Chest tube, thoracentesis and fibrinolytics

Intercostal drainage, thoracentesis and fibrinolytics

Dr. Navdeep Singh

Junior resident

Pulmonary medicine

DEFINITION

A chest drain is a tube inserted through the chest wall between the ribs and into the pleural cavity to allow drainage of air (pneumothorax), blood (haemothorax), fluid (pleural effusion) or pus (empyema) out of the chest.

This allows drainage of the pleural contents and re-expansion of the lung. In the case of a pneumothorax or haemothorax this helps restore haemodynamic and respiratory stability by optimising ventilation/perfusion and minimizing mediastinal shift.

INDICATIONS OF ITS USE

Pneumothorax not all pneumothoraces require insertion of a chest drain.

Primary spontaneous pneumothorax :Patients with underlying lung disease and traumatic pneumothoraces usually require chest drainage. The differential diagnosis between a pneumothorax and bullous disease requires careful radiological assessment

persistent or recurrent pneumothorax after simple aspiration

tension pneumothorax should always be treated with a chest drain after initial relief with a small bore cannula or needle

in any ventilated patient with a pneumothorax as the positive airway pressure will force air into the pleural cavity and quickly produce a tension pneumothorax

large secondary spontaneous pneumothorax in patients over 50 years of age

iatrogenic eg.following insertion of a central venous catheter. Not all will require drainage.

Pleural effusion

Pleural fluid

Malignant pleural effusion

Simple pleural effusions in ventilated patients

Empyema and complicated parapneumonic pleural effusion

Traumatic pneumothorax or haemopneumothorax

Peri-operative eg. thoracotomy, oesophageal surgery, cardiothoracic surgery

Insertion of a chest drain

Before insertion of the chest drain:

Consent

Consent should be obtained and documented as per Trust guidance.

The identity of the patient should be checked and the site and insertion of the chest drain confirmed by reviewing the clinical signs and the radiological information.

PRE-DRAINAGE RISK ASSESSMENT

Risk of haemorrhage: where possible, any coagulopathy or platelet defect should be corrected prior to chest drain insertion but routine measurement of the platelet count and prothrombin time are only recommended in patients with known risk factors.

The differential diagnosis between a pneumothorax and bullous disease requires careful radiological assessment. Similarly it is important to differentiate between the presence of collapse and a pleural effusion when the chest radiograph shows a unilateral whiteout.

Lung densely adherent to the chest wall throughout the hemithorax is an absolute contraindication to chest drain insertion.

The drainage of a post pneumonectomy space should only be carried out by or after consultation with a cardiothoracic surgeon.

EQUIPMENT

Equipment required for insertion of chest drains.

Sterile gloves and gown

Skin antiseptic solution, e.g. iodine or chlorhexidine in alcohol

Sterile drapes

Gauze swabs

A selection of syringes and needles (2125 gauge)

Local anaesthetic, e.g. lignocaine (lidocaine) 1% or 2%

Scalpel and blade

Suture (e.g. 1 silk)

Instrument for blunt dissection (e.g. curved clamp)

Guidewire with dilators (if small tube being used)

Chest tube

Connecting tubing

Closed drainage system (including sterile water if underwater seal being used)

Dressing

Equipment may also be available in kit form.

CONSENT AND PREMEDICATION

Unless there are contraindications to its use, premedication (benzodiazepine or opioid) should be given to reduce patient distress.

Premedication could be an intravenous anxiolyticfor example, midazolam 15 mg titrated to achieve adequate sedationgiven immediately before the procedure or an intramuscular opioid given 1 hour before, although neither drug has e clearly superior.

PATIENT POSITION

The preferred position for drain insertion is on the bed, slightly rotated, with the arm on the side of the lesion behind the patients head to expose the axillary area. An alternative is for the patient to sit upright leaning over an adjacent table with a pillow or in the lateral decubitus position.Insertion should be in the safe triangle

CONFIRMING SITE OF DRAIN INSERTION

A chest tube should not be inserted without further image guidance if free air or fluid cannot be aspirated with a needle at the time of anaesthesia.

