DSpace Repository :: Browsing by Author "Kheir, Fayez"

Browsing by Author "Kheir, Fayez"

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Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience
(American Thoracic Society, 2016) Majid, Adnan; Kheir, Fayez; Folch, Alejandro; Fernández‐Bussy, Sebastián; Chatterji, Sumit; Maskey, Ashish; Fashjian, Meghan; Cheng, George; Ochoa, Sebastian; Alape, Daniel; Folch, Erik
RATIONALE: Treatment of pleural infection with instillation of intrapleural tissue plasminogen activator (tPA) and human recombinant DNase (DNase) has been proven to decrease the length of hospital stay, decrease surgical referral, and improve drainage. The optimal dosage, administration, timing, and frequency of the regimen remain unclear. It is unknown if the two drugs can be administered immediately one after the other (referred to as concurrent) instead of instilling them separately with a 1- to -2-hour interval in between. OBJECTIVES: To assess the safety and efficacy of concurrent instillation of intrapleural tPA/DNase guided by radiographic and clinical response in patients with pleural infection. METHODS: We conducted a retrospective cohort study. Consecutive patients with pleural infection who received concurrent tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on pleural fluid drainage, clinical response, and radiographic findings. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients received concurrent tPA/DNase therapy. Treatment was successful in 90.4% of them; 80.8% were effectively treated with fewer than six doses of therapy (median, 2; interquartile range [IQR], 1-3.5); and 71.2% received their first dose of tPA/DNase within 24 hours after chest tube insertion. The median hospital stay from the first dose of tPA/DNase to discharge was 7 days (IQR, 5-11 d). The volume of pleural fluid drained increased from a median of 295 ml (IQR, 97.5-520 ml) 24 hours before treatment to a median of 1,102 ml (IQR, 627-2,200 ml) 72 hours following therapy (P < 0.001). Nonfatal pleural bleeding occurred in 5.4%, 15.1% had chest pain, and 2.7% died as a result of pleural infection. CONCLUSIONS: This cohort study shows that early administration of concurrent tPA/DNase in patients with pleural infection is relatively safe and effective. Given the high cost of therapy, it is feasible to guide therapy on the basis of clinical and radiographic response.
Concurrent Versus Sequential Intrapleural Instillation of Tissue Plasminogen Activator and Deoxyribonuclease for Pleural Infection
(2018) Kheir, Fayez; Cheng, George; Rivera, Estefania; Folch, Alejandro; Folch, Erik; Fernández-Bussy, Sebastián; Keyes, Colleen; Parikh, Mihir; Channick, Colleen; Chee, Alex; Majid, Adnan
Background: Treatment of pleural infection with instillation of sequential intrapleural tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) twice daily for a total of 6 doses has been shown to decrease surgical referral and improve radiographic imaging. This labor-intensive regimen was empirically chosen. Thus, it remains unclear whether the 2 drugs can be administered immediately one after the other (concurrent administration) instead of instilling them separately with a 1-hour to 2-hour interval in between (sequential administration). The aim of this study was to compare the efficacy and safety of sequential versus concurrent tPA/DNase therapy in patients with pleural infection. Methods: This was a prospective observational study. Consecutive patients with pleural infection who received concurrent and sequential tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on the amount of pleural fluid drainage, clinical response and radiographic findings. Results: A total of 38 patients with pleural infection received tPA/DNase treatment: 18 in the sequential group and 20 in the concurrent group. Treatment was successful in 77.7% in the sequential group and 75% in concurrent group (P=0.57). There was no statistically significant difference between the 2 treatment groups (sequential and concurrent) in median pleural fluid drainage (P=0.45), median volume of pleural effusion estimated on chest computed tomography scan (P=0.4) or median hemithorax occupied by effusion on chest radiography (P=0.83) following intrapleural therapy. One patient required a blood transfusion for gradual pleural blood loss in each treatment group. Pain needing escalation of analgesia affected 3 patients in each arm but none required cessation of therapy. Conclusion: A simpler regimen of concurrent administration of intrapleural tPA/DNase as compared with sequential intrapleural therapy is safe, effective, and represents a viable option for the management of pleural infection.
