My presentation about intrapleural alteplase application

1. Intrapleural Alteplase Decreases
Parapneumonic Effusion
Volume in Children More Than
Saline Irrigation
Dr. Oğuz Kızılkaya
Trakya University Pediatric Surgery Clinic
oguz@fikrikumbara.com

3. Parapneumonic pleural inflammation may progress from the exudative or “simple” stage of clear,
free-flowing pleural fluid to the fibro-purulent or “complicated” stage with intrapleural fibrin deposition
forming fibrin strands and septations to the “organized” stage with a thick pleural peel.
Simple thoracostomy tube placement may be adequate to fully drain an early exudative effusion, but
at later stages either intrapleural fibrinolysis or surgical intervention5,6 may be needed to clear the
complicated effusion with empyema or a pleural peel.
Intrapleural fibrinolysis in adults produces greater thoracostomy tube output than normal saline
irrigation

4. Study hypothesized that in children with complicated parapneumonic effusion, intrapleural irrigation
with alteplase would increase thoracostomy tube drainage from the mobilization of existing pleural
inflammatory debris rather than by stimulation of additional pleural fluid formation, determined by
volumetric CT measurements showing a greater decrease in pleural volüme following alteplase
compared to normal saline irrigation.
Study reports a prospective, double-blind, randomized, crossover trial to compare the effects of
alteplase versus normal saline thoracostomy tube irrigation on pleural volume and thoracostomy
tube output.

5. All patients less than 18 years of age with a clinical diagnosis of acute pneumonia referred to the
interventional radiology service at Children’s Hospital Wisconsin for thoracostomy tube drainage of a
parapneumonic effusion between October 1, 2005 and March 1, 2007 were eligible for initial approach
by the study team.
The decision to place a chest tube for parapneumonic effusion was under the direction of the primary
team and not under the control of study personnel.
Patients with any known contraindication to the intravascular administration of alteplase were
excluded.

6. For entry criteria to the treatment arm, the pleural fluid thickness was measured by upright chest
radiograph and ultrasound and pleural fluid volume by low-dose chest CT.
After 8–12 hr of drainage via a patent thoracostomy tube, each patient was imaged with a low dose
protocol chest CT.
If any of the imaging met study criteria of pleural fluid occupying >20% of the ipsilateral chest cavity
volume or the pleura was >2 cm in thickness then the patient was randomized into one of the
treatment arms.
Monitoring group. If the pleural fluid occupied < 20% of the ipsilateral chest cavity volume or the
pleura was <2 cm in thickness, patients did not enter the treatment arm of the study. They were
monitored for 4 days with the same imaging protocol as the randomized treatment groups.
Treatment group. If the pleural fluid occupied >20% of the ipsilateral chest cavity volume or was >2
cm in thickness, the patients were randomized to receive alteplase thoracostomy tube irrigation twice
daily on days 1 and 3 or days 2 and 4, with normal saline irrigation alone on the alternating days.

8. Irrigation of the thoracostomy tube occurred twice daily, at 0900 and 2100 hr, with normal saline or
alteplase
The irrigation volumes were based on patient weight targeted at 1 ml/kg with 10 ml minimum and 50 ml
maximum volume.
The alteplase dose administered was 0.1 mg/kg/dose, maximum dose 6 mg

9. Main outcome measures: (i) Thoracostomy tube output (ml/24 hr period); (ii) change in pleural volume
(ml) as determined by volumetric chest CT and calculated as the difference in subsequent day pleural
volüme measurements.

15. Intrapleural fibrinolysis with alteplase safely increases pleural drainage and decreases the volume of pleural
inflammatory debris compared to intrapleural administration of normal saline. While the effect is greatest with
earlier doses, the benefit of alteplase administration on decreasing volume of pleural inflammatory debris
occurs for up to 72 hr with repeated twice daily dosing.