Imaging should be used to select the appropriate site for chest tube placement.

Fluoroscopy, ultrasonography, and CT scanning can all be used as adjunctive guides to the site of tube placement.Before insertion, air or fluid should be aspirated; if none is forthcoming, more complex imaging than a chest radiograph is required.

The use of ultrasonography guided insertion is particularly useful for empyema and effusions as the diaphragm can be localised and the presence of loculations and pleural thickening defined.

Using real time scanning at the time of the procedure can help to ensure that the placement is safe despite the movement of the diaphragm during respiration. The complication rate following image guided thoracocentesis is low with pneumothoraces occurring in approximately 3% of cases.

Success rates of image guided chest tube insertion are reported to be 7186%.

TRIANGLE OF SAFETY

ANTERIOR: LATERAL BORDER OF PECTORALIS MAJOR.

LATERAL: LATERAL BORDER OF LATTISMUS DORSI/MID-AXILLARY LINE.

INFERIOR: LINE IN 5TH INTERCOSTAL SPACE/ IMAGINARY HORIZONTAL LINE FROM NIPPLE.

SUPERIOR: BASE OF AXILLA.

SIGNIFICANCE:MINIMIZE THE RISK OF INJURY,BLOOD VESSEL,MUSCLES,HEART TISSUE AND INTERNAL MAMMARY ARTERY AND DECRREASED SCARING

Insertion site

Fourth or fifth intercostal space in the anterior axillary or mid-axillary line.

Second intercostal space in the mid-clavicular line

alternate site

dissection through the pectoralis muscle

leaves a visible scar

loculated anterior pneumothorax with the use of a small bore catheter (10 to 14 Fr) rather than a standard chest tube.

DRAIN SIZE

Chest drains come in a range of sizes suitable for a variety of purposes (typically 10-36Ch) and may be inserted via an open surgical incision (thoracostomy) or using the Seldinger technique incorporating a guide wire and dilator system.

The following chest drain tube sizes are available for use in adult patients within the Trust

12Ch

18 Ch

20Ch

28Ch

32Ch

Specific ConsiderationsHow to choose a chest tube size?

Pneumothorax A 16 to 24 Fr chest tube.

Traumatic pneumothorax 28 to 40 Fr chest tube

drainage of blood in addition to air may be necessary.

Malignant effusion A 20 to 24 Fr chest tube

Empyema 28 to 36 Fr chest tube

May need more than one tube for loculated areas

Hemothorax 32 to 40 Fr chest

Larger caliber helps prevent occlusion

Insertion of a small bore drain under image guidance with a guidewire does not require blunt dissection. These have been successfully used for pneumothorax, effusions, or loculated empyemas.

Medium bore tube (1624 F)

Large bore tube (>24F): Large bore drains are recommended for drainage of acute haemothorax to monitor further blood loss.

The use of large bore drains has previously been recommended as it was felt that there was an increase in the frequency of drain blockage, particularly by thick malignant or infected fluid. The majority of physicians now use smaller catheters (1014 French (F)) and studies have shown that these are often as effective as larger bore tubes and are more comfortable and better tolerated by the patient

The use of small bore pigtail catheters has allowed outpatient treatment of malignant pleural effusions which have not responded to chemotherapy.

Empyemas are often successfully drained with ultrasonically placed small bore tubes with the aid of thrombolytic agents.

In the case of acute haemothorax, however, large bore tubes (2830 F minimum) continue to be recommended for their dual role of drainage of the thoracic cavity and assessment of continuing blood loss.

ASEPTIC TECHNIQUE

Aseptic technique should be employed during catheter insertion.

Prophylactic antibiotics should be given in trauma cases.

ANAESTHESIA

Local anaesthetic should be infiltrated prior to insertion of the drain.

Local anaesthetic is infiltrated into the site of insertion of the drain. A small gauge needle is used to raise a dermal bleb before deeper infiltration of the intercostal muscles and pleural surface.

Local anaesthetic such as lignocaine (up to 3 mg/kg ) is usually infiltrated.