Convex Probe EBUS-guided Fiducial Placement for Malignant Central Lung Lesions
(2018) Majid, Adnan; Palkar, Atul; Kheir, Fayez; Alape, Daniel; Fernández-Bussy, Sebastián; Aronovitz, Joseph; Guerrero, Jorge; Gangadharan, Sidhu; Kent, Michael; Whyte, Richard; Folch, Erik
Background: Stereotactic body radiotherapy (SBRT) had become a therapeutic modality in patients with primary tumors, locally recurrent as well as oligometastasis involving the lung. Some modalities of SBRT require fiducial marker (FM) for dynamic tumor tracking. Previous studies have focused on evaluating bronchoscopic-guided FM placement for peripheral lung nodules. We describe the safety and feasibility of placing FM using real-time convex probe endobronchial ultrasound (CP-EBUS) for SBRT in patients with centrally located hilar/mediastinal masses or lymph nodes. Methods: This is a retrospective review of patients who were referred to Beth Israel Deaconess Medical Center’s multidisciplinary thoracic oncology program for FM placement to pursue SBRT. Results: Thirty-seven patients who underwent real-time CP-EBUS were included. Patients had a median age of 71 years [interquartile range (IQR), 59.5 to 80.5]. The median size of the lesion was 2.2 cm (IQR, 1.4 to 3.3 cm). The median distance from the central airway was 2.4 cm (IQR, 0 to 3.4 cm). A total of 51 FMs (median of 1 per patient) were deployed in 37 patients. At the time of SBRT planning, 46 (90.2%) were confirmed radiologically in 32 patients. Patients with unsuccessful fiducial deployment (n=5) underwent a second procedure using the same technique. Of those, 3 patients had a successful fiducial placement via bronchoscopy, 1 patient required FM placement by percutaneous computed tomography-guided approach and 1 patient required FM placement through EUS by gastroenterology. Conclusion: CP-EBUS-guided FM placement for patients with malignant lymph nodes and central parenchymal lung lesions appears to be safe and feasible
Safety and efficacy of tissue plasminogen activator and DNase for complicated pleural effusions secondary to abdominal pathology
(American Thoracic Society, 2017) Majid, Adnan; Ochoa, Sebastián; Chatterji, Sumit; Fernández‐Bussy, Sebastián; Kheir, Fayez; Rivera, Estefania; Cheng, George; Folch, Erik
RATIONALE: Exudative pleural effusions may arise secondary to inflammation of intra-abdominal structures. Pleural space loculations can complicate these effusions, preventing adequate chest tube drainage and leading to consideration of surgical intervention. Previous studies have demonstrated that intrapleural administration of tissue plasminogen activator (tPA) combined with human recombinant DNase can improve fluid drainage and reduce surgery for patients with loculated parapneumonic effusions; however, the efficacy of this treatment has not been evaluated for complicated pleural effusions attributed to intra-abdominal inflammation. OBJECTIVES: We assessed the safety and efficacy of tPA/DNase for 17 pleural effusions associated with nonmalignant intra-abdominal pathology that did not drain adequately after placement of one or more chest tubes. METHODS: Efficacy was measured by comparing post- to pretreatment fluid drainage rates, volumetric assessment of pleural fluid on radiographic images before and after treatment, and clinical improvement, including the need for surgical intervention. Symptomatic relief was assessed using the Borg scale for breathlessness. MEASUREMENTS AND MAIN RESULTS: After a median of two doses of tPA/DNase, 23.5% of patients had chest pain and none had pleural bleeding. The volume of pleural fluid drained increased from a median of 325 ml to 890 ml per 24 hours after therapy (P = 0.018). The area of pleural space opacity on chest radiographs decreased from a median of 42.8-17.8% of the hemithorax (P = 0.001). tPA/DNase reduced the pleural fluid volume on chest computed tomographic imaging from a median of 294.4 ml to 116.1 ml. Borg scores improved from a median of 3 (interquartile range = 1-6) to 0 (interquartile range = 0-2) after therapy (P = 0.001). The median duration of chest tube placement and hospital stay were 4 and 11 days, respectively. Two patients required surgical intervention for lung entrapment. Overall, treatment was considered successful for 88.2% of patients. CONCLUSIONS: This retrospective case series suggests that intrapleural tPA/DNase can be safe and effective for patients with complicated pleural effusions attributed to abdominal pathology that do not drain adequately after chest tube placement. Additional studies are needed to determine whether the combination of tPA and DNase is more effective than tPA for this indication
