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Drug Treatment of Chronic Tuberculous Empyema
this difficult, due to extreme disabili~ In this case, we initiate a home care referral so that stripping can be done in the home. We use a frequency of twice a week for the first week, with a decrease in frequency if the patient is successful in independently expelling mucus balls. We have found that experienced home care Dursesand respiratory therapists who perform tracheostomy tube changes learn this skill easily. The case report by Burton and colleaguesl does not discuss whether the catheter was stripped to check for mucus ball formation, although we presume that this was not done, given the size of the mucus ball formation. We strongly advocate a program of close monitoring, with stripping if symptoms develop or routinely if the patient is at high risk.
laUe A Hoffman, R.N., Ph.D.,
LIpan F. ReInke, R.N., M.S.N., Swan W ~ R.N., M.S.N., and Frank C. Sciurba, M.D., University of Pittsburgh,
Pittsburgh
Reprint requests: Dr Hoffman, Uni~ of Pittsburgh School Nursing, 367 Victoria Hill, Pittsburgh, PA 15261
of
REFERENCES 1 Burton GG, Wagshul FA, Henderson D, IGme SW Fatal airway obstruction caused by a mucus ball from a transtracheal oxygen catheter. Chest 1991; 99:1520-23 2 Hoftinan LA, Johnson J'I: Wesmiller S~ Sciurba FC, Ferson PF, Mazzocco MC, et ale Transtracheal delivery of oxygen: efficacy and safety for long-term continuous the~ Ann Otol Rhinol Laryngoll991; 100:108-15 3 Adamo J~ Mehta AC, Stelmach Ie, Meeker D, Rice T, Stoller JK. The Cleveland Clinic's initial experience with transtracheal oxygen thera~ Respir Care 1990; 35:153-60 4 Fletcher EC, Nickeson D, Costarangos-Galarza C. Endotracheal mass resulting from a transtracheal oxygen catheter. Chest 1988; 93:438-39 5 Spofford BT, Christopher KL. SCOOP transtracheal oxygen therapy clinician guide. Englewood, Colo: Transtracheal Systems, 1990 7b the Editor:
The communications of van der Werf et al and Hoftinan et al reinforce our concern about the potentially serious complication of mucus ball airway obstruction complicating 110;1: In our case, catheter stripping was performed seven days after SCOOP I catheter placement, as recommended by the Institute of Transtracheal Oxygen Thera~ No expectoration of mucus balls was observed following this procedure. The fatal outcome described in our case reportl has resulted in a heightened clinical index of suspicion for the presence of this complication, but has not prevented our team's use of this valuable therapy adjunct in appropriately selected patients. Vigorous mucolytic therapy in such patients is clearly important, as it is in all patients with chronic obstructive pulmonary disease who demonstrate airway secretion clearance impairments. I George G. Burton, M.D., F.C.C.I!, Fred A. WJgshul, M.D., Diannah Hendersoo, R.N., and S. Wesley Kime, M.D., Kettering Medical Center; Kettering, Ohio
REFERENCES
1 Burton GG, Wagshul FA, Henderson D, IGme SW Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter. Chest 1991; 99:1520-23 2 Petty TL. The National Mucolytic Stud~ Chest 1990; 97:75-83
Drug Treatment of Chronic Tuberculous Empyema ~ read with great interest the article by Iseman and Madsen, 1 which appeared in the July 1991 issue of Chest. The message that impaired drog penetration into infected tuberculous empyema can
result in subtherapeutic concentrations, leading to acquired drug resistance and treabnent failure, deserves attention. Adjunctive surgical intervention, as put forward by Iseman and Madsen, should be advocated. However, when one is limited by the compromised cardiopulmonary status of the patient or refusal of surgical treatment, intensive chemotherapy with multiple drugs has to be considered. Ofloxacin, a 8uoroquinolone, has been shown to be active against Mycobacterium tuberculosis in vitro.1.3 It has also been demonstrated to exhibit clinical efficacy in patients with severe cavitary pulmonary tuberculosis who harbor multiply resistant organisms. 4 In addition, we have found lately that the drog penetrates tuberculous effusion exceedingly well. s The sputum/serum and pleural 8uidlserum drog ratios have been found to be about 0.8 and 0.9, respectivel~ in the two aforementioned studies. Although, as Iseman and Madsen l pointed out, the behavior of tuberculous empyema might be different from that of effusion, we still feel, subject to further verification studies on tuberculous empyema, that ofloxacin might have a place in combination chemotherapy in the former clinical setting.