Chest Tube Insertion

chest tubes are inserted into the pleural space by four methods:

Tube thoracostomy with a guidewire and dilators.

Tube thoracostomy with a trocar.

Operative tube thoracostomy.

Tube thoracoscopy through a single-port thoracoscope

Operative Tube Thoracostomy

It is important to emphasize that operative tube thoracotomy can be very painful. Therefore, it is recommended that patients be given a narcotic or an anxiolytic medication 10 to 15 minutes before the procedure and that liberal doses of local anesthetic be used.

To perform an operative tube thoracostomy, a 3- to 4- cm incision is made in the skin parallel to the chosen intercostal space. The incision should be made down to the fascia overlying the intercostal muscle. This fascia is then incised throughout the length of the incision, with care taken not to cut the muscle.

Once the fascia has been incised, the muscle fibers are spread with a blunt-tipped hemostat until the intercostal interspace is identified.

Then, an incision is made in the intercostal fascia just above the superior border of the inferior rib over which the tube will pass.

The parietal pleura is then penetrated by pushing a blunt-tipped hemostat through it. The hole in the parietal pleura is then enlarged by means of the operator's index finger. At this time, the operator should palpate the adjacent pleural space to detect any adhesions.

Then, the chest tube with its distal end clamped is inserted into the pleural space. A hemostat is used to guide the tube into the pleural space as the operator's finger is withdrawn

Operative tube thoracostomy. A: The physician's index finger is used to enlarge the opening and to explore the pleural space. B: Placement of chest tube intrapleurally using a large hemostat.

Single-Port Thoracoscopy

A rod-lens telescope was placed into the most proximal port of a 28 F chest tube.

Then under direct visualization, the chest tube was placed into the costodiaphragmatic gutter and the telescope was removed.

A flexible pleuroscope should not be used because of its larger diameter and potential for damage to the distal flexible portion of the scope when placed or removed from within the chest tube.

Guidewire tube thoracostomy.

A: Making a small skin incision slightly larger than the diameter of the chest tube.

B: Introduction of 18-gauge needle into the pleural space.

C: Insertion of wire with end into the pleural space.

D: With guidewire in place, the tract is enlarged by advancing progressively larger dilators over the wire guide. Introduction of the dilators is facilitated by rotating and advancing the dilators in the same plane of the wire guide.

E: Introduction of the chest tube inserter or chest tube assembly over the guidewire.

F: The guidewire and the chest tube inserter have been removed, leaving the chest tube positioned within the pleural space.

Trocar Tube Thoracostomy

A: Insertion of trocar into the pleural space. Note the position of the hands, the position of the trocar relative to the ribs, and the cephalad position of the flat edge of the trocar.

B: Insertion of chest tube through the trocar.

COMPLICATIONS

The most serious complications of tube thoracostomy are insertion of the tube ectopically, namely, into the lung, stomach, spleen, liver, or heart.

These complications are more likely when a trocar chest tube is used. With the operative method, digital exploration of the insertion site delineates whether the tract leads into the pleural space and whether any tissue or organ is adherent to the parietal pleura at the planned site of tube insertion.

Verification of Chest Tube Placement

After the chest tube has been inserted and connected to a drainage system, a chest radiograph should be obtained to verify the correctness of its position.

Ideally, both a posteroanterior (PA) and a lateral view should be obtained, because certain ectopic locations may not be apparent on the PA view alone.

A CT scan should be obtained when the chest tube does not drain adequately and the chest radiograph is noncontributory.

Draining systems: Prevent air & fluid from returning to the pleural space

Most basic concept

Straw attached to chest tube from patient is placed under 2cm of fluid (water seal)

Just like a straw in a drink, air can push through the straw, but air cant be drawn back up the straw

Tube open to atmosphere vents air

Tube from patient

When the pleural pressure is positive, the pressure in the rigid straw becomes positive, and if the pressure inside the rigid straw is greater than the depth to which the straw is inserted into the saline solution, air (or liquid) will enter the bottle and will be vented to the atmosphere (or collect in the bottle).

