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Adhikari S, Marwah V, Choudhary R, Pandey I, Kumar TA, Malik V, Pemmaraju A, Vasudevan S, Kapoor S. Intrapleural Fibrinolysis with Urokinase versus Alteplase in Complicated Pleural Effusions and Empyema: A Prospective Randomized Controlled Trial. Tuberc Respir Dis (Seoul) 2024; 87:378-385. [PMID: 38449316 PMCID: PMC11222100 DOI: 10.4046/trd.2022.0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/26/2023] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Intrapleural fibrinolytic therapy (IPFT) has been used as an effective agent since 1949 for managing complicated pleural effusion and empyema. Several agents, such as streptokinase, urokinase (UK), and recombinant tissue plasminogen activator (rt-PA), have been found to be effective with variable effectiveness. However, a head-tohead controlled trial comparing the efficacy of the most frequently used agents, i.e., UK and rt-PA (alteplase) for managing complicated pleural effusion has rarely been reported. METHODS A total of 50 patients were randomized in two intervention groups, i.e., UK and rt-PA. The dose of rt-PA was 10 mg, and that of UK was 1.0 lac units. UK was given thrice daily for 2 days, followed by clamping to allow the retainment of drugs in the pleural space for 2 hours. rt-PA was instilled into the pleural space twice daily for 2 days, and intercostal drainage was clamped for 1 hour. RESULTS A total of 50 patients were enrolled into the study, of which 84% (n=42) were males and 16% (n=8) were females. Among them, 30 (60%) patients received UK, and 20 (40%) patients received alteplase as IPFT agents. The percentage of mean± standard deviation changes in pleural opacity was -33.0%±9.9% in the UK group and -41.0%±14.9% in the alteplase group, respectively (p=0.014). Pain was the most common adverse side effect, occurring in 60% (n=18) of the patients in the UK group and in 40% (n=8) of the patients in the alteplase group (p=0.24), while fever was the second most common side effect. Patients who reported early (within 6 weeks of onset of symptoms) showed a greater response than those who reported late for the intervention. CONCLUSION IPFT is a safe and effective option for managing complicated pleural effusion or empyema, and newer agents, such as alteplase, have greater efficacy and a similar adverse effect profile when compared with conventional agents, such as UK.
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Affiliation(s)
- Sudipt Adhikari
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Vikas Marwah
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Robin Choudhary
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Indermani Pandey
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Tentu Ajai Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Virender Malik
- Department of Radiology, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Arpita Pemmaraju
- Department of Pathology, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Shrinath Vasudevan
- Department of Pulmonary, Critical Care and Sleep Medicine, Army Institute of Cardiothoracic Sciences (AICTS), Pune, India
| | - Suraj Kapoor
- Department of Community Medicine, Armed Forces Medical College (AFMC), Pune, India
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De Vera CJ, Emerine RL, Girard RA, Sarva K, Jacob J, Azghani AO, Florence JM, Cook A, Norwood S, Singh KP, Komissarov AA, Florova G, Idell S. A Novel Rabbit Model of Retained Hemothorax with Pleural Organization. Int J Mol Sci 2023; 25:470. [PMID: 38203639 PMCID: PMC10779131 DOI: 10.3390/ijms25010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.
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Affiliation(s)
- Christian J. De Vera
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Rebekah L. Emerine
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - René A. Girard
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Krishna Sarva
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Jincy Jacob
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Ali O. Azghani
- Department of Biology, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX 75799, USA;
| | - Jon M. Florence
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Alan Cook
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Scott Norwood
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA;
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Galina Florova
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Steven Idell
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
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Abdul Hamid MF, Hasbullah AHH, Mohamad Jailaini MF, Nik Abeed NN, Ng BH, Haron H, Md Ali NA, Ismail MI, Nik Ismail NA, Abdul Rahman MR, Ban AYL. Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion. BMC Pulm Med 2022; 22:439. [PMID: 36419155 PMCID: PMC9685928 DOI: 10.1186/s12890-022-02239-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Intrapleural fibrinolytic therapy (IPFT) is one of the treatment options for complex pleural effusion. In this study, the IPFT agent used was alteplase, a tissue plasminogen activator (t-PA). This study aims to determine the difference in the outcome of patients with complex pleural effusion between IPFT and surgery in terms of radiological improvement, inflammatory parameters, length of stay, and post-intervention complications.
