İNTRAPLEVRAL FİBRİNOLİTİK TEDAVİ ETKİNLİĞİ

Öz

Giriş: Komplike olmuş plevral aralığı dolduran sıvılar akciğerin restriksiyonuna neden olarak ekspansiyonunu engeller. Böylece akciğerin normal işlevini bozarak müdahale gerektirecek duruma gelmesine neden olabilirler. Streptokinaz ya da Tissue Plazminojen Activatörü (tPA) intra plevral boşluğa verilerek bu alanda oluşan fibrin ve diğer bazı proteinleri parçalayarak etki eder. Uygun zamanda yapılan intraplevral fibrinolitik tedavi (IPFT) ile fibrin oluşma süreci kesintiye uğratılır. Böylece akciğer üzerinde fibröz kabuk gelişimi önlenerek hasta daha invaziv işlemlerden kurtarılabilir. Metot: Bu çalışmada 2003-2020 yılları arasında komplike olmuş plevral aralığı dolduran sıvılar için tüp veya kateter torakostomisi ile IPFT uygulanan 280 olgu retrospektif olarak incelendi. Fibrinolitik ajan, 100 cc serum fizyolojik içerisinde tüp veya kateter torakostomi aracılığı ile intraplevral boşluğa verildi. Optimum etkiyi sağlamak için tüp veya kateter torakostomi 1-4 saat klemplendi. Sonrasında klemp açılarak yakın drenaj takipleri yapıldı. IPFT ajanı olarak 100 cc SF içinde 250000 IU streptokinaz veya 5-10mg/gün Tissue Plazminojen Activatörü (tPA) uygulandı. Bulgular: IPFT uygulanan 280 hastanın 195’i (%69.6) erkek, 85’i (%30.6) kadın hastaydı. Hastaların ortalama yaşı 51.5 (en küçük 5y ve en büyük 86y) olarak hesaplandı. Plevral aralıktan 85 (%30.3) olguya streptokinaz, 195 (%69.7) olguya Tissue Plazminojen Activatörü (tPA) uygulandı. Uygulanan bu tedavi sonrası hastaların 252’sinde tam yanıt, 11’inde kısmi yanıt alınırken, tedavi uygulanmasına rağmen 17 hastada tedaviye yanıt alınamadı. Komplikasyon olarak hastaların 12’sinde intraplevral kanama ve 13’ünde aseptik poş gözlendi. Uyguladığımız bu tedavinin başarısı %90 olarak belirlendi. Sonuç: Drene olmayan komplike plevral efüzyon tedavisinde daha invazif cerrahi girişimler yerine IPFT güvenli, etkili ve yan etkisi az başarısı yüksek , bir uygulamadır.

Anahtar Kelimeler

• İntraplevral fibrinolitik
• Streptokinaz
• Tissue plazminojen aktivatörü (t-PA)
• Plevral efüzyon.

EFFECTIVENESS OF INTRAPLEURAL FIBRINOLYTIC THERAPY

Öz

Objectives: Fluids filling the complicated pleural space may disrupt the normal function of the lung and require medical or surgical intervention. Streptokinase or Tissue Plasminogen Activator (tPA) acts by breaking down fibrin and some other proteins, and with intrapleural fibrinolytic therapy (IPFT) performed at the appropriate time, this process can be interrupted, the development of fibrous crust on the lung can be prevented, and the patient can be saved from undergoing more invasive procedures. Method: In this study, 280 cases who underwent IPFT with tube/catheter thoracostomy between 2003 and 2020 were reviewed retrospectively. Fibrinolytic agent dissolved in 100 cc saline was administered through the intrapleural space via tube or catheter thoracostomy. Thoracostomy tube or catheter was clamped for 1-4 hours to ensure optimum effect. Then, the clamp was opened, and the patient was followed up with close drainage. As an IPFT agent in 100 cc of saline solution, 250000 IU of streptokinase or daily doses of 5-10mg Tissue Plasminogen Activator (tPA) was applied. Results: A total of 280 patients (195 (69.6%) male and 85 (30.6%) female) with a mean age of 51.5 (5-86) years underwent IPFT. Streptokinase was applied through the pleural space to 85 (30.3%) and Tissue Plasminogen Activator (tPA) to 195 (69.7%) cases. After this treatment, complete response was obtained in 252 and partial response in 11 patients. As complications, intrapleural bleeding was observed in 12 and aseptic pouch in 13 cases. The success of the treatment was determined as 90 percent. Conclusion: Instead of more invasive surgical procedures in the treatment of non-draining complicated pleural effusion, IPFT is a safe, effective, and highly successful procedure with a lower side effect profile.