If the pleural pressure is negative, fluid will be drawn from the bottle into the rigid straw and no extra air will enter the system of the pleural space and the rigid straw.

This system is called a water seal because the water in the bottle seals the pleural space from air or fluid from outside the body.

Prevent air & fluid from returning to the pleural space

This system works if only air is leaving the chest

If fluid is draining, it will add to the fluid in the water seal, and increase the depth

As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest

Prevent air & fluid from returning to the pleural space

For drainage, a second bottle was added

The first bottle collects the drainage

The second bottle is the water seal

With an extra bottle for drainage, the water seal will then remain at 2cm

Tube from patient

Tube open to atmosphere vents air

Fluid drainage

2cm fluid

With this system, the bottle adjacent to the patient acts as a collection bottle for the drainage, and the second bottle provides the water seal and the air vent.

Therefore, the degree of water seal does not increase as the drainage accumulates. The water-seal bottle functions identically in both the one and two-bottle systems.

Restore negative pressure in the pleural space

2cm fluid water seal

Collection bottle

Suction control

Tube from patient

Fluid drainage

Tube open to atmosphere vents air

Straw under 20 cmH2O

Tube to vacuum source

It is desirable to apply negative pressure to the pleural space to facilitate reexpansion of the underlying lung or to expedite the removal of air or fluid from the pleural space.

Suction at a fixed level, usually -15 to -20 cm H2O, can be applied to the vent on a one- or two-bottle collection system with an Emerson pump.

Three-bottle systems are unwieldy to set up and are cumbersome to move if the patient needs to be transported.

Following insertion of the chest drain it is essential to :-

check the underwater seal oscillates during respiration

order a repeat chest x-ray to confirm the position of the tube and the

degree of lung re-expansion and exclude any complication

advise the patient to keep the underwater bottle below the drain insertion site,` upright and avoid compressing the tube by sitting or lying on it

ensure regular analgesia is prescribed whilst the chest drain is in place

Commercially Available Drainage Systems

An acceptable drainage system should have the following characteristics: (a) the water seal should be easily visualized, so one can determine whether the chest tube is patent and whether an air leak is present. Some systems have a one-way valve that does not contain water, but one can (and should, if dealing with a pneumothorax) fill the chamber with water to view the bubbling.

(b) the tube should be functional when no suction is applied.

(c) the volume of the collection chamber should be adequate and the markings should be such that the drainage is easily quantitated.

(d) there should be a pop-off valve to provide a safety factor if pressure builds up in the system.

Pleur-Evac Unit

Pleur-Evac collection system, which is analogous to a three-bottle collection system. The area labeled C is the calibrated collection system; W is the water-seal chamber; S is the suction-control chamber. Arrows demonstrate the pathway for air to leave the pleural space. If the suction vent is left open to atmospheric pressure, the Pleur-Evac system functions as a two-bottle collection system. When suction is applied, atmospheric air enters through S and leaves through the suction apparatus.

Care of a Chest Tube

Is there bubbling through the water-seal bottle or the water-seal chamber on the disposable unit?

Is the tube functioning?

What is the amount and type of drainage from the tube?

Bubbling through Water-Seal Chamber

If the patient is receiving water-seal drainage without suction, the presence of bubbling in the water seal usually indicates a persistent air leak from the lung into the pleural space.

If no air bubbles are seen on the initial inspection of the water seal, the patient should be asked to cough, and the water seal should be observed for bubbling.

The coughing maneuver increases the patient's pleural pressure and should demonstrate small air leaks into the pleural space.

If the patient is receiving suction, disconnection or partial disconnection anywhere between the water seal and the patient will lead to bubbling through the water seal

Leaks in the system may be detected by clamping the chest tube at the point where it exits from the chest.

If bubbling through the water seal persists, the drainage system itself is responsible for the leak, and it should be examined thoroughly for leaks.

If the bubbling stops when the chest tube is clamped, then the air is coming from the pleural space.

The presence of bubbling through the water seal does not necessarily indicate a communication between the lung and the pleural space.

