PURPOSE: To document the safety and efficacy of intrapleural instillation of Alteplase in the management of complicated pleural effusions and empyemas.
METHODS: Patients with pleural effusions that failed standard medical treatment and simple chest tube drainage were evaluated for Alteplase therapy. These patients were symptomatic and had persistent pleural fluid and/or continued sepsis. Alteplase was instilled intrapleurally daily until 70% or more improvement in pleural effusion was noted, and all symptoms resolved. Complete response was documented if the pleural fluid/pneumonia resolved completely and did not recur for at least 8 weeks. Partial response was documented if the residual pleural effusions after eight weeks were mild to moderate, clinical symptoms were minimal, and these patients did not need surgical intervention. Failed response was documented if the pleural effusions did not change, clinical symptoms persisted and these patients needed surgical intervention.
RESULTS: 120 patients were treated with intrapleural Alteplase. 52 patients had empyema, 41 patients had CPE, 10 patients with hemothorax and 17 patients with complicated malignant pleural effusions. A total of 345 doses of Alteplase were instilled intrapleurally in these patients, with doses ranging from 10 mg to 100mg daily. Most patients required at least three doses of Alteplase. Complete response was noted in 102 patients (85%); 10 patients (8.3%) had partial response and 8 patients (6.7%) failed therapy. Patients that failed therapy had chronic empyema or had empyema associated with lung abscess. Adverse effects of Alteplase therapy were chest pain in 7 patients (6%), and bleeding at the chest tube site in 2 patients (2%).
CONCLUSION: Intrapleural instillation of Alteplase should be considered in the initial management of complicated pleural effusions and empyemas that fail to respond to simple chest tube drainage. Patients with chronic empyemas or empyemas with associated lung abscess should go directly to surgery.
CLINICAL IMPLICATIONS: VATS and or decortications can be avoided in patients with complicated pleural effusion and empyema if intrapleural instillation of Alteplase is effective.
DISCLOSURE: George Thommi, Grant monies (from industry related sources) Genetech, Inc; Product/procedure/technique that is considered research and is NOT yet approved for any purpose, Alteplase.