Anahtar Kelimeler

• Intrapleural fibrinolytic
• Streptokinase
• Tissue plasminogen activator (tPA)
• Pleural effusion

Kaynakça

1. Referans1. Ulutaş H, Çelik MR, Kuzucu A. Intrapleural Fibrinolytic Treatment: Management of 85 Cases. Journal of Turgut Ozal Medical Center 2015;22(2):99-102. DOI: 10.7247/jtomc.2014.2367
2. Referans2. Tillett WS, Sherry S. The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent, and sanguinous pleural exudations. J Clin Invest 1949; 28:173-90.
3. Referans3. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc 2006; 3: 75-80.
4. Referans4. Maskell NA, Davies CW, Nunn AJ. UK Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352: 865-74.
5. Referans5. Bridevaux PO, Tschopp JM, Cardillo G, Marquette CH, Noppen M, Astoul P. Short-term safety of thoracoscopic talc pleurodesis for recurrent primary spontaneous pneumothorax: a prospective Referans6. European multicentre study. Eur Respir J 2011; 38: 770-3.
6. Referans7. Robinson LA, Moulton AL, Fleming WH. Intrapleural fibrinolytic treatment of multiloculated thoracic empyemas. Ann Thorac Surg 1994; 57:803-14.
7. Referans8. Inci I, Ozcelik C, Ulku R, et al. Intrapleural fibrinolytic treatment of traumatic clotted hemothorax. Chest 1998; 114:160-5.
8. Referans9. Thommi G, Chandra KN, Aronow WS, et al. Efficacy and safety of intrapleural instillation of Alteplase in the management of complicated pleural effusion or empyema. Am J Ther 2007; 14:341–5.

9. Referans10. Tunçözgür B, Üstünsoy H, Sivrikoz C, et al. Intrapleural urokinase in the management of parapneumonic empyema: a ranodmized controlled trial. International Journal of clinical practice 2001;55:658-60.
10. Referans11. Maskell NA, Davies CM, Nunn AJ, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Eng J MEd 2005;352:865-74.
11. Referans12. Cameron R, Davies HR. Intrapleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2008; CD002312.
12. Referans13. Skeete DA, Rutherford EJ, Schlidt SA, et al. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma 2004;57:1178-83.
13. Referans14. Ozcelik C, Inci I. Nizam O, Onat S. Intrapleural fibrinolytic treatment of multıloculated postpneumonic empyemas. Ann Thorc Surg 2003;76:1849-53.
14. Referans15. Piccolo F, Pitman N, Bhatnagar R, et al. Intrapleural tissue plasminogen activator and deoxyribonuclease for pleural infection. An effective and safe alternative to surgery. Ann Am Thorac Soc 2014;11:1419-25.
15. Referans16. Majid A, Kheir F, Folch A, et al. Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience. Ann Am Thorac Soc 2016;13:1512-8.
16. Referans17. Mehta HJ, Biswas A, Penley AM, et al. Management of Intrapleural Sepsis with Once Daily Use of Tissue Plasminogen Activator and Deoxyribonuclease. Respiration 2016; 91:101-6.
17. Referans18. Alemán C, Porcel JM, Alegre J, et al. Intrapleural Fibrinolysis with Urokinase Versus Alteplase in Complicated Parapneumonic Pleural Effusions and Empyemas: A Prospective Randomized Study. Lung 2015;193:993-1000.
18. Referans19. Abu Daft S, Donna E.M, Derar A. et al. Intrapleural fibrinolytic therapy (IPFT) in loculated pleural effusionsanalysis of predictors for failure of therapy and bleeding: a cohort study. BMJ Open 2013;3:e001887.
19. Referans20. Ulutas H, Yekeler E, Sak ZHA, Doru I, Kuzucu A. Fibrinolytic therapy for parapneumonic empyema during pregnancy. Respiratory Medicine Case Reports 2012; volume 5, page 55-58.