Disorders of the Pleura |

Prolonged Intrapleural Fibrinolytic Therapy in Complicated Pleural Space Infections: Identification of Risk Factors and Complications of Use FREE TO VIEW

Jason McClune, MD; Jennifer Toth, MD; Michael Reed, MD; Matthew Taylor, MD; Christopher Gilbert, DO
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Penn State Hershey Medical Center, Hershey, PA

Chest. 2015;148(4_MeetingAbstracts):441A. doi:10.1378/chest.2268213
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SESSION TITLE: Disorders of the Pleura Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM

PURPOSE: Complicated Parapneumonic effusions (CPE) and empyema can develop in 36-66% of hospitalized patients with pneumonia; with 10-20% mortality rates. Antimicrobials and pleural drainage are often advocated, especially in non-surgical candidates. The MIST II trial demonstrated improved drainage with intrapleural fibrinolytic therapy (IPFT), with decreased surgical referrals and hospital days. Predictive factors of IPFT success have yet to be identified. We sought to identify prognostic factors and the safety profile of prolonged IPFT utilization.

METHODS: A single-center, retrospective review of patients receiving IPFT for CPE or empyema was performed from June 2014 to February 2015. Clinical information was retrieved including demographics, comorbidities, radiographic findings, lytic dosing, pleural fluid characteristics, and outcomes. Inclusion criteria were: documented empyema or CPE with tube thoracostomy and subsequent IPFT. Exclusion criteria were: less than 18, or preexisting indwelling catheter. Lytic therapy included tPA and DNase, 10 mg and 5 mg respectively, dosed twice daily per MIST II protocol.

RESULTS: We identified 24 patients receiving IPFT. Three exclusions: never received IPFT(1), age less than 18(1), previous intrapleural catheter(1). Demographics of the remaining 21: mean age of 61 years with 57% female. Chest tube size: 7 to 28 French, 90% placed with imaging. Overall mortality was 9.5%. Five patients failed standard IPFT (23.8%). Four required additional dosing and two referred for surgery. Within this failed cohort, the mean number of doses was 10.5 and hospital stay was 5.2 days longer. Complications identified: One hemothorax requiring transfusion in a patient undergoing prolonged IPFT. New narcotic requirement was established in 48% of the entire cohort.

CONCLUSIONS: Our single institution experience suggests IPFT remains effective in reducing surgical referrals for complicated pleural space infections. Those failing initial IPFT can be given additional IPFT therapy with minimal risk of additional complications. Identification of patients that may require prolonged IPFT appears difficult but deserves further study.

CLINICAL IMPLICATIONS: Prolonged IPFT may benefit patients that failed initial standard therapy, but needs further investigation.

DISCLOSURE: The following authors have nothing to disclose: Jason McClune, Jennifer Toth, Michael Reed, Matthew Taylor, Christopher Gilbert

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