If the chest tube is not inserted far enough into the pleural space, one or more of the holes in the chest tube may lie outside the pleural space.

Patients with poor tissue turgor, the negative pleural pressure will cause air to enter the pleural space around the chest tube at the insertion site.

At times it may be difficult to tell whether the air is leaking around the chest tube or whether it is due to a bronchopleural fistula.

One may make this differentiation by measuring the level of PCO2 in the air coming from the chest tube.

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Is the Chest Tube Functioning?

If the patient is not receiving suction, one should observe the level of the liquid in the water seal.

If the chest tube is patent and in the pleural space, the level of the liquid should move higher on inspiration in the limb of the water seal proximal to the patient, indicating a more negative pleural pressure.

Of course, if the patient is receiving mechanical ventilation, the level of liquid in the proximal limb will go down on inspiration because the pleural pressure becomes more positive.

When no fluctuations are observed synchronous with respiratory movements, the patient should be asked to make a maximal inspiratory effort, and if still no movement is observed, it indicates that the chest tube is not functioning.

If a chest tube is not functioning, its functional status should be restored, or it should be removed. Chest tubes can become obstructed with tissue around the holes or by clots within the tube. The simplest method for restoring patency is to flush the tube with 50 mL of saline.

Amount and Type of Drainage

The amount and the character of the drainage from the chest tube should be recorded for each 24-hour period.

The amount of drainage is most easily quantitated by marking the level of the liquid in the collection chamber each day. This record-keeping is important because many therapeutic decisions based on the quantity of the drainage.

The character of the drainage is best described by quantitating the percentage of solid drainage material.

This quantitation is easily done by marking the level of the sediment in the collection chamber each day. If the increase in volume of the entire collection system is known and if the increase in volume of the solid sediment is known, it is simple to calculate what percentage of the daily drainage is solid.

Monitoring/recording

The frequency of observations depends on clinical presentation/progress and medical request but should happen at least 4 hourly.

Fluid within the tube should swing with respiration due to changes in intrapleural pressure.

With normal respiration, the fluid should rise on inspiration and fall on expiration.

Absence of swinging indicates that the drain is occluded or is no longer in the pleural space.

It may be necessary following clinical assessment and unsuccessful flushing of the drain to obtain a chest x-ray to determine the underlying cause.

A drain inserted for drainage of a haemothorax (+/- pneumothorax) needs blood loss to be recorded accurately with any sudden increases in drain volume referred immediately for medical review.

With fractured ribs most bleeding is from the intercostal vessels, which slows down as the lung reinflates.

However continued bleeding into the drain bottle is indicative of pathology that may need thoracic surgical intervention. After thoracic trauma more than 1500ml of blood into the bottle initially or continued bleeding of greater than 200ml/hr requires discussion with the thoracic surgeons.

When to clamp?

Clamping drain

A bubbling chest tube should never be clamped.

Drainage of a large pleural effusion should be controlled to prevent the potential complication of re-expansion pulmonary oedema.

In cases of pneumothorax, clamping of the chest tube should usually be avoided.

If a chest tube for pneumothorax is clamped, this should be under the supervision of a respiratory physician or thoracic surgeon, the patient should be managed in a specialist ward with experienced nursing staff, and the patient should not leave the ward environment.

If a patient with a clamped drain becomes breathless or develops subcutaneous emphysema, the drain must be immediately unclamped and medical advice sought.

Changing the drain bottle

When changing the drain bottle because it is overfull, temporary clamping of the drainage tube may be necessary to prevent ingress of air into the pleural cavity.

It is acceptable to clamp the tube between thumb and forefinger.

This has the advantage of removing the risk of inadvertently leaving the tube clamped.

Suction

A patient who is free from pain, to the degree that an effective cough can be produced, will generate a much higher pleural pressure differential than can safely be produced with suction.

This combined with a functional underwater seal will result in re-inflation of the lung.

If a patient cannot re-inflate his own lung or persistent air leak is preventing re-inflation, high volume, lowpressure thoracic suction in the range of 3-5kPa (approx 30-50cmH2O) should be used.

