plasminogen activator and DNase improves the chest radiographic appearance after a week, but this approach is expensive and requires further validation.[4] Intrapleural saline irrigation is a simple technique that has been performed in many European countries despite the lack of evidence of its efficacy from controlled trials.A recent randomised controlled pilot study -the Pleural Irrigation Trial (PIT) -was performed in 35 patients with pleural infection requiring chest-tube drainage in which pleural irrigation with saline plus best-practice management was compared with the latter alone.[5] Patients receiving the additional saline irrigation had a greater reduction in pleural collection volume on computed tomography compared with those receiving standard care: 32.3% v. 15.3%.Additionally, significantly fewer patients in the irrigation group were subsequently referred for surgery (odds ratio 7.1, 95% confidence interval 1.23 -41.0; p=0.03).There was no difference in length of hospital stay, fall in C-reactive protein, white cell count, procalcitonin or adverse events between the treatment groups, and no serious complications were documented.This pilot study indicates that pleural irrigation with normal saline may increase pleural fluid drainage and reduce referrals for surgery in pleural infections.This may provide a simple and cost-effective alternative to more expensive regimens should the results of this pilot study be reproduced in larger controlled studies.