Original Article

The use of thrombolytics in the management of complex pleural fluid collections

Jessica Heimes, Hannah Copeland, Aditya Lulla, Marjulin Duldulao, Khaled Bahjri, Salman Zaheer, Jason M. Wallen


Background: To determine the efficacy of thrombolytics for the management of complex pleural fluid collections.
Methods: We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d).
Results: One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20–91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1–32 days) and 16.2 days (range, 4–48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1–11 days). The time from alteplase to chest tube removal was 4.5 days (1–21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest.
Conclusions: Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.

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