Tunneled pleural catheter placement with and without talc poudrage for treatment of pleural effusions due to congestive heart failure
(American Thoracic Society, 2016) Majid, Adnan; Kheir, Fayez; Fashjian, Meghan; Chatterji, Sumit; Fernández-Bussy, Sebastián; Ochoa, Sebastian; Cheng, George; Folch, Erik
RATIONALE: There is a paucity of evidence regarding the role of tunneled pleural catheters in pleural effusions caused by congestive heart failure that is refractory to medical management. OBJECTIVES: The aim of this study was to assess the feasibility of tunneled pleural catheter drainage for treatment of refractory pleural effusions associated with congestive heart failure, either when used alone or with concomitant talc pleurodesis performed during thoracoscopy. METHODS: This was a retrospective cohort study. We identified patients with congestive heart failure and recurrent symptomatic pleural effusions who were treated between 2005 and 2015 by placement of a tunneled pleural catheter. Patients underwent either thoracoscopy followed by talc poudrage and pleural catheter placement (group 1) or catheter insertion alone (group 2). MEASUREMENTS AND MAIN RESULTS: Forthy-three catheters were inserted in 36 patients, with 15 placed in group 1 and 28 in group 2. Successful pleurodesis was seen in 80% in group 1 and 25% in group 2. The median time of catheter placement was 11.5 days in group 1 and 66 days in group 2. There was a significant decrease in hospital admissions and pleural interventions after catheter placement compared with before insertion (P < 0.05). CONCLUSIONS: This single-center, retrospective study demonstrated the feasibility of catheter placement used alone or with talc poudrage for the treatment of refractory pleural effusions associated with congestive heart failure. The addition of talc poudrage might increase the pleurodesis rate and reduce the days to catheter removal in highly selected patients. Prospective studies on a larger number of patients are warranted to verify the safety and efficacy of this intervention.
Tunneled Pleural Catheters for Patients With Chronic Pleural Infection and Nonexpandable Lung
(2019) Majid, Adnan; de Lima, Andrés; Parikh, Mihir; Chee, Alex; Fernandez, Sebastian; Kheir, Fayez
Chronic pleural infection is characterized by thickened pleura and nonexpandable lung often requiring definitive surgical intervention, such as decortication and/or pleural obliteration procedures. Such procedures are associated with significant morbidity and require proper patient selection for a successful outcome. We report a cohort of 11 patients with pleural space infection and a nonexpandable lung treated with tunneled pleural catheters (TPCs). Following placement, hospital discharge and TPC removal occurred after a median of 5 and 36 days, respectively. Three patients presented with residual loculated effusion that resolved with instillation of intrapleural fibrinolytic therapy. One patient eventually required open window thoracostomy for ongoing pleural infection due to poor medical compliance with TPC care and drainage instructions. TPCs represent an alternative option for drainage of an infected pleural space in nonsurgical candidates with a nonexpandable lung. Their use, as a compliment to traditional treatment, may facilitate prompt hospital discharge and ambulatory management in patients with limited life expectancy.

Browsing by Author "Kheir, Fayez"

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