Empyema is often associated with substantial morbidity and potential mortality. Antibiotics and tube thoracostomy alone may be insufficient due to loculations. This has led to the use of intrapleural thrombolytics as a therapeutic adjunct. The most commonly used thrombolytics have been urokinase and streptokinase. This report describes our three-year experience with an alternative fibrinolytic agent, alteplase.
A search was performed of our electronic medical record utilizing the terms empyema or loculated effusion, and activase, t-PA or alteplase. Patients were included if they met the criteria for empyema or loculated pleural effusion and were treated with alteplase via thoracostomy tube. Charts were reviewed and baseline data recorded: demographics, indication for hospitalization and thrombolytic therapy, dose and frequency of activase therapy, need for surgical decortication, lytic complications, RBC transfusion, hospital LOS, degree of effusion by chest radiography at presentation, hospital discharge and 30 days post discharge follow-up.
Patient characteristics appear in Table 1.
Patient CharacteristicsFrequency (percentage)N30Age (yrs.)55 ± 19GenderMale21 (70.00%)Female9 (30.00%)DiagnosisEmpyema19 (63.33%)Loculated pleural effusion11 (36.67%)Admission Diagnosis:Pneumonia14 (46.66%)Cancer3 (10.00%)S/P CABG4 (13.33%)Other*9 (30.00%)Initial chest X-ray opacifation<25%3 (10.00%)25%∼50%6 (20.00%)50%∼75%12 (40.00%)>75%9 (30.00%)*
gastric bypass, perforated esophagus, mediastinal abscess, s/p lung resectionAll patients except one received daily 10 mg doses of alteplase ranging from 3-7 doses. One patient had 4 doses of 4 mg each. The total number was at the discretion of the treating physician. Table 2Table 2.
Fibrinolytic Frequency & ComplicationsNumber patients30TPA dose 10mgNo. pts.Frequency doses: 13 (10.00%)25 (16.67%)36 (20.00%)47 (23.33%)54 (13.33%)63 (10.00%)71 ( 3.33%)Complications in hospital:Pain with lytic treatment6 (20.00%)Fever associated with lytic TX1 ( 3.33%)Allergic reaction lytic TX–Hypotension (BP < 90 systolic)–Blood transfusion9 (30.00%)Patient refusal of further lytic TX–Bleeding from anywhere after lytic TX2 (6.67%)Duration of lytic therapy (days)3.60 ± 1.59summarizes dosing frequency and complications. One patient had bleeding after therapy requiring transfusion. One patient developed minor hemoptysis after 4 treatments and bronchoscopy showed bleeding from the upper lobe (area of chest tube tip). T-PA was discontinued and hemoptysis resolved without transfusion. The correlation between bleeding complications and number of alteplase treatments is 0.1 (p=0.6). Six of thirty patients (20%) had a surgical intervention. These patients received 2-5 doses of alteplase preoperatively. There was no statistical correlation between requirement for surgery and the number of fibrinolytic doses (p=0.56).
These results support our clinical experience that this treatment is safe however due to the small sample size and retrospective nature further investigation is warranted.
Alteplase has properties which differ from previously used intrapleural thrombolytics. Further study with alteplase for empyema will help determine efficacy.
J.D. O’Brien, Genentech