Extended Dwell Time Improves Results of Fibrinolytic Therapy for Complex Pleural Effusions

Abstract

Introduction Published trials of intrapleural therapy for complex pleural effusions rely on fibrinolytics and deoxyribonuclease (DNase) with dwell times of less than six hours and frequent dosing. We reviewed our experience with fibrinolytics alone but with a longer dwell time (12 hours). Methods Tissue plasminogen activator (tPA, 1-6 mg per dose) was given through pigtail catheters placed using image guidance. Planned treatment was for a dwell time of 12 hours with repeat dosing daily for three days or until drainage was less than 100 cc or grossly bloody. Chest x-ray and/or computed tomography (CT) were used to determine completeness of pleural drainage. Results Forty-six patients presenting with 47 complex pleural effusions were given 131 doses of tPA. Doses of 4, 5, and 6 mg were most common (n=17, 70, and 33, respectively). Dwell time ranged from five to 14 hours with 12 hours being most common (n=115). Additional chest tubes were placed in 18 effusions. Ten effusions (21%) required decortication: seven for trapped lung and three for incomplete drainage. Drainage was considered complete in 33/40 (82.5%) effusions without trapped lung. Median chest tube duration was seven days (range three to 28 days). tPA therapy was discontinued in two patients for bleeding, but neither experienced hemodynamic instability. Conclusions tPA with a 12-hour dwell time is effective and safe for management of complex pleural effusions, although chest tube duration was prolonged. tPA alone is less expensive and easier than when combined with DNase, and this strategy warrants a prospective evaluation.

Tissue plasminogen activator with prolonged dwell time effectively evacuates pleural effusions

“…In these patients effusion drainage was surprisingly brisk, leading us to modify our treatment regimen to the use of tPA alone with a prolonged dwell time. In reviewing that early experience we concluded that a 4 mg dose of tPA was sufficient, and that a 12 h dwell time was most effective [ 12 ]. In this report we review our experience with that standardized protocol.…”

“…The serendipitous result was the discovery that tPA alone with a longer dwell time seemed effective. In a review of our experience treating 47 effusions in 46 patients with tPA alone, in doses ranging from 1 to 6 mg and dwell times ranging from 5 to 14 h, we found that only 6% required surgery [ 12 ]. Based on this review we concluded that a once daily dose of 4 mg with a dwell time of 12 h seemed most effective and most easily administered.…”

Tissue Plasminogen Activator with Prolonged Dwell Time Effectively Evacuates Pleural Effusions

“…In these patients effusion drainage was surprisingly brisk, leading us to modify our treatment regimen to the use of tPA alone with a prolonged dwell time. In reviewing that early experience we concluded that a 4 mg dose of tPA was su cient, and that a 12 hour dwell time was most effective 12 . In this report we review our experience with that standardized protocol.…”

“…The serendipitous result was the discovery that tPA alone with a longer dwell time seemed effective. In a review of our experience treating 47 effusions in 46 patients with tPA alone, in doses ranging from 1 to 6 mg and dwell times ranging from 5 to 14 hours, we found that only 6% required surgery 12 . Based on this review we concluded that a once daily dose of 4 mg with a dwell time of 12 hours seemed most effective and most easily administered.…”

Intrapleural Fibrinolytic Therapy Improves Results With Talc Slurry Pleurodesis

“…Tissue plasminogen activator (tPA) is a fibrinolytic that has been shown to be effective for drainage of loculated pleural effusions [10][11][12]. Based on our favorable experience with intrapleural tPA for management of complex pleural effusions [13], we started using it to eliminate loculated collections that developed after pleurodesis. To the best of our knowledge, this had not been attempted before.…”