Intrapleural Tissue Plasminogen Activator for Complicated Pleural Effusions

Skeete, Dionne; Rutherford, Edmund J.; Schlidt, Scott A.; Abrams, Jeffrey E.; Parker, Leonard A.; Rich, Preston B.

doi:10.1097/01.ta.0000141879.67441.52

Cited by 66 publications

(70 citation statements)

References 24 publications

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“…Currently, the only fibrinolytic agents available in the United States are urokinase [36][37][38] and tissue plasminogen activator [39][40][41][42]. The typical dosage of urokinase is 100,000 U once or twice per day (the cost per 250,000-U vial is ∼$465).…”

Section: Managementmentioning

confidence: 99%

Diagnosis and Management of Parapneumonic Effusions and Empyema

2007

Clinical Infectious Diseases

176

144

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Approximately 1 million patients develop parapneumonic effusions (PPEs) annually in the United States. The outcome of these effusions is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. Pleural fluid analysis provides diagnostic information and guides therapy. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, 17.30), it is highly likely that antibiotic treatment alone will be effective. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH !7.20, and loculated pleural fluid suggest the need for pleural space drainage. The presence of pus (empyema) aspirated from the pleural space always requires drainage. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.Parapneumonic effusion (PPE; i.e., pleural fluid that results from pneumonia or lung abscess) is the most common cause of an exudative pleural effusion. PPE may be the consequence of either community-acquired or nosocomial pneumonia. Between 20% and 57% of the 1 million patients hospitalized yearly in the United States with pneumonia develop a PPE [1][2][3]. Although PPEs are relatively common, empyema (i.e., the accumulation of pus in the pleural space) is less common, occurring in 5%-10% of patients who experience PPE [4]. In a review of 14 studies of empyema that involved a total of 1383 patients, 70% of PPEs were secondary to pneumonia (figure 1) [4]. CLASSIFICATIONA practical, clinical classification of PPE is as follows: (1) an uncomplicated parapneumonic effusion (UPPE) resolves with antibiotic therapy alone, without pleural space sequelae; (2) a complicated parapneumonic effusion (CPPE) requires pleural space drainage to resolve pleural sepsis and prevent progression to an empyema; and (3) empyema, the end stage of a PPE, occurs. Empyema is defined by its appearance; it is an opaque, whitish-yellow, viscous fluid that is the result of serum coagulation proteins, cellular debris, and fibrin deposition. Empyemas develop primarily because of delayed presentation by the patient with advanced pneumonia and progressive pleural infection and, less often, from inappropriate clinical management. Early antibiotic treatment prevents progression of pneumonia and the development of a PPE. Early antibiotic treatment will prevent development of an UPPE and progression to empyema. Risk factors for empyema include age (empyemas occur most frequently among children and elderly persons), debilitation, male sex, pneumonia requiring hospitalization, and comorbid diseases, such as bronchiectasis, chronic obstructive pulmonary disease, rheumatoid arthritis, alcoholism, diabetes, and gastroesophageal reflux disease [5]. Bacterial pneumonia, pneumon...

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Section: Managementmentioning

confidence: 99%

Diagnosis and Management of Parapneumonic Effusions and Empyema

2007

Clinical Infectious Diseases

176

144

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“…In their 237-patient series, Abu Daft et al have stated that 15 patients developed pleural bleeding and three of these patients required emergency thoracotomy (8). The incidence of bleeding was reported to be around 2-15% in numerous series (6,13,14). In our study, apart from minor complications, the only major complication was pleural haemorrhage in one…”

