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Abstract

Introduction:The purpose of this study was to compare the use of t-PA and t-PA + Dornase for the management of complicated pleural effusions and to determine if a dose-response relationship exists for t-PA. Methods: Retrospective cohort study that examined all adult patients at the University of Colorado Hospital who received t-PA or t-PA + Dornase for the management of a complicated pleural effusion from September 2011 to December 2012. Outcomes were success of therapy [defined as avoidance of secondary interventions (i.e. VATS or decortication)], chest tube output, radiographic findings, t-PA dose, and bleeding. Results: Thirty-five patients were enrolled: 25 received t-PA and 10 received t-PA + Dornase. Overall, patients were 53 ± 21 years old and 51% were male. Infection was the primary cause of pleural effusions (52% in t-PA vs 80% in t-PA + Dornase group). No differences in demographics were observed between groups. Successful pharmacologic treatment occurred in 88% of patients receiving t-PA and 100% of patients receiving t-PA + Dornase (p=0.54). In the t-PA group, chest tube output increased from 75 ml/day to 538 ml/day after administration of t-PA (p=0.001), and from 103 ml/day to 502 ml/day (p=0.001) in the t-PA + Dornase group. Radiographic improvement occurred in 84% of t-PA patients and 90% of t-PA + Dornase patients (p=0.99). In the t-PA group, a successful response occurred in 90% of patients receiving a cumulative dose of ≤ 20 mg (n=21) and 67% of patients receiving a cumulative dose of > 20 mg (n=3). There was 100% success rate in the t-PA + Dornase group with a median cumulative t-PA dose of 40 mg (range 20-100mg). Administration of fibrinolytic therapy did not result in increased bleeding risk. Conclusions: Both t-PA and t-PA + Dornase were highly effective for reducing a patient's need for surgical intervention. A cumulative t-PA dose of >20 mg did not appear to provide additional benefit.