Methods A retrospective review of patients with complex pleural effusion treated at Universiti Kebangsaan Malaysia Medical Center from January 2012 to August 2020 was performed. Patient demographics, chest imaging, drainage chart, inflammatory parameters, length of hospital stay, and post-intervention and outcome were analyzed. Results Fifty-eight patients were identified (surgical intervention, n = 18; 31% and IPFT, n = 40, 69%). The mean age was 51.7 ± 18.2 years. Indication for surgical intervention was pleural infection (n = 18; 100%), and MPE (n = 0). Indications for IPFT was pleural infection (n = 30; 75%) and MPE (n = 10; 25%). The dosages of t-PA were one to five doses of 2–50 mg. The baseline chest radiograph in the IPFT group was worse than in the surgical intervention group. (119.96 ± 56.05 vs. 78.19 ± 55.6; p = 0.029) At week 1, the radiological success rate for IPFT and surgical intervention were 27% and 20%, respectively, and at weeks 4–8, the success rate was 56% and 80% respectively. IPFT was associated with lesser complications; fever (17.5%), chest pain (10%), and non-life-threatening bleeding (5%). Conclusion IPFT was comparable to surgery in radiological outcome, inflammatory parameters, and length of stay with lesser reported complications.
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Affiliation(s)
- Mohamed Faisal Abdul Hamid
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Ahmad Hadyan Husainy Hasbullah
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mas Fazlin Mohamad Jailaini
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Nuratiqah Nik Abeed
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Boon Hau Ng
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Hairulfaizi Haron
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nur Ayub Md Ali
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Muhammad Ishamuddin Ismail
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Azuan Nik Ismail
- grid.240541.60000 0004 0627 933XDepartment of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Andrea Yu-Lin Ban
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
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Baumgartner L, Huang E, Sherman D. Evaluation of intrapleural fibrinolytic therapy and dosing strategies used for complicated pleural effusions. Pulm Pharmacol Ther 2022; 76:102146. [PMID: 35868601 DOI: 10.1016/j.pupt.2022.102146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 07/10/2022] [Accepted: 07/14/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES Compare the use of Tissue Plasminogen Activator (t-PA) and t-PA + Dornase (DNase) for the management of complicated pleural effusions, and to determine if a dose-response relationship exists for t-PA. METHODS Retrospective cohort study that examined all adult patients at a large academic medical center who received intrapleural t-PA or t-PA + DNase for the management of a complicated pleural effusions. Outcomes were success of therapy [defined as avoidance of secondary interventions (i.e. VATSD or thoracotomy)], chest tube output pre- and post-administration, radiographic findings, t-PA dose and frequency, and bleeding complications. RESULTS Thirty-five patients were enrolled: 25 received t-PA and 10 received t-PA + DNase. Successful pharmacologic treatment occurred in 88% of patients receiving t-PA and 100% of patients receiving t-PA + DNase (p = 0.54). In the t-PA group, chest tube output increased from 75 ml/12 h to 538 ml/12 h after administration of t-PA (p = 0.001), and from 103 ml/12 h to 502 ml/12 h (p = 0.001) in the t-PA + DNase group. Radiographic improvement occurred in 84% of t-PA patients and 90% of t-PA + DNase patients (p = 0.99). In the t-PA group, a successful response occurred in 92% of patients receiving a cumulative dose of ≤10 mg (n = 13) and 83% of patients receiving a cumulative dose of >10 mg (n = 12), p = 0.43. Patients who received a single t-PA dose compared to those who received multiple doses also had similar success rates (p = 1). There was one instance of bleeding following drug administration. CONCLUSION Both t-PA and t-PA + DNase were highly effective for reducing a patient's need for surgical intervention. Higher cumulative doses or more frequency administrations did not appear to provide additional benefit.
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Affiliation(s)
- Laura Baumgartner
- Touro University California College of Pharmacy, Department of Clinical Sciences, USA.
