Majid Adnan, Ochoa Sebastian, Chatterji Sumit, Fernandez-Bussy Sebastian, Kheir Fayez, Rivera Estefania, Cheng George, Folch Erik
1 Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
2 Department of Internal Medicine, Medstar Georgetown University Hospital, Washington, D.C.
Ann Am Thorac Soc. 2017 Mar;14(3):342-346. doi: 10.1513/AnnalsATS.201608-594BC.
Exudative pleural effusions may arise secondary to inflammation of intra-abdominal structures. Pleural space loculations can complicate these effusions, preventing adequate chest tube drainage and leading to consideration of surgical intervention. Previous studies have demonstrated that intrapleural administration of tissue plasminogen activator (tPA) combined with human recombinant DNase can improve fluid drainage and reduce surgery for patients with loculated parapneumonic effusions; however, the efficacy of this treatment has not been evaluated for complicated pleural effusions attributed to intra-abdominal inflammation.
We assessed the safety and efficacy of tPA/DNase for 17 pleural effusions associated with nonmalignant intra-abdominal pathology that did not drain adequately after placement of one or more chest tubes.
Efficacy was measured by comparing post- to pretreatment fluid drainage rates, volumetric assessment of pleural fluid on radiographic images before and after treatment, and clinical improvement, including the need for surgical intervention. Symptomatic relief was assessed using the Borg scale for breathlessness.
After a median of two doses of tPA/DNase, 23.5% of patients had chest pain and none had pleural bleeding. The volume of pleural fluid drained increased from a median of 325 ml to 890 ml per 24 hours after therapy (P = 0.018). The area of pleural space opacity on chest radiographs decreased from a median of 42.8-17.8% of the hemithorax (P = 0.001). tPA/DNase reduced the pleural fluid volume on chest computed tomographic imaging from a median of 294.4 ml to 116.1 ml. Borg scores improved from a median of 3 (interquartile range = 1-6) to 0 (interquartile range = 0-2) after therapy (P = 0.001). The median duration of chest tube placement and hospital stay were 4 and 11 days, respectively. Two patients required surgical intervention for lung entrapment. Overall, treatment was considered successful for 88.2% of patients.
This retrospective case series suggests that intrapleural tPA/DNase can be safe and effective for patients with complicated pleural effusions attributed to abdominal pathology that do not drain adequately after chest tube placement. Additional studies are needed to determine whether the combination of tPA and DNase is more effective than tPA for this indication.
渗出性胸腔积液可能继发于腹腔内结构的炎症。胸腔内分隔可使这些积液变得复杂，妨碍胸腔闭式引流充分进行，从而导致考虑采取手术干预。既往研究表明，对于有分隔的类肺炎性胸腔积液患者，胸腔内注射组织型纤溶酶原激活剂（tPA）联合重组人脱氧核糖核酸酶（DNase）可改善液体引流并减少手术治疗；然而，对于由腹腔内炎症引起的复杂性胸腔积液，这种治疗方法的疗效尚未得到评估。
我们评估了tPA/DNase对17例与非恶性腹腔内病变相关的胸腔积液的安全性和有效性，这些胸腔积液在放置一根或多根胸腔引流管后引流不充分。
通过比较治疗前后的液体引流率、治疗前后胸部X线片上胸腔积液的体积评估以及临床改善情况（包括是否需要手术干预）来衡量疗效。使用Borg呼吸困难量表评估症状缓解情况。
在中位给予两剂tPA/DNase后，23.5%的患者出现胸痛，无患者发生胸腔出血。治疗后胸腔积液引流量从每24小时中位325 ml增加至890 ml（P = 0.018）。胸部X线片上胸腔积液不透明区域从半侧胸腔的中位42.8%降至17.8%（P = 0.001）。胸部计算机断层扫描成像显示胸腔积液量从中位294.4 ml降至116.1 ml。治疗后Borg评分从中位3分（四分位间距 = 1 - 6）改善至0分（四分位间距 = 0 - 2）（P = 0.001）。胸腔引流管放置的中位持续时间和住院时间分别为4天和11天。两名患者因肺陷闭需要手术干预。总体而言，88.2%的患者治疗被认为成功。
这个回顾性病例系列表明，对于因腹部病变导致的复杂性胸腔积液且胸腔引流管放置后引流不充分的患者，胸腔内注射tPA/DNase可能是安全有效的。需要进一步研究以确定tPA与DNase联合使用在此适应证上是否比单独使用tPA更有效。
