Short-course modified regimen intrapleural alteplase and pulmozyme (DNase) in pleural infection

Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion

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.

Modified regimen intrapleural alteplase with pulmozyme in pleural infection management: a tertiary teaching hospital experience

Background

Current management of poorly draining complex effusions favours less invasive image-guided placement of smaller tubes and adjunctive intrapleural fibrinolysis therapy (IPFT). In MIST-2 trial, intrapleural 10 mg alteplase (t-PA) with 5 mg of pulmozyme (DNase) twice daily for 72 h were used. We aimed to assess the effectiveness and safety of a modified regimen 16 mg t-PA with 5 mg of DNase administered over 24 h in the management of complex pleural infection.

Methods

This was a single centre, prospective study involving patients with poorly drained pleural infection. Primary outcome was the change of pleural opacity on chest radiograph at day 7 compared to baseline. Secondary outcomes include volume of fluid drained, inflammatory markers improvement, surgical referral, length of hospitalisation, and adverse events.

Results

Thirty patients were recruited. Majority, 27 (90%) patients were successfully treated. Improvement of pleural opacity on chest radiograph was observed from 36.9% [Interquartile range (IQR 21.8–54.9%)] to 18.1% (IQR 8.8–32.7%) of hemithorax (P < 0.05). T-PA/DNase increased fluid drainage from median of 45 mls (IQR 0–100) 24 h prior to intrapleural treatment to 1442 mls (IQR 905–2360) after 72 h; (P < 0.05) and reduction of C-reactive protein (P < 0.05). Pain requiring escalation of analgesia affected 20% patients and 9.9% experienced major adverse events. None required surgical intervention.

Conclusion

This study suggests that a modified regimen 16 mg t-PA with 5 mg DNase can be safe and effective for patients with poorly drained complex pleural infection.

Trial registration The study was registered retrospectively on 07/06/2021 with ClinicalTrials number NCT04915586 (https://clinicaltrials.gov/ct2/show/NCT04915586).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01995-z.

Intrapleural alteplase and DNase for complex tuberculous pleurisy: a medical approach

Tuberculous pleurisy is extra-pulmonary tuberculosis caused by Mycobacterium tuberculosis (MTB), which is one of the main cause of pleural effusions in developing countries. Intercostal chest catheter is useful for drainage of infected pleural fluid and facilitates sepsis control. However, management might be challenging in complex tuberculous pleural effusion as the septations within the effusion hinder pleural drainage. Intrapleural fibrinolysis therapy improved infected fluid drainage and septic parameter in parapneumonic effusions; however, there seems to be little data on its use in tuberculous pleurisy. In our case series of seven patients with complex tuberculous pleurisy, the use of intrapleural alteplase and deoxyribonuclease (DNase) facilitated fluid drainage which resulted in clinical and radiological improvement. These medications should not be confined to bacterial aetiology only as our case series highlights that in complex tuberculous pleurisy, intrapleural alteplase and DNase may be used as an adjunctive treatment which are proven to be successful and safe.