Mobility

If appropriate, patients should be encouraged to walk around.

If the drain is on suction the patient will be restricted to the bedside.

Exercise to prevent complications such as a frozen shoulder or deep venous thrombosis is essential, as are deep breathing exercises to aid re-expansion of the lung.

Dressings

Dressings should be changed daily for the following reasons:-

to enable the insertion site to be monitored for signs of infection.

A swab should be taken from the chest drain site if there are any clinical signs of infection

- to monitor for surgical emphysema

- to ensure the chest drain remains well placed and the anchor suture is in tact

complications

Are rare, 1-3%

Chest tube malposition Chest tube malposition is the most common complication of tube thoracostomy

Lung parenchyma perforation

Empyema

Subcutaneous tube placement

Perforation of the ventricle or atrium, and abdominal organs (spleen, liver, stomach, colon)

Other complications include

cardiogenic shock from chest tube compression of the right ventricle,

mediastinal perforation with contralateral hemothorax and pneumothorax

bleeding from intercostal artery injury

infection at the chest tube site

One of the most common complications is misplacement of the chest tube.

Many life-threatening complications occur when the tube is first inserted and include insertion of the chest tube into the lung, stomach, spleen, liver, or heart.

A PA and lateral chest radiograph should always be obtained after a chest tube is inserted.

Pleural infection is another complication of tube thoracostomy. The administration of antibiotics to patients who have chest tubes for thoracic trauma may decrease the prevalence of empyema.

The antibiotic chosen should have activity against Staphylococcus aureus because this is the organism that causes the most infections.

subcutaneous emphysema, which usually presents as soft tissue crepitus around the drain site but may rapidly spread to virtually any place in the body.

The presence of subcutaneous emphysema in patients with tube thoracostomies indicates one of three possibilities :

(a) a side-hole on the chest tube is lying outside the pleural space within the chest wall, allowing air to enter the tissue planes

(b) the chest tube is blocked.

(c) the drainage system cannot cope with the air leak. The latter situation is unusual and may be related to a chest tube that is too small or a massive air leak.

Injection of Materials Through Chest Tubes

Fibrinolytic or a DNAase in a patient with a loculated complicated parapneumonic effusion .

Tetracycline derivative or a different sclerosing agent through the chest tube in a patient with a malignant pleural effusion.

There is a commercially available adapter called a Thal-Quick Chest Tube Adapter .

CHEST TUBE REMOVAL

Remove when:

Original indication for placement is no longer present

Tube becomes nonfunctional.

The following criteria should be met prior to removing the chest tube:

The lung should be fully expanded

Daily fluid output should be less than 100 to 200 mL/day

An air leak should not exist, either during suction or coughing

Once these criteria are met, the chest tube can be placed on water seal.

CXR on water seal after 6 hours

Some will clamp the chest tube for four to six hours, then confirm the absence of pneumothorax prior to removing the chest tube.

Mechanical ventilation does not prevent removal of CT if no air leak is present.

Following inspiration, the patient performs a Valsalva maneuver and the tube is removed with simultaneous covering of the insertion site with the gauze dressing

In case Parapneumonic Effusions and Empyema

chest tubes should be left in place until the volume of the pleural drainage is less than 50 mL for 24 hours and until the draining fluid becomes clear yellow.

The amount of sediment (representing WBCs and debris) in the collection system should be quantitated daily and the chest tube should not be removed if more than 5 mL sediments collect daily.

In case of pneumothorax

The chest tube should remain in place for 24 hours after the lung reexpands and the air leak ceases.

If the chest tubes are removed too soon after the lung reexpands and the air leak ceases, there is a high likelihood of an early recurrence if removed within 6 hours of expansion.

Thoracentesis

Thoracentesis also known as thoracocentesis or pleural tap is an invasive procedure to remove air or fluid from pleural space for diagnostic and therapeutic purposes.

INDICATIONS forDiagnostic thoracentesis

Establish the cause of a pleural effusion.

