Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection

Akulian, Jason; Bedawi, Eihab; Abbas, Hawazin; Argento, C.; Arnold, David; Balwan, Akshu; Batra, Hitesh; Becerra, Juan Pablo Uribe; Belanger, Adam R.; Berger, Kristen; Burks, Allen Cole; Chang, Jonghwa; Chrissian, Ara A.; DiBardino, David M.; Fuentes, Xavier Fonseca; Gesthalter, Yaron; Gilbert, Christopher R.; Glisinski, Kristen; Godfrey, M.S.; Gorden, Jed A.; Grosu, Horiana B.; Gupta, Mridul; Kheir, Fayez; Kevin, C.; Majid, Adnan; Maldonado, Fabien; Maskell, Nick A; Mehta, Hiren J.; Mercer, Joshua; Mullon, John J.; Nelson, Darlene R.; Nguyen, Elaine; Pickering, E.; Puchalski, Jonathan; Reddy, Chakravarthy; Revelo, Alberto; Roller, Lance; Sachdeva, Ashutosh; Sánchez, Trinidad; Sathyanarayan, Priya; Semaan, Roy; Senitko, Michal; Shojaee, Samira; Story, R.; Thiboutot, Jeffrey; Wahidi, Momen M.; Wilshire, Candice L.; Yu, Diana; Zouk, Aline N.; Rahman, Najib M.; Yarmus, Lonny

doi:10.1016/j.chest.2022.06.008

Cited by 18 publications

(28 citation statements)

References 26 publications

(37 reference statements)

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“…Conventional pleural fluid drainage is difficult to manipulate and is associated with a higher incidence of complications. Efforts are being made to look for an alternative therapy for empyema [ 15 ]. Recently, central venous catheterization has been reported as a suitable drainage procedure for empyema.…”

Section: Discussionmentioning

confidence: 99%

[Retracted] The Effect of CT‐Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

Yang

et al. 2022

Contrast Media & Molecular Imaging

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The aim of the study is to investigate the effect of CT-guided artificial pneumothorax combined with a thoracoscopic and central venous catheter on empyema drainage effect and pulmonary function in children. A total of 82 pediatric patients with empyema admitted to our hospital from January 2020 to December 2021 were retrospectively analyzed. The control group was treated with artificial pneumothorax combined with thoracoscopy. The study group was treated with a CT-guided and central venous catheter. The operation time, intraoperative bleeding, surgical field exposure, WBC, C-reactive protein, and pulmonary function were compared between the two groups. The size of effusion and sonographic staging were compared between the two groups. All children underwent spirometry and a maximal incremental cardiopulmonary exercise test. The operation indicators (operation time, intraoperative blood loss, etc.) and adverse reactions were compared between the two groups. The differences in the operation time, intraoperative blood loss, postoperative hospital stay, postoperative drainage volume, and surgical field exposure between the two groups had a statistical significance ( P < 0.05 ); the differences in the body temperature, total peripheral white blood cell count, C-reactive protein, size of effusion, and sonographic staging between the two groups had no statistical significance ( P > 0.05 ); before operation, the differences in the expression levels of FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) and indicators of cardiopulmonary function including VE/VO2, breathing reserve(%), VD/VT(%), and VO2/work between the two groups had no statistical significance, but at 6 months after operation, FVC (%), FEV1 (%), FEV1/FVC, and MVV (%) in the study group were significantly higher than those in the control group ( P < 0.05 ) and VE/VO2 and VD/VT(%) in the study group were obviously lower than those in the control group ( P < 0.05 ); the incidence rate of chest pain, pulmonary edema, and skin infection in the study group was lower than that in the control group ( P < 0.05 ). CT-guided artificial pneumothorax combined with thoracoscopic and central venous catheter drainage of empyema in children is more thorough, with less bleeding, less trauma, rapid recovery of pulmonary function, and is worthy of clinical promotion.

