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Disorders of the Pleura |

Response Based Intrapleural Instillation of Alteplase and DNase for Complicate Pleural Effusion

Ashish Maskey, MBBS; Erik Folch, MD; Megan Fashjian, NP; Manju Paul, MBBS; Adnan Majid, MD
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BIDMC, Boston, MA


Chest. 2013;144(4_MeetingAbstracts):508A. doi:10.1378/chest.1703950
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Abstract

SESSION TITLE: Pleural Disease Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 30, 2013 at 01:30 PM - 02:30 PM

PURPOSE: The treatment of empyema with instillation of intra-pleural t-PA and DNase has proven to decrease the length of hospital stay, surgical referral and improve drainage. The optimal dosage and schedule regimen remains unclear. Complicated pleural effusions are defined by the presence of pus, positive gram stain, pH < 7.2, LDH > 1000, loculations, isoechoic fluid or massive effusion. We describe our experience in treating complicated pleural effusions by simultaneous instillation of intrapleural t-PA and DNase in patients who failed initial drainage using an ad-hoc treatment regimen.

METHODS: Retrospective data collection of 15 consecutive patients who presented with complicated pleural effusion. The patients underwent simultaneous instillation of t-PA (10 mg) and DNase (5 mg) through the existing 14 Fr pigtail catheter. The number of doses of t-PA and DNase was determined by the treating physician based on the chest tube output and imaging findings. Pre and post t-PA/DNase CXR and chest CT scans were performed and reviewed to quantify the change in the pleural effusion.

RESULTS: Fifteen consecutive patients with complicated pleural effusion were included on this study. Eleven were male. Median age was 61 years. Most common underlying etiologies included pneumonia (5) and hepato-biliary disease (4). The median days in hospital prior to chest tube insertion was 5 days. Only 2 (13%) patients required surgical decortication. The mean number of doses of t-PA and DNase was 4 (Range 1 to 9). There was radiological improvement in 13 (86%) patients. The median number of chest tube and hospital days was 5 and 11 respectively. There were no major complications.

CONCLUSIONS: Small bore pig tail catheter in combination with simultaneous instillation of intrapleural t-PA and Dnase was successful in draining complicated pleural effusions.

CLINICAL IMPLICATIONS: Given the high cost of t-PA and DNase, it is feasible to guide the number of doses based on clinical and radiological response. This strategy is likely to decrease the number of surgical interventions and/or need for placement of large-bore chest tubes.

DISCLOSURE: The following authors have nothing to disclose: Ashish Maskey, Erik Folch, Megan Fashjian, Manju Paul, Adnan Majid

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