Intrapleural Fibrinolytic Therapy Improves Results With Talc Slurry Pleurodesis.

Objective Talc slurry pleurodesis (TSP) can lead to permanent small loculations. Intrapleural tissue plasminogen activator (tPA) breaks down loculations, and therefore may improve results but may also inhibit pleurodesis. tPA was given with and after talc slurry to promote more uniform talc distribution and eliminate loculations. Methods Charts were reviewed for patients treated with TSP with or without tPA. Chest x-rays after TSP were compared to chest x-rays before and graded as "worse", "same", or "better". Incidence of need for repeat TSP was recorded. Results There were 52 patients, eight with bilateral effusions, for a study cohort of 60 effusions. One-third of the effusions were malignant. No patients experienced significant bleeding. Results were better than baseline for 14 (26%) patients given tPA, but not for patients that never received tPA. The addition of tPA 4-6 mg with talc slurry resulted in no patients requiring repeat TSP. When tPA was given after talc slurry, a delay of three days was associated with the lowest incidence of repeat TSP (3/14, 21%). Conclusions There were no significant complications from tPA use to supplement TSP, and tPA may improve results without interfering with pleurodesis. A prospective trial is warranted.

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

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.