To evaluate the safety of various doses of Alteplase in the management of complicated pleural effusions(CPE)/empyema.
One hundred twenty patients admitted to Methodist Hospital with CPE/empyema that failed standard medical treatment and simple chest tube drainage were treated with intrapleural Alteplase in doses ranging from 10mg to 100mg. A total of 330 doses of Alteplase were instilled intrapleurally as follows: 17 doses of 100mg of Alteplase, 70 doses of 50mg alteplase, 211 doses of 25mg alteplase and 10 doses of 10mg alteplase. Alteplase was administered daily through the chest tube intapleurally in 100cc of normal saline. Alteplase instillation was stopped when the drainage was less than 150cc in 24 hours, or if the drainage fluid appeared to be more bloody with each instillation, or if any complications occurred. A few patients received pre-and post coagulation profile with Alteplase instillation. Patients were monitored for any adverse events during, and for 24 hours after the procedure.
Two patients had significant bleeding post procedure (over 1gm Hemoglobulin), one needing transfusion. One patient had an intrapleural hematoma that resolved over a few days. One patient with severe COPD and respiratory failure had progressive shortness of breath several hours after Alteplase instillation, but when rechallenged a few days later had no adverse events. Seven patients experienced chest pain with only the first dose of Alteplase. Five had mild chest pain, one had moderate chest pain and one had severe chest pain. No significant change in coagulation was noted pre and post-Alteplase instillation in the patients that were monitored.
Intrapleural instillation of Alteplase is safe in doses up to 100mg administered daily. Side effects are minimal, with chest pain and bleeding at the chest tube site being the most common.
Alteplase in doses of up to 100mg daily can be safely instilled intrapleurally in complicated pleural effusions/emyema.
G. Thommi, Supported by Genetech, Inc