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Intrapleural alteplase decreases parapneumonic effusion volume in children more than saline irrigation
Sheila J Hanson1, Peter L Havens1, Pippa M Simpson1
1Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
Insights
Intrapleural fibrinolysis with alteplase significantly improved pleural drainage and reduced effusion volume in children compared to saline. Early administration of alteplase was more effective, with no observed bleeding complications.
Area of Science:
- Pediatric Pulmonology
- Interventional Radiology
- Critical Care Medicine
Background:
- Complicated parapneumonic effusion in children often requires thoracostomy tube drainage.
- The efficacy of intrapleural fibrinolysis in pediatric patients with pleural effusions is an area of ongoing research.
- Optimizing pleural drainage and reducing effusion volume are crucial for patient recovery.
Purpose of the Study:
- To compare the effectiveness of intrapleural alteplase (a fibrinolytic agent) versus normal saline irrigation in managing pediatric complicated parapneumonic effusions.
- To evaluate the impact of alteplase on thoracostomy tube output and pleural effusion volume.
- To assess the safety profile of intrapleural alteplase in this patient population.
Main Methods:
- A prospective, double-blind, randomized crossover trial involving 27 children with complicated parapneumonic effusion.
- Patients received either intrapleural alteplase or normal saline irrigation, with treatments alternated.
- Pleural fluid volume was measured daily using low-dose chest computed tomography (CT), and thoracostomy tube output was recorded.
Main Results:
- Alteplase irrigation led to significantly increased thoracostomy tube drainage compared to normal saline.
- Intrapleural alteplase resulted in a greater reduction in pleural effusion volume.
- Earlier administration of alteplase showed improved fluid mobilization, and no bleeding complications were reported.
Conclusions:
- Intrapleural fibrinolysis with alteplase is a safe and effective method for enhancing pleural drainage in children with complicated parapneumonic effusions.
- Alteplase administration leads to a significant decrease in pleural inflammatory debris volume compared to saline.
- Repeated, twice-daily dosing of intrapleural alteplase demonstrates benefits up to 72 hours.
Objective:
In this prospective, double-blind, randomized crossover trial, we determined the effect of intrapleural fibrinolysis with alteplase compared to that of normal saline irrigation on the thoracostomy tube output and pleural effusion volume in children with complicated parapneumonic effusion.
Methods:
Twenty seven children, median age 3.5 years, referred to the interventional radiology service for thoracostomy tube drainage of a parapneumonic effusion were studied. Seventeen patients with pleural fluid thickness greater than 2 cm or >20% ipsilateral chest volume after 8 hr of thoracostomy tube drainage entered the treatment arm. They were randomized to receive alteplase 0.1 mg/kg twice a day on days 1 and 3, or on days 2 and 4, with normal saline irrigation on the alternate days. Daily pleural fluid volume measured by low dose chest computed tomography (CT) and thoracostomy tube output was compared between the saline and alteplase groups.
Results:
Compared to normal saline irrigation, alteplase irrigation resulted in increased thoracostomy tube drainage and to a greater decline in pleural fluid volume. Earlier alteplase administration resulted in increased fluid mobilization compared to administration later in the hospital course. There were no bleeding complications.
Conclusions:
Intrapleural fibrinolysis with alteplase safely increases pleural drainage and decreases the volume of pleural inflammatory debris compared to intrapleural administration of normal saline. The benefit of intrapleural alteplase on decreasing the volume of pleural inflammatory debris occurs for up to 72 hr with repeated twice daily dosing.
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