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

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          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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          Most cited references33

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          U.K. Controlled trial of intrapleural streptokinase for pleural infection.

          John F. Gleeson, T. Peto, Jeffrey Rees … (2005)
          Intrapleural fibrinolytic agents are used in the drainage of infected pleural-fluid collections. This use is based on small trials that did not have the statistical power to evaluate accurately important clinical outcomes, including safety. We conducted a trial to clarify the therapeutic role of intrapleural streptokinase. In this double-blind trial, 454 patients with pleural infection (defined by the presence of purulent pleural fluid or pleural fluid with a pH below 7.2 with signs of infection or by proven bacterial invasion of the pleural space) were randomly assigned to receive either intrapleural streptokinase (250,000 IU twice daily for three days) or placebo. Patients received antibiotics and underwent chest-tube drainage, surgery, and other treatment as part of routine care. The number of patients in the two groups who had died or needed surgical drainage at three months was compared (the primary end point); secondary end points were the rates of death and of surgery (analyzed separately), the radiographic outcome, and the length of the hospital stay. The groups were well matched at baseline. Among the 427 patients who received streptokinase or placebo, there was no significant difference between the groups in the proportion of patients who died or needed surgery (with streptokinase: 64 of 206 patients [31 percent]; with placebo: 60 of 221 [27 percent]; relative risk, 1.14 [95 percent confidence interval, 0.85 to 1.54; P=0.43), a result that excluded a clinically significant benefit of streptokinase. There was no benefit to streptokinase in terms of mortality, rate of surgery, radiographic outcomes, or length of the hospital stay. Serious adverse events (chest pain, fever, or allergy) were more common with streptokinase (7 percent, vs. 3 percent with placebo; relative risk, 2.49 [95 percent confidence interval, 0.98 to 6.36]; P=0.08). The intrapleural administration of streptokinase does not improve mortality, the rate of surgery, or the length of the hospital stay among patients with pleural infection. Copyright 2005 Massachusetts Medical Society.
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            Intrapleural use of tissue plasminogen activator and DNase in pleural infection.

            Najib M Rahman, Nicholas Maskell, Alex West … (2011)
            More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).
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              The American Association for Thoracic Surgery consensus guidelines for the management of empyema

              K Robert Shen, Alejandro Bribriesco, Traves Crabtree … (2017)
              Article 0 comments Cited 116 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Mohamed Faisal Abdul Hamid: faisal.hamid@ppukm.ukm.edu.my
                Journal
                Journal ID (nlm-ta): BMC Pulm Med
                Journal ID (iso-abbrev): BMC Pulm Med
                Title: BMC Pulmonary Medicine
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2466
                Publication date (Electronic): 23 November 2022
                Publication date PMC-release: 23 November 2022
                Publication date Collection: 2022
                Volume: 22
                Electronic Location Identifier: 439
                Affiliations
                [1 ]GRID grid.240541.6, ISNI 0000 0004 0627 933X, Respiratory Unit, Department of Medicine, Faculty of Medicine, , Universiti Kebangsaan Malaysia Medical Centre (UKMMC), ; Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
                [2 ]GRID grid.240541.6, ISNI 0000 0004 0627 933X, Cardiothoracic Unit, Department of Surgery, Faculty of Medicine, , Universiti Kebangsaan Malaysia Medical Centre (UKMMC), ; Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
                [3 ]GRID grid.240541.6, ISNI 0000 0004 0627 933X, Department of Radiology, Faculty of Medicine, , Universiti Kebangsaan Malaysia Medical Centre (UKMMC), ; Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
                [4 ]GRID grid.240541.6, ISNI 0000 0004 0627 933X, Heart and Lung Institute, Faculty of Medicine, , Universiti Kebangsaan Malaysia Medical Centre (UKMMC), ; Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
                Article
                Publisher ID: 2239
                DOI: 10.1186/s12890-022-02239-w
                PMC ID: 9685928
                PubMed ID: 36419155
                SO-VID: 897da67e-f1f4-41f5-9201-e27b7e91c3dd
                Copyright © © The Author(s) 2022
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 4 September 2022
                Date accepted : 14 November 2022
                Categories
                Subject: Research
                Custom metadata
                issue-copyright-statement © The Author(s) 2022

                ScienceOpen disciplines: Respiratory medicine
                Keywords: thoracic surgery,respiratory infection,clinical respiratory medicine,pleural disease
                Data availability:
                ScienceOpen disciplines: Respiratory medicine
                Keywords: thoracic surgery, respiratory infection, clinical respiratory medicine, pleural disease

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