Kheir Fayez, Cheng George, Rivera Estefania, Folch Alejandro, Folch Erik, Fernandez-Bussy Sebastian, Keyes Colleen, Parikh Mihir, Channick Colleen, Chee Alex, Majid Adnan
Department of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School.
Critical Care and Environmental Medicine, Tulane University Health Sciences Center, Division of Pulmonary Diseases, New Orleans, LA.
J Bronchology Interv Pulmonol. 2018 Apr;25(2):125-131. doi: 10.1097/LBR.0000000000000461.
Treatment of pleural infection with instillation of sequential intrapleural tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) twice daily for a total of 6 doses has been shown to decrease surgical referral and improve radiographic imaging. This labor-intensive regimen was empirically chosen. Thus, it remains unclear whether the 2 drugs can be administered immediately one after the other (concurrent administration) instead of instilling them separately with a 1-hour to 2-hour interval in between (sequential administration). The aim of this study was to compare the efficacy and safety of sequential versus concurrent tPA/DNase therapy in patients with pleural infection.
This was a prospective observational study. Consecutive patients with pleural infection who received concurrent and sequential tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on the amount of pleural fluid drainage, clinical response and radiographic findings.
A total of 38 patients with pleural infection received tPA/DNase treatment: 18 in the sequential group and 20 in the concurrent group. Treatment was successful in 77.7% in the sequential group and 75% in concurrent group (P=0.57). There was no statistically significant difference between the 2 treatment groups (sequential and concurrent) in median pleural fluid drainage (P=0.45), median volume of pleural effusion estimated on chest computed tomography scan (P=0.4) or median hemithorax occupied by effusion on chest radiography (P=0.83) following intrapleural therapy. One patient required a blood transfusion for gradual pleural blood loss in each treatment group. Pain needing escalation of analgesia affected 3 patients in each arm but none required cessation of therapy.
A simpler regimen of concurrent administration of intrapleural tPA/DNase as compared with sequential intrapleural therapy is safe, effective, and represents a viable option for the management of pleural infection.
每日两次胸膜腔内滴注序贯组织型纤溶酶原激活剂（tPA）和重组人脱氧核糖核酸酶（DNase），共6剂，用于治疗胸膜感染，已显示可减少手术转诊并改善影像学表现。这种劳动强度大的治疗方案是凭经验选择的。因此，尚不清楚这两种药物是否可以依次立即给药（同时给药），而不是在两者之间间隔1至2小时分别滴注（序贯给药）。本研究的目的是比较序贯与同时给予tPA/DNase治疗胸膜感染患者的疗效和安全性。
这是一项前瞻性观察性研究。纳入接受同时和序贯tPA/DNase治疗的连续胸膜感染患者。tPA/DNase治疗的起始剂量和剂量数基于胸腔积液引流量、临床反应和影像学表现。
共有38例胸膜感染患者接受了tPA/DNase治疗：序贯组18例，同时组20例。序贯组治疗成功率为77.7%，同时组为75%（P=0.57）。胸膜腔内治疗后，两个治疗组（序贯组和同时组）在胸腔积液引流中位数（P=0.45）、胸部计算机断层扫描估计的胸腔积液中位数体积（P=0.4）或胸部X线片上胸腔积液占据的半侧胸腔中位数（P=0.83）方面无统计学显著差异。每个治疗组各有1例患者因胸腔逐渐失血需要输血。需要增加镇痛的疼痛在每组中影响3例患者，但无人需要停止治疗。
与序贯胸膜腔内治疗相比，胸膜腔内同时给予tPA/DNase这种更简单的治疗方案是安全、有效的，是治疗胸膜感染的一个可行选择。
