Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study.
BACKGROUND
Indwelling pleural catheters (IPCs) are an effective option in the management of malignant pleural effusion. Up to 14% of patients with IPCs develop symptomatic pleural loculations causing ineffective fluid drainage and breathlessness. To our knowledge, this is the first study to describe intrapleural fibrinolytic therapy for IPC-related symptomatic loculations.


METHODS
All patients who received intrapleural fibrinolytic therapy for symptomatic loculations between January 1, 2002, and June 30, 2014, in four established IPC centers were retrospectively included. Patient outcomes, treatment effectiveness, and adverse events were recorded.


RESULTS
Sixty-six patients (mean age, 64.7 ± 14.2 years; 52% women) were included. Lung cancer (31.3%) and malignant pleural mesothelioma (20.3%) were the most common malignancies. Fibrinolytic instillation was performed in outpatient (61%) and inpatient settings. Tissue-plasminogen activator (n = 52), urokinase (n = 12), and streptokinase (n = 2) were used. The majority (69.7%) received only one fibrinolytic dose (range, one to six). Pleural fluid drainage increased in 93% of patients, and dyspnea improved in 83% following therapy. The median cumulative pleural fluid volume drained at 24 h posttreatment was 500 mL (interquartile range 300-1,034 mL). The area of opacity caused by pleural effusion on chest radiograph decreased from (mean, SD) 52% (14%) to 31% (21%) of the hemithorax (n = 13; P = .001). There were two cases of nonfatal pleural bleed (3%).


CONCLUSIONS
Intrapleural fibrinolytic therapy can improve pleural fluid drainage and symptoms in selected patients with IPC and symptomatic loculation, but it carries a small risk of pleural bleeding. There is significant heterogeneity in its use currently, and further studies are needed to determine patient selection and optimal dosing regimen and to define its safety profile.
Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia.
Rajesh
R
Thomas
Department of Internal Medicine, Swan District Hospital, Perth, WA, Australia.
Francesco
F
Piccolo
Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada.
Daniel
D
Miller
Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada.
Paul R
PR
MacEachern
Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada.
Alex C
AC
Chee
Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
Taha
T
Huseini
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
Lonny
L
Yarmus
Academic Respiratory Unit, University of Bristol, Bristol, England.
Rahul
R
Bhatnagar
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
Hans J
HJ
Lee
Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
David
D
Feller-Kopman
Academic Respiratory Unit, University of Bristol, Bristol, England.
Nick A
NA
Maskell
Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada.
Alain
A
Tremblay
Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia. Electronic address: gary.lee@uwa.edu.au.
Y C Gary
YCG
Lee
D000368:Aged; D002408:Catheters, Indwelling / Q000009:adverse effects*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008297:Male; D008875:Middle Aged; D016066:Pleural Effusion, Malignant / Q000628:therapy*; D012189:Retrospective Studies; D013300:Streptokinase / Q000627:therapeutic use; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014568:Urokinase-Type Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D013300:Streptokinase; D010959:Tissue Plasminogen Activator; D014568:Urokinase-Type Plasminogen Activator