title: Safety and Efficacy of Tissue Plasminogen Activator and DNase for Complicated Pleural Effusions Secondary to Abdominal Pathology.
abstract: BACKGROUND
  Exudative pleural effusions may arise secondary to inflammation of intra-abdominal structures. Pleural space loculations can complicate these effusions, preventing adequate chest tube drainage and leading to consideration of surgical intervention. Previous studies have demonstrated that intrapleural administration of tissue plasminogen activator (tPA) combined with human recombinant DNase can improve fluid drainage and reduce surgery for patients with loculated parapneumonic effusions; however, the efficacy of this treatment has not been evaluated for complicated pleural effusions attributed to intra-abdominal inflammation.
  
  
  OBJECTIVE
  We assessed the safety and efficacy of tPA/DNase for 17 pleural effusions associated with nonmalignant intra-abdominal pathology that did not drain adequately after placement of one or more chest tubes.
  
  
  METHODS
  Efficacy was measured by comparing post- to pretreatment fluid drainage rates, volumetric assessment of pleural fluid on radiographic images before and after treatment, and clinical improvement, including the need for surgical intervention. Symptomatic relief was assessed using the Borg scale for breathlessness.
  
  
  RESULTS
  After a median of two doses of tPA/DNase, 23.5% of patients had chest pain and none had pleural bleeding. The volume of pleural fluid drained increased from a median of 325 ml to 890 ml per 24 hours after therapy (P = 0.018). The area of pleural space opacity on chest radiographs decreased from a median of 42.8-17.8% of the hemithorax (P = 0.001). tPA/DNase reduced the pleural fluid volume on chest computed tomographic imaging from a median of 294.4 ml to 116.1 ml. Borg scores improved from a median of 3 (interquartile range = 1-6) to 0 (interquartile range = 0-2) after therapy (P = 0.001). The median duration of chest tube placement and hospital stay were 4 and 11 days, respectively. Two patients required surgical intervention for lung entrapment. Overall, treatment was considered successful for 88.2% of patients.
  
  
  CONCLUSIONS
  This retrospective case series suggests that intrapleural tPA/DNase can be safe and effective for patients with complicated pleural effusions attributed to abdominal pathology that do not drain adequately after chest tube placement. Additional studies are needed to determine whether the combination of tPA and DNase is more effective than tPA for this indication.
authors.affiliation: 1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Adnan
authors.initials: A
authors.lastname: Majid
authors.affiliation: 1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.|2 Department of Internal Medicine, Medstar Georgetown University Hospital, Washington, D.C.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Ochoa
authors.affiliation: 3 Department of Respiratory Medicine, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom.
authors.forename: Sumit
authors.initials: S
authors.lastname: Chatterji
authors.affiliation: 4 Section of Interventional Pulmonology, Clinica Alemana, Universidad Del Desarrollo, Santiago, Chile.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Fernandez-Bussy
authors.affiliation: 1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.|5 Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana; and.
authors.forename: Fayez
authors.initials: F
authors.lastname: Kheir
authors.affiliation: 1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Estefania
authors.initials: E
authors.lastname: Rivera
authors.affiliation: 1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: George
authors.initials: G
authors.lastname: Cheng
authors.affiliation: 6 Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Erik
authors.initials: E
authors.lastname: Folch
mesh_terms: D000328:Adult; D000368:Aged; D015505:Chest Tubes / Q000009:adverse effects; D003851:Deoxyribonucleases / Q000008:administration & dosage*; D004322:Drainage / Q000009:adverse effects; D016724:Empyema, Pleural / Q000150:complications; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D059413:Intraabdominal Infections / Q000150:complications; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010996:Pleural Effusion / Q000000981:diagnostic imaging* / Q000628:therapy*; D012189:Retrospective Studies; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D014057:Tomography, X-Ray Computed; D014481:United States
chemical_list: D005343:Fibrinolytic Agents; D003851:Deoxyribonucleases; D010959:Tissue Plasminogen Activator
keywords: DNase; complicated pleural effusion; pleural effusion secondary to abdominal pathology; sympathetic pleural effusion; tissue plasminogen activator