Department of Medicine, University of Alberta.
Department of Medicine, Western University, London, ON, Canada.
J Bronchology Interv Pulmonol. 2023 Jul 1;30(3):238-243. doi: 10.1097/LBR.0000000000000871.
Indwelling pleural catheters (IPCs) are frequently used for the management of malignant pleural effusions (MPEs), but drainage can be impaired by pleural loculations. We aimed to evaluate the safety and effectiveness of intrapleural tissue plasminogen activator (tPA) versus combination tPA-deoxyribonuclease (DNase) in the treatment of loculated MPE.
We performed a retrospective review of patients with confirmed or presumed MPEs requiring IPC insertion. We compared the efficacy of intrapleural tPA, tPA-DNase, and procedural intervention on pleural fluid drainage. Secondary endpoints included the need for future pleural procedures (eg, thoracentesis, IPC reinsertion, chest tube insertion, or surgical intervention), IPC removal due to spontaneous pleurodesis, and IPC-related complications.
Among 437 patients with MPEs, loculations developed in 81 (19%) patients. Twenty-four (30%) received intrapleural tPA, 46 (57%) received intrapleural tPA-DNase, 4 (5%) underwent a procedural intervention, and 7 (9%) received ongoing medical management. tPA improved pleural drainage in 83% of patients, and tPA-DNase improved pleural drainage in 80% of patients. tPA alone may be associated with increased rates of spontaneous pleurodesis compared with tPA-DNase. There was no difference in complications when comparing tPA, combination tPA-DNase, procedural intervention, and no therapy.
Both intrapleural tPA and combination tPA-DNase appear to be safe and effective in improving pleural fluid drainage in selected patients with loculated MPE, although further studies are needed.
留置胸腔导管（IPC）常用于治疗恶性胸腔积液（MPE），但胸腔分隔会影响引流效果。我们旨在评估腔内组织纤溶酶原激活剂（tPA）与 tPA-脱氧核糖核酸酶（DNase）联合应用于分隔性 MPE 的安全性和有效性。
我们对需要插入 IPC 的确诊或疑似 MPE 患者进行了回顾性研究。我们比较了腔内 tPA、tPA-DNase 和操作干预对胸腔积液引流的疗效。次要终点包括未来需要进行的胸腔操作（如胸腔穿刺、IPC 再插入、胸管插入或手术干预）、因自发性胸膜粘连而拔除 IPC 以及与 IPC 相关的并发症。
在 437 例 MPE 患者中，81 例（19%）发生胸腔分隔。24 例（30%）接受腔内 tPA 治疗，46 例（57%）接受腔内 tPA-DNase 治疗，4 例（5%）接受操作干预，7 例（9%）接受持续的药物治疗。tPA 使 83%的患者胸腔引流得到改善，tPA-DNase 使 80%的患者胸腔引流得到改善。与 tPA-DNase 相比，单独使用 tPA 可能会增加自发性胸膜粘连的发生率。比较 tPA、联合 tPA-DNase、操作干预和无治疗时，并发症发生率无差异。
腔内 tPA 和联合 tPA-DNase 似乎都能安全有效地改善分隔性 MPE 患者的胸腔积液引流，但还需要进一步研究。