| | - Eric Huang
- Touro University California College of Pharmacy, Department of Clinical Sciences, USA
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Janowak CF, Becker BR, Philpott CD, Makley AT, Mueller EW, Droege CA, Droege ME. Retrospective Evaluation of Intrapleural Tissue Plasminogen Activator With or Without Dornase Alfa for the Treatment of Traumatic Retained Hemothorax: A 6-Year Experience. Ann Pharmacother 2022; 56:10600280221077383. [PMID: 35184602 DOI: 10.1177/10600280221077383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intrapleural fibrinolytic instillation is second-line treatment for retained hemothorax. Dornase alfa (DNase) has demonstrated efficacy in parapneumonic effusion, but the lack of deoxyribonucleoproteins limits direct extrapolation to traumatic retained hemothorax treatment. OBJECTIVE This study evaluated the effectiveness of intrapleural tissue plasminogen activator (tPA) with and without DNase in the treatment of retained traumatic hemothorax. METHODS This retrospective cohort study included patients aged 16 years and older admitted to a level 1 trauma center from January 2013 through July 2019 with retained hemothorax and one or more intrapleural tPA instillations. Exclusion criteria were tPA for other indications or concomitant empyema. The primary endpoint was treatment failure defined as the need for operative intervention. RESULTS Fifty patients were included (tPA alone: 28; tPA with DNase: 22). Baseline characteristics were similar between groups, including time to diagnosis (6.5 [interquartile range (IQR), 4-15.5] days vs 6 [IQR, 6.3-10.8] days, P = 0.52). Median tPA dose per treatment (6 [IQR, 6-6.4] mg vs 10 [IQR, 8.4-10] mg, P < 0.001) and cumulative tPA (18 [IQR, 6.5-24] mg vs 30 [IQR, 29.5-40], P < 0.001) dose were significantly lower in the tPA alone group. Treatment failure was similar between groups. Chest tube output, retained hemothorax reduction, and bleeding incidences were similar between groups. Multivariate logistic regression demonstrated no significant risk factors for treatment failure. CONCLUSIONS AND RELEVANCE Dornase alfa added to tPA may not reduce the need for operation to treat retained hemothorax. Further studies should be directed at optimal tPA dose determination and economic impact of inappropriate DNase use.
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Affiliation(s)
- Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bradley Robert Becker
- IngenioRX, Inc, Morristown, NJ, USA
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Carolyn Dosen Philpott
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amy Teres Makley
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric William Mueller
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Christopher Allen Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Molly Elizabeth Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
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Karandashova S, Florova G, Idell S, Komissarov AA. From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema. Front Pharmacol 2022; 12:806393. [PMID: 35126140 PMCID: PMC8811368 DOI: 10.3389/fphar.2021.806393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.
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Affiliation(s)
- Sophia Karandashova
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
- *Correspondence: Andrey A. Komissarov,
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Baram A, Yaldo F. Pediatric Thoracic Empyema-Outcomes of Intrapleural Thrombolytics: Ten Years of Experience. Glob Pediatr Health 2020; 7:2333794X20928200. [PMID: 32551331 PMCID: PMC7281637 DOI: 10.1177/2333794x20928200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 03/31/2020] [Accepted: 04/13/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction. Pediatric thoracic empyema is a special entity with increasing frequency. Consensus regarding the best management strategy is still evolving. We describe our single-center 10-year experience adopting intrapleural thrombolytics using tissue plasminogen activator as first-line treatment following failure of simple thoracostomy drainage techniques. Methods. Observational prospective study included all children from 1 day to 18 years admitted for parapneumonic effusion and treated with intrapleural thrombolytics. Results. From January 2008 to December 2018, 95 patients were treated by intrapleural thrombolytics for different stages of empyema thoracis. Number of thrombolytic doses required is 2.1 (range = 1-3), and mean amount of drainage is 1050 mL (range = 400-2500 mL). Mean total days of hospitalization is 7.3 days. Complete re-expansion was the primary outcome in 94 patients (98.9%). Conclusion. Intrapleural thrombolytics in complicated pediatric thoracic empyema results in excellent outcome and should be encouraged particularly in limited resource countries.
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Affiliation(s)
- Aram Baram
- University of Sulaimani, Sulaymaniyah, Kurdistan, Iraq
| | - Fitoon Yaldo
- Kurdistan Board for Medical Specialties, Erbil, Kurdistan Region, Iraq
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Holsen MR, Tameron AM, Evans DC, Thompson M. Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax. Ann Pharmacother 2019; 53:1060-1066. [DOI: 10.1177/1060028019846122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax.
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Affiliation(s)
- Maya R. Holsen
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - David C. Evans
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Molly Thompson
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Maskell NA, Cardillo G. ERS/EACTS statement on the management of malignant pleural effusions. Eur J Cardiothorac Surg 2019; 55:116-132. [PMID: 30060030 DOI: 10.1093/ejcts/ezy258] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 12/26/2022] Open
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomized clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE. The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.Management options for malignant pleural effusions have advanced over the past decade, with high-quality randomized trial evidence informing practice in many areas. However, uncertainties remain and further research is required http://ow.ly/rNt730jOxOS.
