Thomas Rajesh, Piccolo Francesco, Miller Daniel, MacEachern Paul R, Chee Alex C, Huseini Taha, Yarmus Lonny, Bhatnagar Rahul, Lee Hans J, Feller-Kopman David, Maskell Nick A, Tremblay Alain, Lee Y C Gary
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.
Department of Internal Medicine, Swan District Hospital, Perth, WA, Australia.
Chest. 2015 Sep;148(3):746-751. doi: 10.1378/chest.14-2401.
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.
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.
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%).
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.
留置胸膜导管（IPC）是治疗恶性胸腔积液的一种有效选择。高达14%的IPC患者会出现有症状的胸膜分隔，导致液体引流无效和呼吸困难。据我们所知，这是第一项描述针对IPC相关有症状分隔进行胸腔内纤溶治疗的研究。
回顾性纳入2002年1月1日至2014年6月30日期间在四个成熟的IPC中心接受胸腔内纤溶治疗以缓解有症状分隔的所有患者。记录患者的结局、治疗效果和不良事件。
纳入66例患者（平均年龄64.7±14.2岁；52%为女性）。肺癌（31.3%）和恶性胸膜间皮瘤（20.3%）是最常见的恶性肿瘤。纤溶药物注入在门诊（61%）和住院环境中进行。使用了组织型纤溶酶原激活剂（n = 52）、尿激酶（n = 12）和链激酶（n = 2）。大多数患者（69.7%）仅接受一剂纤溶药物（范围为一至六剂）。93%的患者胸腔积液引流量增加，治疗后83%的患者呼吸困难得到改善。治疗后24小时引流的胸腔积液累积中位数体积为500 mL（四分位间距300 - 1034 mL）。胸部X线片上胸腔积液导致的模糊区域占半侧胸腔的比例从（均值，标准差）52%（14%）降至31%（21%）（n = 13；P = .001）。有2例非致命性胸膜出血（3%）。
胸腔内纤溶治疗可改善部分伴有有症状分隔的IPC患者的胸腔积液引流和症状，但存在小的胸膜出血风险。目前其使用存在显著异质性，需要进一步研究以确定患者选择、最佳给药方案并明确其安全性。
