CHEST
Volume 148, Issue 3, September 2015, Pages 746-751
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Original Research
Pulmonary Procedures
Intrapleural Fibrinolysis for the Treatment of Indwelling Pleural Catheter-Related Symptomatic Loculations: A Multicenter Observational Study

https://doi.org/10.1378/chest.14-2401Get rights and content

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.

Section snippets

Demographics

One hundred sixty-five patients at SCGH, 105 at SMH, 220 at JHH, and an estimated 1,200 patients at the University of Calgary underwent IPC insertion for the management of recurrent pleural effusions during the study period. A total of 66 patients (52% women) with a mean age of 64.7 (14.2) years fulfilled the inclusion criteria. Most patients (n = 64) had an MPE: 13 (20.3%) from malignant pleural mesothelioma, 20 (31%) from lung carcinoma, and the remainder from pleural metastases of

Discussion

Symptomatic pleural loculation is increasingly recognized as a relatively frequent complication of IPC use.3, 5 Fibrinolytic agents have been used in many centers to break down pleural loculations in the hope of reestablishing IPC fluid drainage, without the support of quality evidence or clear guidelines. To our knowledge, this multicenter observational study from four established IPC centers is the first to describe the clinical outcome of intrapleural fibrinolytics for IPC-related

Conclusions

Intrapleural fibrinolytic therapy can improve pleural 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 how intrapleural fibrinolytics are currently used for IPC-related symptomatic loculation. This therapeutic option needs to be explored further to aid patient selection, determine the optimal dosing regimen, and define its safety profile.

Acknowledgments

Author contributions: Y. C. G. L. is the guarantor of this manuscript. R. T. and Y. C. G. L. contributed to the conception and design of the study; R. T., F. P., and T. H. contributed to the imaging analyses; R. T., F. P., and Y. C. G. L. contributed to the statistical analyses; and R. T., F. P., D. M., P. R. M., A. C. C., T. H., L. Y., R. B., H. J. L., D. F.-K., N. A. M., A. T., and Y. C. G. L. contributed to the pleural data collection and manuscript drafting, revision, and final approval.

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    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.

    originally published Online First March 5, 2015.

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

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