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Affiliation(s)
- Anna C Bibby
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Patrick Dorn
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | | | - Jose M Porcel
- Pleural Medicine Unit, Arnau de Vilanova University Hospital, IRB Lleida, Lleida, Spain
| | - Julius Janssen
- Department of Pulmonary Diseases, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Marios Froudarakis
- Department of Respiratory Medicine, Medical School of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dragan Subotic
- Clinic for Thoracic Surgery, Clinical Center of Serbia, Belgrade, Serbia
| | - Phillippe Astoul
- Department of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, Hospital North Aix-Marseille University, Marseille, France
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Ralph Schmid
- Division of Thoracic Surgery, University Hospital Bern, Bern, Switzerland
| | - Arnaud Scherpereel
- Pulmonary and Thoracic Oncology Department, Hospital of the University (CHU) of Lille, Lille, France
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, University Hospitals, NHS Foundation Trust, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK
- North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
- Task force chairperson
| | - Giuseppe Cardillo
- Task force chairperson
- Department of Thoracic Surgery, Carlo Forlanini Hospital, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
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Hendriksen BS, Kuroki MT, Armen SB, Reed MF, Taylor MD, Hollenbeak CS. Lytic Therapy for Retained Traumatic Hemothorax. Chest 2019; 155:805-815. [DOI: 10.1016/j.chest.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 12/06/2018] [Accepted: 01/02/2019] [Indexed: 01/08/2023] Open
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11
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Joslyn LR, Pienaar E, DiFazio RM, Suliman S, Kagina BM, Flynn JL, Scriba TJ, Linderman JJ, Kirschner DE. Integrating Non-human Primate, Human, and Mathematical Studies to Determine the Influence of BCG Timing on H56 Vaccine Outcomes. Front Microbiol 2018; 9:1898. [PMID: 30177934 PMCID: PMC6110197 DOI: 10.3389/fimmu.2018.01898] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/31/2018] [Indexed: 12/21/2022] Open
Abstract
Background Acute lung injury (ALI) is characterized by suppressed fibrinolytic activity in bronchoalveolar lavage fluid (BALF) attributed to elevated plasminogen activator inhibitor-1 (PAI-1). Restoring pulmonary fibrinolysis by delivering tissue-type plasminogen activator (tPA), urokinase plasminogen activator (uPA), and plasmin could be a promising approach. Objectives To systematically analyze the overall benefit of fibrinolytic therapy for ALI reported in preclinical studies. Methods We searched PubMed, Embase, Web of Science, and CNKI Chinese databases, and analyzed data retrieved from 22 studies for the beneficial effects of fibrinolytics on animal models of ALI. Results Both large and small animals were used with five routes for delivering tPA, uPA, and plasmin. Fibrinolytics significantly increased the fibrinolytic activity both in the plasma and BALF. Fibrin degradation products in BALF had a net increase of 408.41 ng/ml vs controls (P < 0.00001). In addition, plasma thrombin–antithrombin complexes increased 1.59 ng/ml over controls (P = 0.0001). In sharp contrast, PAI-1 level in BALF decreased 21.44 ng/ml compared with controls (P < 0.00001). Arterial oxygen tension was improved by a net increase of 15.16 mmHg, while carbon dioxide pressure was significantly reduced (11.66 mmHg, P = 0.0001 vs controls). Additionally, fibrinolytics improved lung function and alleviated inflammation response: the lung wet/dry ratio was decreased 1.49 (P < 0.0001 vs controls), lung injury score was reduced 1.83 (P < 0.00001 vs controls), and BALF neutrophils were lesser (3 × 104/ml, P < 0.00001 vs controls). The mortality decreased significantly within defined study periods (6 h to 30 days for mortality), as the risk ratio of death was 0.2-fold of controls (P = 0.0008). Conclusion We conclude that fibrinolytic therapy may be effective pharmaceutic strategy for ALI in animal models.