Wing Wai y~ M.B., F.C.C.E!, and joseph Lee, M.B.,
1bberculosis and Chest Unit, Grantham Hospital,
Hong Kong
REFERENCES 1 Iseman MD, Madsen LA. Chronic tuberculous empyema with bronchopleuralfistula resulting in treatment failure and progressive drog resistance. Chest 1991; 100:124-27 2 Berlin OG~ Young LS, Bruckner DA. In vitro activity of six fluorinated quinolones against Mycobacterium tuberculosis. J Antimicrob Chemother 1987; 19:611-15 3 Texier-Maugein J, Mormede M, Fourche J, Bebear C. In vitro activity of four 8uoroquinolones against eighty-six isolates of mycobacteria. Eur J Clin Microbioll987; 6:584-86 4 Yew ~ Kwan SYL, Ma WK, Aung MK, Chau PY. In vitro activity of 080xacin against Mycobacterium tuberculosis and its clinical efficacy in multiply resistant pulmonary tuberculosis. J Antimicrob Chemother 1990; 26:227-36 5 Yew ~ Lee J, Chan CY, Cheung S~ Wong PC, Kwan SYL. Ofloxacin penetration into tuberculous pleural effusion. Antimicrob Agents Chemother 1991; 35:2159-60
7b the Editor:
We appreciate very much the interest and comments about our article on the management of chronic tuberculous empyema. Our group has also been studying the role of fluoroquinolone drugs (particularly cipro80xacin and 080xacin) in the treatment of patients with tuberculosis resistant to multiple drogs. In fact, four of the five patients in our article, all four of whom failed therapy, received one of the agents. Although we do not have drug levels directly from the empyema spaces to document poor penetration, we do have serum drug levels to confirm that we achieved high, therapeutic concentrations of the 8uoroquinolones and other medications in the blood of these patients. Hence, in view of the poor response, we infer that there CHEST I 101 I 6 I JUNE, 1992
1741
laUe A Hoffman, R.N., Ph.D.,
LIpan F. ReInke, R.N., M.S.N., Swan W ~ R.N., M.S.N., and Frank C. Sciurba, M.D., University of Pittsburgh,
Pittsburgh
Reprint requests: Dr Hoffman, Uni~ of Pittsburgh School Nursing, 367 Victoria Hill, Pittsburgh, PA 15261
of
REFERENCES 1 Burton GG, Wagshul FA, Henderson D, IGme SW Fatal airway obstruction caused by a mucus ball from a transtracheal oxygen catheter. Chest 1991; 99:1520-23 2 Hoftinan LA, Johnson J'I: Wesmiller S~ Sciurba FC, Ferson PF, Mazzocco MC, et ale Transtracheal delivery of oxygen: efficacy and safety for long-term continuous the~ Ann Otol Rhinol Laryngoll991; 100:108-15 3 Adamo J~ Mehta AC, Stelmach Ie, Meeker D, Rice T, Stoller JK. The Cleveland Clinic's initial experience with transtracheal oxygen thera~ Respir Care 1990; 35:153-60 4 Fletcher EC, Nickeson D, Costarangos-Galarza C. Endotracheal mass resulting from a transtracheal oxygen catheter. Chest 1988; 93:438-39 5 Spofford BT, Christopher KL. SCOOP transtracheal oxygen therapy clinician guide. Englewood, Colo: Transtracheal Systems, 1990 7b the Editor:
The communications of van der Werf et al and Hoftinan et al reinforce our concern about the potentially serious complication of mucus ball airway obstruction complicating 110;1: In our case, catheter stripping was performed seven days after SCOOP I catheter placement, as recommended by the Institute of Transtracheal Oxygen Thera~ No expectoration of mucus balls was observed following this procedure. The fatal outcome described in our case reportl has resulted in a heightened clinical index of suspicion for the presence of this complication, but has not prevented our team's use of this valuable therapy adjunct in appropriately selected patients. Vigorous mucolytic therapy in such patients is clearly important, as it is in all patients with chronic obstructive pulmonary disease who demonstrate airway secretion clearance impairments. I George G. Burton, M.D., F.C.C.I!, Fred A. WJgshul, M.D., Diannah Hendersoo, R.N., and S. Wesley Kime, M.D., Kettering Medical Center; Kettering, Ohio
