Background: Indwelling pleural catheters (IPC) are an effective option in the management of malignant pleural effusion. Up to 13.5% of patients with IPCs develop symptomatic pleural loculations causing ineffective fluid drainage and breathlessness. This study is the first describing intrapleural fibrinolytic therapy for IPC-related symptomatic loculations.
Methods: All patients who received intra-pleural fibrinolytic therapy for symptomatic loculations between 01/01/2002-30/06/2014 in four established IPC centers were retrospectively included. Patient outcomes, treatment effectiveness, and adverse events were recorded.
Results: 66 patients (mean age 64.7±14.2 years; 52% females) 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 1-6).
Outcomes: Pleural fluid drainage increased in 93% of patients and dyspnoea improved in 83% following therapy. Cumulative pleural fluid volume drained at 24 hours post-treatment was 500mL (median, IQR 300-1034). The area of opacity on chest X-ray due to pleural effusion decreased from 52% (mean, SD 14) to 31% (21) of the hemithorax (n=13; p=0.001). There were two (3%) cases of non-fatal pleural bleed.
Conclusion: Intra-pleural 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.