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Ng BH, Nik Abeed NN, Ban AYL, Abdul Hamid MF. Combined intrapleural alteplase and DNase therapy in complicated pleural infection arising from postsurgery oesophageal leak. BMJ Case Rep 2023; 16:e249927. [PMID: 37591627 PMCID: PMC10441048 DOI: 10.1136/bcr-2022-249927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/19/2023] Open
Abstract
Managing a complicated pleural infection related to postsurgery can pose a clinical challenge, especially when initial interventions such as intercostal chest drain and antibiotics prove ineffective. We describe a man in his mid-60s who developed a recurrence of exudative pleural effusion caused by an oesophageal leak following laparoscopic total gastrectomy with Roux-y oesophagojejunostomy for gastric adenocarcinoma. Surgical repairs and oesophageal stenting were performed to address the oesophageal leak. Despite attempts at intercostal chest tube drainage, ultrasonography-guided targeted drainage of the locule and antibiotics, he did not show any improvement. He was unfit for surgical decortication. Due to the risk of bleeding, we chose a modified dose of intrapleural alteplase 5 mg and DNase 5 mg at 12-hour intervals for a total of three doses. This led to the complete resolution of the effusion. This case highlights that intrapleural tPA/DNase can be an adjunctive therapy in postsurgery-related complicated pleural effusion.
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Affiliation(s)
- Boon Hau Ng
- Department of Internal Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia
| | - Nik Nuratiqah Nik Abeed
- Department of Internal Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia
| | - Andrea Yu-Lin Ban
- Department of Internal Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia
| | - Mohamed Faisal Abdul Hamid
- Department of Internal Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Hospital Canselor Tuanku Muhriz, Cheras, Kuala Lumpur, Malaysia
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Abdul Hamid MF, Hasbullah AHH, Mohamad Jailaini MF, Nik Abeed NN, Ng BH, Haron H, Md Ali NA, Ismail MI, Nik Ismail NA, Abdul Rahman MR, Ban AYL. Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion. BMC Pulm Med 2022; 22:439. [PMID: 36419155 PMCID: PMC9685928 DOI: 10.1186/s12890-022-02239-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Intrapleural fibrinolytic therapy (IPFT) is one of the treatment options for complex pleural effusion. In this study, the IPFT agent used was alteplase, a tissue plasminogen activator (t-PA). This study aims to determine the difference in the outcome of patients with complex pleural effusion between IPFT and surgery in terms of radiological improvement, inflammatory parameters, length of stay, and post-intervention complications.
Methods A retrospective review of patients with complex pleural effusion treated at Universiti Kebangsaan Malaysia Medical Center from January 2012 to August 2020 was performed. Patient demographics, chest imaging, drainage chart, inflammatory parameters, length of hospital stay, and post-intervention and outcome were analyzed. Results Fifty-eight patients were identified (surgical intervention, n = 18; 31% and IPFT, n = 40, 69%). The mean age was 51.7 ± 18.2 years. Indication for surgical intervention was pleural infection (n = 18; 100%), and MPE (n = 0). Indications for IPFT was pleural infection (n = 30; 75%) and MPE (n = 10; 25%). The dosages of t-PA were one to five doses of 2–50 mg. The baseline chest radiograph in the IPFT group was worse than in the surgical intervention group. (119.96 ± 56.05 vs. 78.19 ± 55.6; p = 0.029) At week 1, the radiological success rate for IPFT and surgical intervention were 27% and 20%, respectively, and at weeks 4–8, the success rate was 56% and 80% respectively. IPFT was associated with lesser complications; fever (17.5%), chest pain (10%), and non-life-threatening bleeding (5%). Conclusion IPFT was comparable to surgery in radiological outcome, inflammatory parameters, and length of stay with lesser reported complications.