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Affiliation(s)
- Louis R Joslyn
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Elsje Pienaar
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States.,Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Robert M DiFazio
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Sara Suliman
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Benjamin M Kagina
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - JoAnne L Flynn
- Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative and Institute of Infectious Disease and Molecular Medicine, Division of Immunology, Department of Pathology, University of Cape Town, Cape Town, South Africa
| | - Jennifer J Linderman
- Department of Chemical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Denise E Kirschner
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, United States
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12
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Bibby AC, Dorn P, Psallidas I, Porcel JM, Janssen J, Froudarakis M, Subotic D, Astoul P, Licht P, Schmid R, Scherpereel A, Rahman NM, Cardillo G, Maskell NA. ERS/EACTS statement on the management of malignant pleural effusions. Eur Respir J 2018; 52:13993003.00349-2018. [DOI: 10.1183/13993003.00349-2018] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023]
Abstract
Malignant pleural effusions (MPE) are a common pathology, treated by respiratory physicians and thoracic surgeons alike. In recent years, several well-designed randomised clinical trials have been published that have changed the landscape of MPE management. The European Respiratory Society (ERS) and the European Association for Cardio-Thoracic Surgery (EACTS) established a multidisciplinary collaboration of clinicians with expertise in the management of MPE with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified, including the optimum management of symptomatic MPE, management of trapped lung in MPE, management of loculated MPE, prognostic factors in MPE, whether there is a role for oncological therapies prior to intervention for MPE and whether a histological diagnosis is always required in MPE.The literature revealed that talc pleurodesis and indwelling pleural catheters effectively manage the symptoms of MPE. There was limited evidence regarding the management of trapped lung or loculated MPE. The LENT score was identified as a validated tool for predicting survival in MPE, with Brims' prognostic score demonstrating utility in mesothelioma prognostication. There was no evidence to support the use of oncological therapies as an alternative to MPE drainage, and the literature supported the use of tissue biopsy as the gold standard for diagnosis and treatment planning.
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13
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Use of an evidence-based algorithm for patients with traumatic hemothorax reduces need for additional interventions. J Trauma Acute Care Surg 2017; 82:728-732. [PMID: 28099387 DOI: 10.1097/ta.0000000000001370] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Concerted management of the traumatic hemothorax is ill-defined. Surgical management of specific hemothoraces may be beneficial. A comprehensive strategy to delineate appropriate patients for additional procedures does not exist. We developed an evidence-based algorithm for hemothorax management. We hypothesize that the use of this algorithm will decrease additional interventions. METHODS A pre-/post-study was performed on all patients admitted to our trauma service with traumatic hemothorax from August 2010 to September 2013. An evidence-based management algorithm was initiated for the management of retained hemothoraces. Patients with length of stay (LOS) less than 24 hours or admitted during an implementation phase were excluded. Study data included age, Injury Severity Score, Abbreviated Injury Scale chest, mechanism of injury, ventilator days, intensive care unit (ICU) LOS, total hospital LOS, and interventions required. Our primary outcome was number of patients requiring more than 1 intervention. Secondary outcomes were empyema rate, number of patients requiring specific additional interventions, 28-day ventilator-free days, 28-day ICU-free days, hospital LOS, all-cause 6-month readmission rate. Standard statistical analysis was performed for all data. RESULTS Six hundred forty-two patients (326 pre and 316 post) met the study criteria. There were no demographic differences in either group. The number of patients requiring more than 1 intervention was significantly reduced (49 pre vs. 28 post, p = 0.02). Number of patients requiring VATS decreased (27 pre vs. 10 post, p < 0.01). Number of catheters placed by interventional radiology increased (2 pre vs. 10 post, p = 0.02). Intrapleural thrombolytic use, open thoracotomy, empyema, and 6-month readmission rates were unchanged. The "post" group more ventilator-free days (median, 23.9 vs. 22.5, p = 0.04), but ICU and hospital LOS were unchanged. CONCLUSION Using an evidence-based hemothorax algorithm reduced the number of patients requiring additional interventions without increasing complication rates. Defined criteria for surgical intervention allows for more appropriate utilization of resources. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Heimes J, Copeland H, Lulla A, Duldulao M, Bahjri K, Zaheer S, Wallen JM. The use of thrombolytics in the management of complex pleural fluid collections. J Thorac Dis 2017; 9:1310-1316. [PMID: 28616283 DOI: 10.21037/jtd.2017.04.56] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. METHODS We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). RESULTS One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. CONCLUSIONS Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.
