Intrapleural Fibrinolytic Treatment: Management of 85 Cases

Yıl 2015, Cilt: 22 Sayı: 2, 99 - 102, 09.12.2015

Hakkı Ulutaş Muhammet Reha Çelik Akın Kuzucu

Öz

Abstract

Objective: Fibrous cortex developes over the lung in 7-10 days if the benign or malign pleural effusion consisting of blood, coagulum or empyema could not be drained. Thus, clinical conditions like trapped lung, restrictive lung disease, or dyspnea may appear as a result of fibrinous pleuritis. Both streptokinase and tissue plasminogen activator (tPA) are involved in the breakdown of proteins and fibrin. Hence, intrapleural fibrinolytic treatment (IPFT) may prevent invazive procedures by avoiding fibrous cortex develepment if it is applied at a proper time.

Materials and Methods: Eighty five cases undergoing IPFT by tube or catheter thoracostomies between 2003-2013 are evaluated retrospectively. Patients have been evaluated according to age, symptoms, diagnosis, and response to treatment.

Results: The mean age of the patients was 45.5 (65 males and 20 females). IPFT was performed in 30 patients with empyema, and in 20 and 13 patients due to postoperative or posttraumatic organised hematomas, respectively. Eleven patients underwent IPFT for loculated benign pleural effusions while 9 patients recieved the treatment for loculated malign pleural effusions. Complicated hydropneumothorax was the indication for IPFT in 2 patients. A total of sixty patients received tube thoracostomy while 25 patients underwent catheter thoracostomy. Tree patients had decortication and 4 underwent video assisted thoracoscopic (VATS) drainage due to failure of IPFT. Aseptic pleural space remained in 12 patients at the end of our study. One of the patients required blood transfusion and additional medical treatment for intrapleural hemorrhage secondary to the local absorption of the IPFT.

Conclusion: IPFT is a safe, effective treatment which can be performed prior to much invasive surgical procedures in patients with loculated empyema, clotted hemothorax, or postoperative hematoma, and benign or malign pleural effusions which can not be drained due to high fibrinous contents.

Key Words: Intrapleural; Streptokinase; Tissue Plasminogen Activator.

Anahtar Kelimeler

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Journal of Turgut Ozal Medical Center

Öz

Amaç: Komplike plevral efüzyonlarda sadece tüp ve katater torakostomi ile sıvıyı drene etmek her zaman mümkün olmaz. Drene edilemeyen kan, pıhtı, ampiyem, benign veya malign plevral sıvılarda 7-10 gün içinde akciğer üzerinden fibröz bir kabuk oluşmaya başlar. Bu durum ise tuzaklanmış akciğer ve akciğer restriksiyonu, sekonder ampiyem ve dispne ile sonuçlanır. Streptokinaz yada Tissue Plazminojen Activatörü (tPA), fibrin ve diğer bazı proteinleri parçalayarak etki etmekte olup uygun zamanda yapılan fibrinolitik tedavi ile bu süreç kesintiye uğratılıp, akciğer üzerinde fibröz kabuk gelişimi önlenerek hasta daha invaziv işlemlerden kurtarılabilir. Gereç ve Yöntemler: Bu çalışmada 2003- 2013 yılları arasında tüp yada kateter torakostomisi ile intraplevral fibrinolitik tedavi (IPFT) uygulanan 85 olgu retrospektif olarak incelendi. Olgular yaş, cinsiyet, semptom, tanı ve tedaviye yanıt açısından değerlendirildi. Bulgular: Olguların 65’i erkek, 20’si kadın, yaş ortalaması 45.5 idi. Otuz olguya ampiyem, 13 olguya travma sonrası gelişen organize hematom, 20 olguya postoperatif, 9 olguya malign plevral efüzyon, 11 olguya benign hastalıklara bağlı drene olmayan loküle plevral efüzyon ve 2 olguya hidropnömotoraks sonrası gelişen komplikasyonlar nedeniyle intraplevral fibrinolitik tedavi uygulandı. Olguların 25’sine kateter torakostomi, 60 olguya tüp torakostomi uygulandı. Olguların 7’sinde IPFT başarısız oldu, 4 olguya dekortikasyon, 3 olguya VATS (video-assisted thoracoscopic surgery) ile debridman uygulandı. Oniki olguda aseptik kısmi poş kaldı. Bir olguda lokal etkiye bağlı, kan transfüzyonu ve medikal tedavi ile kontrol altına alınan intraplevral kanama saptandı. Sonuç: Loküle ampiyemlerde, pıhtılı hemotoraks ve postoperatif organize hematomlarda, yoğun fibrinli, drenajı olmayan malign plevral efüzyon ve benign plevral efüzyonlarda daha invaziv cerrahi girişimlerden önce uygulanacak IPFT güvenli, etkili, başarısı yüksek, yan etkisi az bir uygulamadır

Anahtar Kelimeler

İntraplevral, Streptokinaz, Doku Plazminojen Activatör

Kaynakça

• Wait MA, Sharma S, Hohn J, Nogare AD. A randomized trial of empyema therapy. Chest 1997;111:1548-51.
• Lim TK, Chin NK. Empirical treatment with fibrinolysis and early surgery reduces the duration of hospitalization in pleural sepsis. Eur Respir J 1999;13:514-8.
• Temes RT, Follis F, Kessler RM, Pett SB Jr, Wernly JA. Intrapleural fibrinolytics in management of empyema thoracis. Chest 1996;110:102–6.
• Davies RJO, Traill ZC, Gleeson FV. Randomized controlled trail of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52:416-21.
• Maskell NA, Davies CW, Nunn AJ, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865-874.
• 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.
• Misthos P, Sepsas E, Konstantinou M. Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. Eur J Cardiothorac Surg 2005;28:599-603.
• Abu Daft S, Donna E.M, Derar A. et al. Intrapleural fibrinolytic therapy (IPFT) in loculated pleural effusions-analysis of predictors for failure of therapy and bleeding: a cohort study. BMJ Open 2013;3:e001887.
• Diacon AH, Theron J, Schuurmans MM, et al. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med 2004;170:49-53.
• Frye MD, Jarratt M, Sahn SA. Acute hypoxemic respiratory failure following intrapleural thrombolytic therapy for hemothorax. Chest 1994; 105:1595-1596.
• Godley PJ, Bell RC. Major hemorrhage following administration of intrapleural streptokinase. Chest 1984;86:486-487.
• Menéndez-González M, Oliva-Nacarino P, Alvarez-Cofiño A. Cerebral gas embolism caused by pleural fibrinolytic treatment. Stroke 2007;38:2602-4.
• Skeete DA, Rutherford EJ, Schlidt SA, et al. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma 2004;57:1178–83.
• Froudarakis ME, Kouliatsis G, Steiropoulos P, et al. Recombinant tissue plasminogen activator in the treatment of pleural infections in adults. Respir Med 2008;102:1694–700.
• Ulutas H, Yekeler E, Sak Z. H. A, Doru I, Kuzucu A. Fibrinolytic therapy for parapneumonic empyema during pregnancy. Respiratory Medicine CME 2011.1-4.
• Gofrit ON, Engelhard D, AbuDalu K. PostPneumonic thoracic empyema in children: A continued surgical challenge. Eur J Pediatr Surg 9,1999;47.
• Rızalar R, Somuncu S, Bernay F. Et al. Postpneumonic empyema in children treat by early decortication. Eur J. Pediatr Surg 1997;7:1357.
• Koslaske AM, Cushing AH, Shuck JM. Early decortication for anaerobic empyema in children. J Pediatr Surg. 1980;15:4229.