Section: Resultsmentioning

confidence: 64%

Intrapleural Fibrinolytic Treatment: Management of 85 Cases

Ulutaş¹,

Çelik²,

Kuzucu³

2015

J Turgut Ozal Med Cent

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Objective: Fibrous cortex developes over the lung in 7-10 days if the benign or malign pleural effusion consisting of blood, coagulum or empyema could not be drained. Thus, clinical conditions like trapped lung, restrictive lung disease, or dyspnea may appear as a result of fibrinous pleuritis. Both streptokinase and tissue plasminogen activator (tPA) are involved in the breakdown of proteins and fibrin. Hence, intrapleural fibrinolytic treatment (IPFT) may prevent invazive procedures by avoiding fibrous cortex develepment if it is applied at a proper time. Materials and Methods: Eighty five cases undergoing IPFT by tube or catheter thoracostomies between 2003-2013 are evaluated retrospectively. Patients have been evaluated according to age, symptoms, diagnosis, and response to treatment. Results: The mean age of the patients was 45.5 (65 males and 20 females). IPFT was performed in 30 patients with empyema, and in 20 and 13 patients due to postoperative or posttraumatic organised hematomas, respectively. Eleven patients underwent IPFT for loculated benign pleural effusions while 9 patients recieved the treatment for loculated malign pleural effusions. Complicated hydropneumothorax was the indication for IPFT in 2 patients. A total of sixty patients received tube thoracostomy while 25 patients underwent catheter thoracostomy. Tree patients had decortication and 4 underwent video assisted thoracoscopic (VATS) drainage due to failure of IPFT. Aseptic pleural space remained in 12 patients at the end of our study. One of the patients required blood transfusion and additional medical treatment for intrapleural hemorrhage secondary to the local absorption of the IPFT. Conclusion: IPFT is a safe, effective treatment which can be performed prior to much invasive surgical procedures in patients with loculated empyema, clotted hemothorax, or postoperative hematoma, and benign or malign pleural effusions which can not be drained due to high fibrinous contents. Key Words: Intrapleural; Streptokinase; Tissue Plasminogen Activator. İntraplevral Fibrinolitik Tedavi Uygulamaları: 85 Olguluk Seri SunumuÖzet: Amaç: Komplike plevral efüzyonlarda sadece tüp ve katater torakostomi ile sıvıyı drene etmek her zaman mümkün olmaz. Drene edilemeyen kan, pıhtı, ampiyem, benign veya malign plevral sıvılarda 7-10 gün içinde akciğer üzerinden fibröz bir kabuk oluşmaya başlar. Bu durum ise tuzaklanmış akciğer ve akciğer restriksiyonu, sekonder ampiyem ve dispne ile sonuçlanır. Streptokinaz yada Tissue Plazminojen Activatörü (tPA), fibrin ve diğer bazı proteinleri parçalayarak etki etmekte olup uygun zamanda yapılan fibrinolitik tedavi ile bu süreç kesintiye uğratılıp, akciğer üzerinde fibröz kabuk gelişimi önlenerek hasta daha invaziv işlemlerden kurtarılabilir. Gereç ve Yöntemler: Bu çalışmada 2003-2013 yılları arasında tüp yada kateter torakostomisi ile intraplevral fibrinolitik tedavi (IPFT) uygulanan 85 olgu retrospektif olarak incelendi. Olgular yaş, cinsiyet, semptom, tanı ve tedaviye yanıt açısından değerlendirildi. Bulgular: O...

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“…Skeete ve ark. retrospektif olarak hemotoraks ve komplike plevral efüzyon olan 41 hastayı irdelemiş 38 hasta tedaviyi tamamlamıştır (19). Hastaların %79'unda TPA uygulaması ile birlikte radyolojik gerileme izlendiği belirtilmiş-tir.…”

Section: Tpa (Doku Plasminojen Aktivatörü)unclassified

Fibrinolytic Treatment for Pleural Effusion

Cuhadaroglu¹,

Özgül²,

Demir³

2012

Plev Bult

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Bacterial pneumonias are frequently associated with pleuropulmonary infections. Although most of these infections are treated with appropriate antibiotic treatment, complicated parapneumonic effusion and empyema represent the two situations where surgical interventions should be considered. In early stages with selected patients and close follow-up, the use of fibrinolytic agents has become a safe treatment modality. These fibrinolytic agents include streptokinase, urokinase and recombinant tissue plasminogen activator (TPA) and are used for the breakdown of the fibrinous tissue where drainage has been ineffective. Deoxyribonuclease is another enzyme used to decrease the viscosity of pleural effusion and promote drainage via chest tubes. Although there are many different studies regarding fibrinolytic treatment with different results, it is generally accepted that in the early stage where antibiotic treatment and chest tube drainage have been unsuccessful and the clinical status and radiology progress, another option should be to lyse the fibrinous bands and increase drainage. This treatment protocol was accepted as C levelbased evidence at the consensus guideline meeting of the Infectious Diseases Society of America (IDSA)/ American Thoracic Society (ATS) where fibrinolytic treatment, videoassisted thoracic surgery (VATS) and surgery were determined to be acceptable strategies with lower mortality rates and no need for secondary intervention for phase 3 and 4 parapneumonic effusions.

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Intrapleural Tissue Plasminogen Activator for Complicated Pleural Effusions

Abstract: Intrapleural TPA administration appears safe for use in complicated pleural effusions and may decrease the need for operative intervention.

Cited by 66 publications

References 24 publications

Diagnosis and Management of Parapneumonic Effusions and Empyema

Diagnosis and Management of Parapneumonic Effusions and Empyema

Intrapleural Fibrinolytic Treatment: Management of 85 Cases

Fibrinolytic Treatment for Pleural Effusion

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