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Original Research: Pulmonary Procedures |

Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic LoculationsIndwelling Catheter-Related Symptomatic Loculation: A Multicenter Observational Study

Rajesh Thomas, MBBS; Francesco Piccolo, MBBS; Daniel Miller, MD; Paul R. MacEachern, MD, FCCP; Alex C. Chee, MD, FCCP; Taha Huseini, MBBS; Lonny Yarmus, DO, FCCP; Rahul Bhatnagar, MBChB; Hans J. Lee, MD, FCCP; David Feller-Kopman, MD, FCCP; Nick A. Maskell, DM, FCCP; Alain Tremblay, MDCM, FCCP; Y. C. Gary Lee, PhD, FCCP
Author and Funding Information

From the Department of Respiratory Medicine (Drs Thomas, Huseini, and Y. C. G. Lee), Sir Charles Gairdner Hospital, Perth, WA, Australia; the School of Medicine and Pharmacology (Drs Thomas and Y. C. G. Lee), University of Western Australia, Perth, WA, Australia; the Lung Institute of Western Australia (Drs Thomas and Y. C. G. Lee), Perth, WA, Australia; the Department of Internal Medicine (Dr Piccolo), Swan District Hospital, Perth, WA, Australia; the Division of Respiratory Medicine and Southern Alberta Cancer Research Institute (Drs Miller, MacEachern, Chee, and Tremblay), University of Calgary, Calgary, AB, Canada; the Division of Pulmonary and Critical Care Medicine (Drs Yarmus, H. J. Lee, and Feller-Kopman), Johns Hopkins University, Baltimore, MD; and the Academic Respiratory Unit (Drs Bhatnagar and Maskell), University of Bristol, Bristol, England.

CORRESPONDENCE TO: Y. C. Gary Lee, PhD, FCCP, University of Western Australia School of Medicine & Pharmacology, 533 Harry Perkins Research Bldg, QE II Medical Centre, Perth, WA 6009, Australia; e-mail: gary.lee@uwa.edu.au


FUNDING/SUPPORT: Dr Thomas has received research scholarship support from NH&MRC, the Western Australia Cancer and Palliative Care Network (WACPCN), and LIWA, Australia. Dr Maskell has received research grant support from the National Institutes of Health Research (NIHR). Dr Y. C. G. Lee has received research grant support from the Sir Charles Gairdner Research Foundation, the Cancer Council of Western Australia, the Lung Institute of Western Australia (LIWA), Westcare, and the Dust Disease Board of New South Wales, Australia. Dr Y. C. G. Lee is a recipient of a National Health and Medical Research Council (NH&MRC) Career Development Fellowship.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(3):746-751. doi:10.1378/chest.14-2401
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BACKGROUND:  Indwelling pleural catheters (IPCs) are an effective option in the management of malignant pleural effusion. Up to 14% of patients with IPCs develop symptomatic pleural loculations causing ineffective fluid drainage and breathlessness. To our knowledge, this is the first study to describe intrapleural fibrinolytic therapy for IPC-related symptomatic loculations.

METHODS:  All patients who received intrapleural fibrinolytic therapy for symptomatic loculations between January 1, 2002, and June 30, 2014, in four established IPC centers were retrospectively included. Patient outcomes, treatment effectiveness, and adverse events were recorded.

RESULTS:  Sixty-six patients (mean age, 64.7 ± 14.2 years; 52% women) were included. Lung cancer (31.3%) and malignant pleural mesothelioma (20.3%) were the most common malignancies. Fibrinolytic instillation was performed in outpatient (61%) and inpatient settings. Tissue-plasminogen activator (n = 52), urokinase (n = 12), and streptokinase (n = 2) were used. The majority (69.7%) received only one fibrinolytic dose (range, one to six). Pleural fluid drainage increased in 93% of patients, and dyspnea improved in 83% following therapy. The median cumulative pleural fluid volume drained at 24 h posttreatment was 500 mL (interquartile range 300-1,034 mL). The area of opacity caused by pleural effusion on chest radiograph decreased from (mean, SD) 52% (14%) to 31% (21%) of the hemithorax (n = 13; P = .001). There were two cases of nonfatal pleural bleed (3%).

CONCLUSIONS:  Intrapleural fibrinolytic therapy can improve pleural fluid drainage and symptoms in selected patients with IPC and symptomatic loculation, but it carries a small risk of pleural bleeding. There is significant heterogeneity in its use currently, and further studies are needed to determine patient selection and optimal dosing regimen and to define its safety profile.

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