Management of empyema with intrapleural dnase-b/tpa compared to surgical decortication in high risk and non surgical candidates

Abstract

Introduction: Pleural infection (empyema) is associated with significant morbidity and mortality. As conservative management often fails, themainstay of treatment has become surgical decortication. The recent MIST2 trial demonstrated better patient outcomes with intrapleural DNase-B (Pulmozyme) and tPA (Alteplase) compared to placebo or drainage alone. At our institution, we manage empyema with early drainage and decortication of the visceral pleura (via posterolateral minithoracotomy or VATS) in fit patients who fail conservative management. In poor surgical candidates, we have recently used intrapleural DNase-B/ tPA via intercostal catheter, according to a policy based on the MIST2 protocol. Last year we presented our early experience with intrapleural DNase-B and tPA in high risk surgical candidates, demonstrating overall comparable outcomes, despite greater age, more comorbidities, and poorer preoperative function. We add to this body of work. Methods: We conducted a retrospective clinical audit of patients treated at Fremantle Hospital from 1 January 2011 to 30 August 2014. Patients were identified from our Operating Suite Database (TMS v2.17 HINWA) andHospital Pharmacy dispensing records. Patients then were grouped into Surgical and Intrapleural Fibrinolytic groups, and data obtained by file review on multiple parameters, including age, empyema risk category, aetiology, comorbidities and biochemical parameters. Outcomes including length of stay, complications and all-cause mortality were compared. Results: With greater numbers of patients, our results from last year’s audit of 42 patients now becomesmore statistically robust, with subgroup analysis of comorbidities including malignancy and higher RAPID scores becoming statistically significant. Despite a highly selected group receiving intrapleural fibrinolytics, complication rates remain low. Discussion: Our sample size remains small, however we are able to demonstrate that intrapleural fibrinolytics according to our protocol is a safe and effective alternative in high risk surgical patients. Since last year we have instituted a hospital policy for the use of intrapleural DNase-B/ tPA via intercostal catheter, ensuring the correct patients receive this treatment, whilst fitter patients receive the gold standard of surgical drainage and decortication. Our protocol is also presented.