Can intrapleural alteplase treatment be an alternative to videothoracoscopic deloculation and decortication in pleural empyema?

Abstract

Introduction: Chest tube drainage is the first step in the management of complicated pleural effusions that have turned into empyema. In cases where adequate drainage cannot be provided or deloculation is required, intrapleural fibrinolytic therapy or surgical deloculation can be performed. Alteplase is a suitable agent for intrapleural fibrinolytic therapy. On the other hand, video-assisted surgery is an effective and minimally invasive treatment option for lung re-expansion. Aim: The effect of intrapleural alteplase irrigation applied through the thoracic tube in the treatment of pleural empyema was investigated and whether it could be an alternative technique to video-assisted thoracoscopic surgery was evaluated. Material and methods: The results of patients who were treated for empyema in our clinic were evaluated retrospectively. Twenty-one patients who underwent tube thoracostomy + intrapleural alteplase and 28 patients who underwent VATS deloculation were included in the study. Results: The study included 35 male and 14 female patients. There were 21 patients in group 1, and 28 patients in group 2. The mean age was 50.6. The average length of thoracic tube stay was determined as 7.1 and 6.96 days. The duration of hospital stay in this group was 6.73 and 6.35 days. In 17 (81%) patients in group 1, the treatment was discontinued without the need for surgery. Conclusions: VATS-D is an effective option in the treatment of pleural empyema. However, as seen in our study, intrapleural alteplase application is at least as effective as VATS-D in terms of treatment success.

Pleural empyema due to Salmonella enterica in a patient affected by lung adenocarcinoma: A clinical case report

“…5]. Afterwards, her case was discussed collegially with thoracic surgeons; the patient was offered the option of fibrinolytic therapy, indicated to ease fluid evacuation as an effective alternative to video-assisted thoracoscopy (VATS) in the treatment of pleural empyema [10]. She accepted to receive intrapleural alteplase irrigation applied through the chest tube, and postprocedural outcome was monitored through a digital thoracic drainage system (DTDS).…”

From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema

“…Thus, the shift from a more invasive surgical approach for stage III empyema towards VATS becomes feasible. A trend towards less invasive procedures to treat stage II/III empyema in combination with the recently reported equal efficacy of VATS and IPFT ( Ohara et al, 2018 ; Samancilar et al, 2018 ; Kermenli and Azar, 2021 ) opens a window of opportunity to expand the use of pharmacological treatment in advanced stage empyema.…”

Targeting the PAI-1 Mechanism with a Small Peptide Increases the Efficacy of Alteplase in a Rabbit Model of Chronic Empyema

“…Thus, preclinical research focused on the development and testing of novel, well-tolerated, pharmacological treatments that may complement surgery with effective alternatives to simple drainage for patients with chronic empyema. Recent advances in technology expanded the purview of less invasive VATS and IPFT to treat stage II and even stage III empyema [ 27 , 28 , 29 , 30 , 31 ], offering the predicate to explore novel, targeted, pharmacological approaches to treat more advanced/chronic empyema. Increasing the intrapleural half-life of fibrinolysins and the rate of fibrinolysis may address both intrapleural fibrin deposition and pleural thickening, thereby widening the therapeutic window for IPFT in empyema.…”