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Section: Discussionmentioning

confidence: 99%

[Retracted] The Effect of CT‐Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

Yang

et al. 2022

Contrast Media & Molecular Imaging

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“…[6][7][8] A large multicentre retrospective study of over 1800 patients, most of whom received the MIST2 regimen, specifically investigated bleeding complicating intrapleural tPA-DNase therapy and found comparable rates to that reported in MIST2, though success rates and surgical referral were not reported. 9 Given that the MIST2 regimen was based on early case reports, the optimal intrapleural dose and administration frequency of tPA-DNase is unknown, 10 and it is conceivable that regimens with lower individual doses could be equally effective in promoting pleural drainage, but with lower bleeding rates. Attempts to assess the efficacy of lower tPA doses and/or shorter therapy duration have been largely successful.…”

Section: Introductionmentioning

confidence: 99%

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema

Smith

Shaw

Ryder

2023

Internal Medicine Journal

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BackgroundPleural infection is life‐threatening and increasingly prevalent. In addition to usual care, twice‐daily, separate administration of tissue plasminogen activator and deoxyribonuclease (tPA‐DNase) reduces radiological pleural opacity with lower surgical referral rates.AimsThis retrospective cohort study examines the use of once‐daily, concurrent administration of tPA‐DNase for complex parapneumonic pleural effusion and empyema.MethodsPatients with pleural infection who received intrapleural tPA‐DNase between October 2014 and July 2020 at Logan Hospital, where it is given concurrently and once‐daily as salvage therapy, were retrospectively identified. Radiographic opacification, inflammatory markers, clinical response and complications were examined.ResultsThirty‐one patients were identified. Mean age was 48.8 years (standard deviation [SD], 17.2). Median tPA‐DNase administration was 3 (interquartile range [IQR], 2–3). Chest x‐ray pleural opacity decreased significantly (P = 0.047) from a median of 39.6% (IQR, 28.8–65.7%) to 9.7% (IQR, 2.5–23.2%), a median relative reduction of 75.5% (IQR, 47.7–93.9%). White cell count and C‐reactive protein improved significantly (P = 0.002 and P = 0.032, respectively) from a median of 16.3 × 109/L (IQR, 11.8–20.6 × 109/L) to 9.9 × 109/L (IQR, 8.0–12.3 × 109/L) and 311.0 mg/L (IQR, 218.8–374.0 mg/L) to 69.0 mg/L (IQR, 36.0–118.0 mg/L), respectively. No patients experienced significant bleeding or died. Five patients (16.1%) were referred for surgery.ConclusionThis is pilot evidence that a practical regimen of concurrent, once‐daily intrapleural tPA‐DNase improved pleural opacification and inflammatory markers without bleeding or mortality. The surgical referral rate was higher than in studies assessing twice‐daily administration, though the validity of this outcome as a measure of treatment success is limited, and further studies are needed to assess the optimal dose and frequency of intrapleural therapy and indications for surgical referral.

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“…The overall bleeding rate was 4.1% and in the 172 patients who received a lower dose tPA regimen (median 5 mg), the bleeding rate was not significantly reduced. Moreover, in a multivariate regression analysis, the data showed that the use of concurrent systemic anticoagulation, increasing RAPID score, elevated urea and platelets <100×10 9 L −1 were associated with a significant increase in bleeding risk [126]. Hold systemic treatment-dose anticoagulation prior to commencing IET for up to 48 h (or maintaining international normalised ratio <2 in case of warfarin) was shown to mitigate the additional bleeding risk.…”

Section: Iet Safety and Adverse Eventsmentioning

confidence: 93%

“…Bleeding risk and complications were specifically evaluated recently in the largest series of IET in pleural infection (over 1800 patients) [126]. The overall bleeding rate was 4.1% and in the 172 patients who received a lower dose tPA regimen (median 5 mg), the bleeding rate was not significantly reduced.…”

Section: Iet Safety and Adverse Eventsmentioning

confidence: 99%

ERS/ESTS statement on the management of pleural infection in adults

et al. 2022

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Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature.Six areas of interest were identified including the epidemiology of pleural infection, the optimal antibiotic strategy, diagnostic parameters for chest tube drainage, the status of intrapleural therapies, the role of surgery and the current place of outcome prediction in management.The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.

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Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection

Cited by 18 publications

References 26 publications

[Retracted] The Effect of CT‐Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

[Retracted] The Effect of CT‐Guided Artificial Pneumothorax plus Thoracoscopy and Central Venous Catheterization on the Drainage Effect of Pediatric Empyema and Pulmonary Function

Intrapleural tissue plasminogen activator and deoxyribonuclease administered concurrently and once daily for complex parapneumonic pleural effusion and empyema

ERS/ESTS statement on the management of pleural infection in adults

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