REFERENCES
1 Burton GG, Wagshul FA, Henderson D, IGme SW Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter. Chest 1991; 99:1520-23 2 Petty TL. The National Mucolytic Stud~ Chest 1990; 97:75-83
Drug Treatment of Chronic Tuberculous Empyema ~ read with great interest the article by Iseman and Madsen, 1 which appeared in the July 1991 issue of Chest. The message that impaired drog penetration into infected tuberculous empyema can
result in subtherapeutic concentrations, leading to acquired drug resistance and treabnent failure, deserves attention. Adjunctive surgical intervention, as put forward by Iseman and Madsen, should be advocated. However, when one is limited by the compromised cardiopulmonary status of the patient or refusal of surgical treatment, intensive chemotherapy with multiple drugs has to be considered. Ofloxacin, a 8uoroquinolone, has been shown to be active against Mycobacterium tuberculosis in vitro.1.3 It has also been demonstrated to exhibit clinical efficacy in patients with severe cavitary pulmonary tuberculosis who harbor multiply resistant organisms. 4 In addition, we have found lately that the drog penetrates tuberculous effusion exceedingly well. s The sputum/serum and pleural 8uidlserum drog ratios have been found to be about 0.8 and 0.9, respectivel~ in the two aforementioned studies. Although, as Iseman and Madsen l pointed out, the behavior of tuberculous empyema might be different from that of effusion, we still feel, subject to further verification studies on tuberculous empyema, that ofloxacin might have a place in combination chemotherapy in the former clinical setting.
Wing Wai y~ M.B., F.C.C.E!, and joseph Lee, M.B.,
1bberculosis and Chest Unit, Grantham Hospital,
Hong Kong
REFERENCES 1 Iseman MD, Madsen LA. Chronic tuberculous empyema with bronchopleuralfistula resulting in treatment failure and progressive drog resistance. Chest 1991; 100:124-27 2 Berlin OG~ Young LS, Bruckner DA. In vitro activity of six fluorinated quinolones against Mycobacterium tuberculosis. J Antimicrob Chemother 1987; 19:611-15 3 Texier-Maugein J, Mormede M, Fourche J, Bebear C. In vitro activity of four 8uoroquinolones against eighty-six isolates of mycobacteria. Eur J Clin Microbioll987; 6:584-86 4 Yew ~ Kwan SYL, Ma WK, Aung MK, Chau PY. In vitro activity of 080xacin against Mycobacterium tuberculosis and its clinical efficacy in multiply resistant pulmonary tuberculosis. J Antimicrob Chemother 1990; 26:227-36 5 Yew ~ Lee J, Chan CY, Cheung S~ Wong PC, Kwan SYL. Ofloxacin penetration into tuberculous pleural effusion. Antimicrob Agents Chemother 1991; 35:2159-60
7b the Editor:
We appreciate very much the interest and comments about our article on the management of chronic tuberculous empyema. Our group has also been studying the role of fluoroquinolone drugs (particularly cipro80xacin and 080xacin) in the treatment of patients with tuberculosis resistant to multiple drogs. In fact, four of the five patients in our article, all four of whom failed therapy, received one of the agents. Although we do not have drug levels directly from the empyema spaces to document poor penetration, we do have serum drug levels to confirm that we achieved high, therapeutic concentrations of the 8uoroquinolones and other medications in the blood of these patients. Hence, in view of the poor response, we infer that there CHEST I 101 I 6 I JUNE, 1992
1741