Abstract
ObjectiveTalc slurry pleurodesis (TSP) can lead to permanent small loculations. Intrapleural tissue plasminogen activator (tPA) breaks down loculations, and therefore may improve results but may also inhibit pleurodesis. tPA was given with and after talc slurry to promote more uniform talc distribution and eliminate loculations.MethodsCharts were reviewed for patients treated with TSP with or without tPA. Chest x-rays after TSP were compared to chest x-rays before and graded as “worse”, “same”, or “better”. Incidence of need for repeat TSP was recorded.ResultsThere were 52 patients, eight with bilateral effusions, for a study cohort of 60 effusions. One-third of the effusions were malignant. No patients experienced significant bleeding. Results were better than baseline for 14 (26%) patients given tPA, but not for patients that never received tPA. The addition of tPA 4-6 mg with talc slurry resulted in no patients requiring repeat TSP. When tPA was given after talc slurry, a delay of three days was associated with the lowest incidence of repeat TSP (3/14, 21%).ConclusionsThere were no significant complications from tPA use to supplement TSP, and tPA may improve results without interfering with pleurodesis. A prospective trial is warranted.
Highlights
Recurrent pleural effusion is a common clinical problem, with an estimated incidence of 1.5 million per year in the United States [1]
When tissue plasminogen activator (tPA) was given after talc slurry, a delay of three days was associated with the lowest incidence of repeat Talc slurry pleurodesis (TSP) (3/14, 21%)
Seven effusions were treated with talc slurry without tPA (“TSP without tPA”), and 53 effusions were treated with talc slurry and tPA (“TSP with tPA”; Table 1)
Summary
Recurrent pleural effusion is a common clinical problem, with an estimated incidence of 1.5 million per year in the United States [1]. If optimal management of the underlying medical condition does not resolve the effusion, options for palliation are intermittent thoracentesis, indwelling pleural catheter, or pleurodesis. Chemical pleurodesis causes an inflammatory response that produces fibrin adhesion and fibrosis, obliterating the pleural space [2]. Of the many agents available for chemical pleurodesis, a Cochrane Review concluded that talc is the agent of choice [3]. Bedside pleurodesis (talc slurry) is easier to perform and less costly than operative pleurodesis (talc poudrage), and may yield similar outcomes [4,5,6]. A critical concern is that uneven distribution of talc may lead to uneven pleurodesis and a multiloculated effusion [79]
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