Transcript BLOOD pleurodesis in a great dane with a persistent

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
Prognosis: variable
Neoplasia
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 + O2 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
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

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

QATs = normal
Venous blood gas = mild respiratory alkalosis
SpO2 = 97% (on room air)
Stabilization: O2 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


Diffuse interstitial pattern


DDX: paraneoplastic, malabsorption/maldigestion,
nutritional, orthopedic disease
Abnormal gait (with scuffed claws)


DDX: atelectasis, lung lobe torsion, pneumonia, neoplasia,
immune mediated dz, hemorrhage
Severe generalized muscle wasting


DDX: ruptured bullae, neoplasia, infectious
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 7th or 8th 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:
 Rat
none established
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.
2.
3.
4.
Talc powder
Silver nitrate
Tetracycline
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 1st 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
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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
Art. Eur Respir J 2006; 28.3:637-650.
Questions?