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Affiliation(s)
- Jessica Heimes
- Department of Thoracic and Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hannah Copeland
- Cardiothoracic Surgery Richmond, McGuire Veterans Affairs Medical Center, Richmond, VA, USA
| | - Aditya Lulla
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marjulin Duldulao
- Weill Cornell Medical Center, New York Presbyterian Hospital, New York, USA
| | - Khaled Bahjri
- School of Public Health, Loma Linda University, Loma Linda, California, USA
| | - Salman Zaheer
- Department of Thoracic and Cardiothoracic Surgery, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Jason M Wallen
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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15
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Intrapleural Fibrinolytic Therapy for Residual Coagulated Hemothorax After Lung Surgery. World J Surg 2016; 40:1121-8. [PMID: 26711639 DOI: 10.1007/s00268-015-3378-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Many studies have described the use of intrapleural fibrinolytics for the treatment of complex pleural processes and traumatic hemothorax, but data are scarce regarding their use for hemothorax after lung surgery. OBJECTIVE To evaluate the utility of intrapleural fibrinolytic therapy with urokinase for residual coagulated hemothorax (blood clot accumulation in the pleural cavity) after lung surgery. METHODS From July 2009 to November 2013, 46 patients (33 males; mean age, 56.9 ± 10.7 years) were treated with intrapleural urokinase (250,000 IU per dose) for residual hemothorax after lung surgery. Complete response was defined as clinical improvement with complete drainage of the retained collection shown by chest X-ray, and partial response as substantial resolution with minimal residual opacity (<25 % of the thorax). Follow-up was at least 30 days. RESULTS The procedure was successful in 42 patients (91.3 %), with complete response observed in 35/46 patients (76.1 %) and partial response in 7/46 (15.2 %). These 42 patients did not require re-intervention for fluid accumulation in the pleural cavity. Treatment failed in 4 patients (8.7 %): one developed bronchopleural fistula that later resolved spontaneously and three (6.5 %) required thoracoscopic drainage for pleural cavity fluid accumulation and lung collapse. No patient required thoracotomy for total decortication. Intrapleural urokinase administration was not associated with serious adverse events, including bleeding complications or allergic reactions. CONCLUSIONS Intrapleural fibrinolytic agents should be considered a useful therapeutic option for the treatment of postoperative residual hemothorax. This method appears to be safe and effective in >90 % of patients with postoperative hemothorax.
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16
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Thomas R, Piccolo F, Miller D, MacEachern PR, Chee AC, Huseini T, Yarmus L, Bhatnagar R, Lee HJ, Feller-Kopman D, Maskell NA, Tremblay A, Lee YCG. Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study. Chest 2015; 148:746-751. [PMID: 25742001 DOI: 10.1378/chest.14-2401] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPCs) are an effective option in the management of malignant pleural effusion. Up to 14% of patients with IPCs develop symptomatic pleural loculations causing ineffective fluid drainage and breathlessness. To our knowledge, this is the first study to describe intrapleural fibrinolytic therapy for IPC-related symptomatic loculations. METHODS All patients who received intrapleural fibrinolytic therapy for symptomatic loculations between January 1, 2002, and June 30, 2014, in four established IPC centers were retrospectively included. Patient outcomes, treatment effectiveness, and adverse events were recorded. RESULTS Sixty-six patients (mean age, 64.7 ± 14.2 years; 52% women) were included. Lung cancer (31.3%) and malignant pleural mesothelioma (20.3%) were the most common malignancies. Fibrinolytic instillation was performed in outpatient (61%) and inpatient settings. Tissue-plasminogen activator (n = 52), urokinase (n = 12), and streptokinase (n = 2) were used. The majority (69.7%) received only one fibrinolytic dose (range, one to six). Pleural fluid drainage increased in 93% of patients, and dyspnea improved in 83% following therapy. The median cumulative pleural fluid volume drained at 24 h posttreatment was 500 mL (interquartile range 300-1,034 mL). The area of opacity caused by pleural effusion on chest radiograph decreased from (mean, SD) 52% (14%) to 31% (21%) of the hemithorax (n = 13; P = .001). There were two cases of nonfatal pleural bleed (3%). CONCLUSIONS Intrapleural fibrinolytic therapy can improve pleural fluid drainage and symptoms in selected patients with IPC and symptomatic loculation, but it carries a small risk of pleural bleeding. There is significant heterogeneity in its use currently, and further studies are needed to determine patient selection and optimal dosing regimen and to define its safety profile.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia
| | - Francesco Piccolo
- Department of Internal Medicine, Swan District Hospital, Perth, WA, Australia
| | - Daniel Miller
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Paul R MacEachern
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Alex C Chee
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Taha Huseini
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Hans J Lee
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Alain Tremblay
- Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia.
