Very low‐dose intrapleural tPA for indwelling pleural catheter‐associated symptomatic fluid loculation

Abstract

Indwelling pleural catheters (IPCs) are effective management options for malignant pleural effusion. Symptomatic fluid loculation is a recognized complication of IPC use and is usually managed with intrapleural instillation of fibrinolytic drugs, such as tissue plasminogen activator (tPA). A previous multicentre observational study showed significant heterogeneity among centres in their dosing regimen for tPA (from 2 to 20 mg) in treating symptomatic loculations. Potential pleural bleeding, especially in high‐risk patients, often deters clinicians from initiating intrapleural fibrinolytic therapy. Lower doses of tPA may reduce bleeding risks. This case report describes the successful use of 0.5 mg (the lowest reported dose) of tPA in a patient with significant bleeding risks whose IPC was complicated by symptomatic loculation.

Incidence of complications from indwelling pleural catheter for pleural effusion: A meta‐analysis

“… 70 Lan et al described an older woman with high bleeding risk in whom the lowest reported dose of 0.5 mg tPA was used to successfully treat loculation from IPC without bleeding. 71 We suggest that older patients, or those with poor tolerance, should specifically have treatment initiation for symptomatic loculation at a small dose.…”

“…Thomas et al showed pleural fluid drainage augmentation in 93% of 66 patients; dyspnea improvement was found in 83%, and only 3% had nonfatal pleural bleeding after antifibrinolytic therapy for IPC‐related symptomatic loculations 70 . Lan et al described an older woman with high bleeding risk in whom the lowest reported dose of 0.5 mg tPA was used to successfully treat loculation from IPC without bleeding 71 . We suggest that older patients, or those with poor tolerance, should specifically have treatment initiation for symptomatic loculation at a small dose.…”

A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients

“…Being a non-invasive modality, it is considered an ideal strategy to restore the flow. The tPA converts plasminogen to active protease plasmin which further degrades fibrin into soluble products [ 2 , 7 , 8 ]. The degree of systemic absorption of intrapleural administered tPA is highly variable and remains unknown.…”

“…large heterogeneity is noted in the clinical practice regarding the ideal dosage of tPA (2–20 mg)2, [ [7] , [8] , [9] ]. Hart et al [ 10 ] demonstrated the success of 1mg tPA with 5mg DNase given twice daily for 2.5 days (total 5 doses) while Lan et al published the efficacy of a single dose of 0.5 mg tPA for restoring patency of IPC [ 2 ]. The concurrent effect of Direct Oral Anticoagulants (DOACs) on bleeding in patients receiving Intrapleural tPA is uncertain.…”

“…The underlying mechanism is believed to be fibrin mediated disruption of pleural fluid drainage. While partial blockage can be managed initially by flushing the catheter with saline solution, certain cases may require either invasive or noninvasive strategies [ 1 , 2 ]. Alteplase, a tissue plasminogen activator (tPA) is often used to restore the flow of non-draining IPC in symptomatic patients [ 3 ].…”