Lung white out: haemothorax after intrapleural tPA and DNase administration

The cost of treatments for retained traumatic hemothorax: A decision analysis

INTRODUCTION

Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies.

METHODS

A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy.

RESULTS

In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900.

CONCLUSION

Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Hemothorax With White-Out Lung After Intrapleural Tissue Plasminogen Activator and Deoxyribonuclease Therapy in a Patient With Complicated Parapneumonic Effusion

Tissue plasminogen activator (tPA) and recombinant deoxyribonuclease (DNase ) are used in treating pleural infection due to their mucolytic activity by effectively reducing pleural fluid viscosity. The combination of tPA and DNase has attracted considerable interest as an alternative to surgical intervention for treating complicated parapneumonic effusion in high-risk patients who are not good candidates for surgery. However, intrapleural hemorrhage has been reported as a villainous outcome in a few cases which needs to be considered as a differential diagnosis with sudden clinical deterioration after the therapy. Here, we report the case of a patient who presented with pneumonia and later developed a large right complicated parapneumonic pleural effusion. A chest tube was placed with drainage of fluid while tPA and DNase were also considered as an additional treatment module. Following the first dose of DNase and tPA, the patient developed hypoxemia with hypotension and was found to have rapid development of white-out right hemothorax.