To review the outcomes of patients who received intrapleural alteplase for complicated parapneumonic effusion (PPE) at our institution.
We conducted a retrospective review of all patients who received alteplase for complicated PPE from January 2002 through October 2003 at our 1,000 bed university hospital. Complicated PPE was determined by presence of pneumonia (diagnosed by chest xray or presence of organisms by bronchoalveolar lavage) and presence of pleural fluid with loculations or evidence of infection (pH<7.2; glucose < 60 mg/dl; or organisms present). Efficacy was defined as radiographic resolution of complicated PPE without requiring surgery. Safety was defined as lack of blood transfusion within 72 hours after alteplase.
Nine patients were reviewed. Pleural fluid pH ranged from 6.0-8.0 and glucose 4-63mg/dL. Four drained frank pus consistent with empyema. Pleural fluid cultures were positive in 5 patients. Duration of symptoms prior to chest tube placement ranged from hours to 4 weeks (median 7 days). Seven patients showed radiographic evidence of loculations. All patients received alteplase 16mg in 100ml 0.9%NaCl instilled and retained in the chest tube for 2-4 hours daily until adequate response. Number of alteplase doses per patient ranged from 1-7. Seven patients showed complete or almost complete radiographic resolution of the PPE; one expired due to ARDS and one required surgical decortication. One patient received a blood transfusion 2 days after the last alteplase dose; no causality was established.
Alteplase had acceptable efficacy and safety when used according to the described regimen. Alteplase led to radiographic improvement more often than expected considering the prolonged symptom-to-treatment time in our patients.
Literature supports early surgical intervention for patients with complicated PPE. When surgery is not an option, intrapleural fibrinolytics may be used. Studies have evaluated urokinase and streptokinase for management of complicated PPE, but alteplase data in adults is limited to case series. With the intermittent availability of urokinase and streptokinase and concern about streptokinase use in patients with streptococcal infections, alteplase is a viable alternative.
Beth Besecker, None.