A retrospective review of concurrent versus sequential administration of intrapleural tissue plasminogen activator and dornase alfa for empyemas

Abstract

Background

Intrapleural tissue plasminogen activator (tPA) and dornase alfa (DNase) administered sequentially, separated by a one to 2 h interval, is a mainstay of pleural infection treatment. Recent literature supports similar efficacy and safety of concurrent therapy (administered immediately after one another). Insufficient evidence are available to utilize concurrent therapy routinely.

Objective

The primary objective of this study was to assess the safety and effectiveness of concurrent versus sequential intrapleural tPA and DNase in pleural infections.

Methods

This was a single-center, retrospective study of patients ≥18 years old admitted to the inpatient setting who received either concurrent or sequential intrapleural tPA or DNase between July 1, 2014, and January 1, 2023. The primary outcome was treatment failure, a composite of 30-day mortality and requirement for a video-assisted thoracoscopic surgery (VATS). Secondary outcomes included cumulative pleural fluid drainage, bleeding adverse events, and pain requiring analgesia dose escalation.

Results

A total of 184 patients were included: 158 patients in the concurrent group and 26 patients in the sequential group. Treatment failure was similar between groups (18.4 % vs 19.2 %, P > 0.99). Increased pleural fluid drainage occurred in the concurrent versus sequential therapy group (1453 mL vs 836 mL, P = 0.05) with no differences in bleeding (23.4 % vs 19.2 %, P = 0.64) or analgesia dose escalation between groups (41.1 % vs 23.1 %, P = 0.09).

Conclusion and Relevance

Concurrent intrapleural fibrinolytics have similar effectiveness and safety compared to sequential administration however, further investigation into the compatibility and stability of the medications is warranted to optimize future pleural infection management.