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Witt CE, Mesher AL, Hermsen JL, Brogan TV, McMullan DM. Intrapleural fibrinolysis during pediatric extracorporeal life support. World J Pediatr Congenit Heart Surg 2015; 6:123-5. [PMID: 25548359 DOI: 10.1177/2150135114553478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric patients who require extracorporeal life support (ECLS) for refractory cardiorespiratory failure are at increased risk for intrapleural hemorrhage due to the effects of systemic anticoagulation and frequent occurrence of pneumothorax. Surgical evacuation is standard therapy for retained hemothorax to prevent secondary empyema, pulmonary compression, and development of fibrothorax. However, surgical interventions during ECLS are hazardous and place patients at increased risk for surgical site bleeding. Intrapleural fibrinolysis with tissue plasminogen activator may be used to facilitate nonsurgical evacuation of retained hemothorax. We present two pediatric patients who were safely and successfully managed with intrapleural fibrinolysis of retained hemothorax during ECLS.
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Affiliation(s)
- Cordelie E Witt
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Andrew L Mesher
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Joshua L Hermsen
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Thomas V Brogan
- Division of Pediatric Critical Care, Seattle Children's Hospital, Seattle, WA, USA
| | - David Michael McMullan
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, WA, USA
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Komissarov AA, Florova G, Azghani AO, Buchanan A, Bradley WM, Schaefer C, Koenig K, Idell S. The time course of resolution of adhesions during fibrinolytic therapy in tetracycline-induced pleural injury in rabbits. Am J Physiol Lung Cell Mol Physiol 2015; 309:L562-72. [PMID: 26163512 DOI: 10.1152/ajplung.00136.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 07/02/2015] [Indexed: 11/22/2022] Open
Abstract
The time required for the effective clearance of pleural adhesions/organization after intrapleural fibrinolytic therapy (IPFT) is unknown. Chest ultrasonography and computed tomography (CT) were used to assess the efficacy of IPFT in a rabbit model of tetracycline-induced pleural injury, treated with single-chain (sc) urokinase plasminogen activators (scuPAs) or tissue PAs (sctPA). IPFT with sctPA (0.145 mg/kg; n = 10) and scuPA (0.5 mg/kg; n = 12) was monitored by serial ultrasonography alone (n = 12) or alongside CT scanning (n = 10). IPFT efficacy was assessed with gross lung injury scores (GLIS) and ultrasonography scores (USS). Pleural fluids withdrawn at 0-240 min and 24 h after IPFT were assayed for PA and fibrinolytic activities, α-macroglobulin/fibrinolysin complexes, and active PA inhibitor 1 (PAI-1). scuPA and sctPA generated comparable steady-state fibrinolytic activities by 20 min. PA activity in the scuPA group decreased slower than the sctPA group (kobs = 0.016 and 0.042 min(-1)). Significant amounts of bioactive uPA/α-macroglobulin (but not tPA; P < 0.05) complexes accumulated at 0-40 min after IPFT. Despite the differences in intrapleural processing, IPFT with either fibrinolysin was effective (GLIS ≤ 10) in animals imaged with ultrasonography only. USS correlated well with postmortem GLIS (r(2) = 0.85) and confirmed relatively slow intrapleural fibrinolysis after IPFT, which coincided with effective clearance of adhesions/organization at 4-8 h. CT scanning was associated with less effective (GLIS > 10) IPFT and higher levels of active PAI-1 at 24 h following therapy. We concluded that intrapleural fibrinolysis in tetracycline-induced pleural injury in rabbits is relatively slow (4-8 h). In CT-scanned animals, elevated PAI-1 activity (possibly radiation induced) reduced the efficacy of IPFT, buttressing the major impact of active PAI-1 on IPFT outcomes.
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Affiliation(s)
- Andrey A Komissarov
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas;
| | - Galina Florova
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Ali O Azghani
- The Department of Biology at the University of Texas at Tyler, Tyler, Texas
| | - Ann Buchanan
- UTHSCT Vivarium, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - William M Bradley
- The Department of Radiation Oncology, The University of Texas Health Science Center at Tyler, Tyler, Texas
| | - Chris Schaefer
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Kathleen Koenig
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
| | - Steven Idell
- The Department of Cellular and Molecular Biology and the Texas Lung Injury Institute, The University of Texas Health Science Center at Tyler (UTHSCT), Tyler, Texas
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Affiliation(s)
- Gene L Colice
- George Washington University School of Medicine & Health Sciences, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington, DC.
| | - Steven Idell
- School of Medical Biological Sciences, The University of Texas Health Science Center at Tyler, Tyler, TX
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Intrapleural Tenecteplase Therapy in Treatment of Loculated Parapneumonic Pleural Effusions and Empyema. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Evaluation of chest tube administration of tissue plasminogen activator to treat retained hemothorax. Am J Surg 2014; 207:960-3. [DOI: 10.1016/j.amjsurg.2013.08.052] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 08/02/2013] [Accepted: 08/02/2013] [Indexed: 11/21/2022]
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Affiliation(s)
- Gene L Colice
- George Washington University School of Medicine & Health Sciences, Washington, DC; Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington, DC.
