Rajesh Thomas1, Francesco Piccolo2, Daniel Miller3, Paul R MacEachern3, Alex C Chee3, Taha Huseini4, Lonny Yarmus5, Rahul Bhatnagar6, Hans J Lee5, David Feller-Kopman5, Nick A Maskell6, Alain Tremblay3, Y C Gary Lee7. 1. Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia. 2. Department of Internal Medicine, Swan District Hospital, Perth, WA, Australia. 3. Division of Respiratory Medicine and Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada. 4. Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia. 5. Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD. 6. Academic Respiratory Unit, University of Bristol, Bristol, England. 7. Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia; Lung Institute of Western Australia, Perth, WA, Australia. Electronic address: gary.lee@uwa.edu.au.
Abstract
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.
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.
Authors: Rajesh Thomas; Edward T H Fysh; Nicola A Smith; Pyng Lee; Benjamin C H Kwan; Elaine Yap; Fiona C Horwood; Francesco Piccolo; David C L Lam; Luke A Garske; Ranjan Shrestha; Christopher Kosky; Catherine A Read; Kevin Murray; Y C Gary Lee Journal: JAMA Date: 2017-11-21 Impact factor: 56.272
Authors: Andrey A Komissarov; Najib Rahman; Y C Gary Lee; Galina Florova; Sreerama Shetty; Richard Idell; Mitsuo Ikebe; Kumuda Das; Torry A Tucker; Steven Idell Journal: Am J Physiol Lung Cell Mol Physiol Date: 2018-01-18 Impact factor: 5.464