Intrapleural tissue plasminogen activator and deoxyribonuclease in complex pleural effusion and empyema, clinical outcomes, and predictors.

BACKGROUND

Complex pleural effusion and empyema (CPPE) is treated with intrapleural fibrinolytic therapy (IPFT) using tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) We present our single-center retrospective observational data using a simplified regimen of coadministering six divided doses of tPA and DNase over the course of 3 days.

OBJECTIVE

To study the safety, utility, and clinical outcomes of IPFT.

DESIGN

This is a single-center retrospective study of patients who received co-administration tPA/DNase for CPPE over a period of 5 years. The primary outcome was successful treatment without the need for surgery. Secondary outcomes were bleeding risk, post-procedural pain, treatment complications, and all-cause mortality at 30 days and 6 months. We have tested the clinical role RAPID score (Renal function measured as urea, Age, fluid Purulence, Infection source, Dietary status measured as albumin) to predict treatment success, and all-cause mortality at 6 months.

RESULTS

A total of ( = 55) patients were included in the study. The mean age of the population studied was 67 (Interquartile range 57-74), including 47.3% male and 52.7% Female. 92.7% of the population studied was Caucasian. Comorbidities including chronic obstructive pulmonary disease, congestive heart failure, and Diabetes mellitus were present in 41.8%, 41.8%, and 43.6.% respectively. Patients were treated with tube thoracostomy with 14 French percutaneous pigtail catheters in 47 (85.5%) or 28-32 French chest tubes in 8 (14.5%) patients. Twenty-nine percent (16) of patients had acceptable clinical and radiographic improvement and did not require additional surgical or radiological intervention. Seventy-one percent (39) of patients required additional surgical drainage; video-assisted thoracoscopic surgery in 37, and open thoracotomy in 2 patients. The discriminating ability of the RAPID score for treatment success after IPFT was found to be poor (AUC: 0.601, 95% CI: 0.429-0.773,  = 0.24). All-cause mortality at 6 months was 23.6% (13) of patients. The predictive ability of the RAPID score for mortality at 6 months was found to be poor (AUC: 0.640, 95% CI: 0.478-0.802,  = 0.13). The optimal cutoff for the RAPID score for mortality was ⩾4, with 84.6% sensitivity and 46.3% specificity.

CONCLUSION

Results of our single-center study suggest that IPFT can be safely adopted by small and mid-sized clinical centers, as the risk of bleeding is low. The results of coadministering tPA and DNase are safe, and it reduces the need for surgical intervention in nearly one-third of patients.