| | - Steven Idell
- School of Medical Biological Sciences, The University of Texas Health Science Center at Tyler, Tyler, TX
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Nie W, Liu Y, Ye J, Shi L, Shao F, Ying K, Zhang R. Efficacy of intrapleural instillation of fibrinolytics for treating pleural empyema and parapneumonic effusion: a meta-analysis of randomized control trials. CLINICAL RESPIRATORY JOURNAL 2014; 8:281-91. [PMID: 24428897 DOI: 10.1111/crj.12068] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2013] [Revised: 09/26/2013] [Accepted: 10/24/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Wencheng Nie
- Department of Cardiology, The First Affiliated Hospital of Zhejiang University; School of Medicine; Hangzhou China
| | - Yanru Liu
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Jian Ye
- Department of Respiratory Medicine; The First People's Hospital of Hangzhou; Hangzhou China
| | - Liuhong Shi
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Fangchun Shao
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Kejing Ying
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
| | - Ruifeng Zhang
- Department of Respiratory Medicine, Sir Run Run Shaw Hospital; Medical School of Zhejiang University; Hangzhou China
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Hendaus MA, Abushahin A. Intrapleural hemorrhage due to alteplase use in a 6-year-old boy with pleural effusion. Int J Gen Med 2013; 6:233-6. [PMID: 23626471 PMCID: PMC3632500 DOI: 10.2147/ijgm.s43783] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Intrapleural fibrinolytics have been used successfully worldwide for the management of complicated pleural effusions and empyema. Bleeding complications are usually mentioned as rare side effects, but there is no clear information in the literature addressing the alarming outcome that might result following the use of alteplase as a fibrinolytic in the management of complicated parapneumonic effusions. We present a rare, if not unique, case of intrapleural hemorrhage requiring transfusion after alteplase use as a fibrinolytic in a 6-year-old male with complicated parapneumonic effusion. Methods A search of the PubMed database was carried out, using a combination of the following terms: alteplase, fibrinolytic, intrapleural hemorrhage, and side effects. Results The majority of studies found in the search concentrated on the efficacy of intrapleural fibrinolytics in the management of pleural effusion, but very few of the reports addressed the bleeding complications which may be caused by the treatment. Conclusion Although intrapleural and systemic hemorrhage are rare side effects of intrapleural fibrinolytic use, the health care provider must be watchful for these potentially life-threatening complications. Further studies are needed to understand not only the efficacy of fibrinolytics but also their safety, especially in children.
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Thommi G, Shehan JC, Robison KL, Christensen M, Backemeyer LA, McLeay MT. A double blind randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions. Respir Med 2012; 106:716-23. [PMID: 22398159 DOI: 10.1016/j.rmed.2012.02.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 12/07/2011] [Accepted: 02/10/2012] [Indexed: 12/01/2022]
Abstract
AIM A double blind randomized cross over trial to compare the rate of decortication, safety and efficacy of intrapleural instillation of Alteplase vs. Placebo in empyema and complicated parapneumonic effusions (CPE). METHODS Patients diagnosed with empyema or CPE and considered for surgery were given the option to enter into this trial. Intrapleural instillation of the 'Drug' was given daily for three days. Patient that failed the first arm of the trial were offered surgery or to cross over to the second arm. Failure was documented if pleural effusions did not improve by 50% on CT scans after three doses of the 'Drug' or if these effusions recurred within six weeks. RESULTS One hundred and eight patients were evaluated and one hundred enrolled in the trial. 32 patients were excluded, 29 for noninfectious loculated effusions, two for protocol violation and one for bleeding at chest tube site. There were 17 patients with empyema and 51 patients with CPE. 58 of the 61 patients (26 crossed over) with empyema/CPE resolved with Alteplase therapy compared to 4 of the 32 patients (one crossed over) treated with Placebo (p value <0.001). None of the patients went to surgery. Adverse events with Alteplase therapy compared to Placebo were not statistically significant, with chest pain and bleeding complications being the most common. CONCLUSION Intrapleural instillation of Alteplase is significantly more effective than Placebo in patients with empyema and PPE (95% vs.12%). This study demonstrates it is safe and efficacious with minimal adverse reactions.
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Affiliation(s)
- G Thommi
- Creighton University/Methodist Hospital, Omaha, NE, USA.
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