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Affiliation(s)
- Mohamed Faisal Abdul Hamid
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Ahmad Hadyan Husainy Hasbullah
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mas Fazlin Mohamad Jailaini
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Nuratiqah Nik Abeed
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Boon Hau Ng
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Hairulfaizi Haron
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nur Ayub Md Ali
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Muhammad Ishamuddin Ismail
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Azuan Nik Ismail
- grid.240541.60000 0004 0627 933XDepartment of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Andrea Yu-Lin Ban
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
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Cheong XK, Ban AYL, Ng BH, Nik Abeed NN, Nik Ismail NA, Nik Fuad NF, Syed Zakaria SZ, Ghan SL, Abdul Hamid MF. Modified regimen intrapleural alteplase with pulmozyme in pleural infection management: a tertiary teaching hospital experience. BMC Pulm Med 2022; 22:199. [PMID: 35581627 PMCID: PMC9115979 DOI: 10.1186/s12890-022-01995-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Current management of poorly draining complex effusions favours less invasive image-guided placement of smaller tubes and adjunctive intrapleural fibrinolysis therapy (IPFT). In MIST-2 trial, intrapleural 10 mg alteplase (t-PA) with 5 mg of pulmozyme (DNase) twice daily for 72 h were used. We aimed to assess the effectiveness and safety of a modified regimen 16 mg t-PA with 5 mg of DNase administered over 24 h in the management of complex pleural infection.
Methods This was a single centre, prospective study involving patients with poorly drained pleural infection. Primary outcome was the change of pleural opacity on chest radiograph at day 7 compared to baseline. Secondary outcomes include volume of fluid drained, inflammatory markers improvement, surgical referral, length of hospitalisation, and adverse events. Results Thirty patients were recruited. Majority, 27 (90%) patients were successfully treated. Improvement of pleural opacity on chest radiograph was observed from 36.9% [Interquartile range (IQR 21.8–54.9%)] to 18.1% (IQR 8.8–32.7%) of hemithorax (P < 0.05). T-PA/DNase increased fluid drainage from median of 45 mls (IQR 0–100) 24 h prior to intrapleural treatment to 1442 mls (IQR 905–2360) after 72 h; (P < 0.05) and reduction of C-reactive protein (P < 0.05). Pain requiring escalation of analgesia affected 20% patients and 9.9% experienced major adverse events. None required surgical intervention. Conclusion This study suggests that a modified regimen 16 mg t-PA with 5 mg DNase can be safe and effective for patients with poorly drained complex pleural infection. Trial registration The study was registered retrospectively on 07/06/2021 with ClinicalTrials number NCT04915586 (https://clinicaltrials.gov/ct2/show/NCT04915586). Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-01995-z.
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Affiliation(s)
- Xiong Khee Cheong
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Kuala Lumpur, Malaysia
| | - Andrea Yu-Lin Ban
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Kuala Lumpur, Malaysia
| | - Boon Hau Ng
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Kuala Lumpur, Malaysia
| | - Nik Nuratiqah Nik Abeed
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Kuala Lumpur, Malaysia
| | - Nik Azuan Nik Ismail
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Nik Farhan Nik Fuad
- Department of Radiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Sheah Lin Ghan
- Department of Pharmacy, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Mohamed Faisal Abdul Hamid
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Kuala Lumpur, Malaysia.
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Faisal M, Farhan R, Cheong XK, Ng BH, Nuratiqah N, Andrea Yl B. Short-course modified regimen intrapleural alteplase and pulmozyme (DNase) in pleural infection. Respir Med Case Rep 2020; 31:101168. [PMID: 32714827 PMCID: PMC7372138 DOI: 10.1016/j.rmcr.2020.101168] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/11/2020] [Indexed: 11/16/2022] Open
Abstract
Pleural infection is a common clinical condition leading to hospitalisation. In the last decade, advances in pleural research have led to a paradigm shift in the treatment of complex effusion from a surgical approach to a less invasive non-surgical approach using a combination of intrapleural fibrinolytics and pulmozyme (DNase). We report 3 patients with pleural infection. Intercostal chest catheter failed to drain the complex effusion. They were subsequently treated with a modified short-course regimen of alteplase and DNase. They received 3 cycles of 16 mg alteplase with 5 mg DNase each within 24 hours and all three had a favourable outcome with no adverse effects. This modified regimen appears effective with good safety profile and adds to the current literature on the safety and effectiveness of different dose combinations of alteplase and DNase.
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Affiliation(s)
- M Faisal
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - R Farhan
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - X K Cheong
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - B H Ng
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - N Nuratiqah
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
| | - Ban Andrea Yl
- Respiratory Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Malaysia
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