When an effusion is suspected on physical examination

Confirm by radiographic

Thoracentesis is not generally required in patients:

Small amount of pleural fluid

And a secure clinical diagnosis (eg, with viral pleurisy)

Thoracentesis should be considered in patients with suspected CHF in the following circumstances:

A unilateral effusion is present, particularly if it is left-sided

Bilateral effusions are present, but are of disparate sizes

There is evidence of pleurisy

The patient is febrile

The cardiac silhouette appears normal on chest radiograph

The alveolar-arterial oxygen gradient is widened out of proportion to the clinical setting

CONTRAINDICATIONS There are no absolute contraindications to diagnostic thoracentesis

Relative contraindications to the procedure:

Anticoagulation or a bleeding diathesis

PT or PTT greater than twice normal

Platelet count less than 25,000/mm3

Serum creatinine concentration greater than 6 mg/dL

Active skin infection at the point of needle insertion

A very small volume of pleural fluid

1.0 to 1.5 liters) or after removal of an obstructing tumor.

The incidence of edema appears to be related to the rapidity of lung reexpansion.

Patients typically present soon after the inciting event, although presentation can be delayed for up to 24 hours in some cases.

A mortality rate as high as 20 percent has been described.

Treatment is supportive, mainly consisting of supplemental oxygen and, if necessary, mechanical ventilation. The disease is usually self-limited.

Prevention drain only 1-1.5 liters of fluid at a time; if need to take more, wait 2-4 hours between drainages

Definition: are Drugs that cause lysis of already formed thrombus

Fibrinolyic drugs

1. Streptokinase.

2. Anistreplase.

3. Urokinase

4. Tissue plasminogen activators ( t -PA).

Fibrinolytics

Mechanism of Action

acts directly or indirectly to convert plasminogen to plasmin within the thrombus

Plasmin degrades fibrin clots and other plasma proteins (non-fibrin specific)

Use of fibrinolytics in pulmonolgy

Fibrinolytic agents are used to allow complete drainage of locules and partial debridement of the pleural surface.

Instillation of fibrinolytics into the pleural cavity may help prevent fibrin deposits and loculations. Clinical success rate ranges from 62 to 100 percent

Streptokinase

Is a protein synthesized by B-hemolytic streptococci.

Mechanism of Action

acts indirectly by forming plasminogen-streptokinase complex which converts inactive plasminogen into active plasmin.

It is the least expensive.

T 1/2 = half an hour.

1.5 million units of stk is used.

Side effects

Bleeding due to activation of circulating plasminogen.

Hypersensitivity due to antigenicity (rash, fever, allergic reaction).

Hypotension.

not used in patients with streptococcal infections (have antistreptococcal antibodies and may develop fever, allergic reactions and resistance upon treatment with streptokinase).

Disadvantages

(less than streptokinase alone).

1. Expensive.

2. Antigenic.

3. Allergic reactions.

4. Bleeding due to minimal fibrin specificity

Urokinase

Human enzyme synthesized by the kidney, obtained from either urine or cultures of human embryonic kidney cells.

acts directly converting plasminogen to active plasmin.

urokinase is also effective when compared to saline alone for intrapleural treatment of loculated parapneumonic effusions.

Compared with placebo, intrapleural instillation of urokinase is effective in improving chest-tube drainage and the radiographic appearance of the chest; early use of urokinase may be more effective than late use when catheter drainage alone has failed.

Comparison of urokinasewith streptokinase shows no difference in effectiveness.

Disadvantages

1. Expensive. 2. Systemic lysis.

Advantages

1. Not antigenic.

2. No Hypotension.

Tissue Plasminogen Activators ( t - PA )

Alteplase

- Alteplase ( Single Chain ).

Reteplase ( Deleted Form ).

Tenecteplase

All are recombinant human t - PA.

Synthesis by recombinant DNA technology.

Tissue plasminogen activator (t-PA) has been shown to be effective in reducing the duration of required chest tube placement in children with complicated parapneumonic effusions (using 4 mg of t-PA in 30 to 50 ml of saline instilled through the chest

, which is clamped for 1 hour before applying suction to the tube). No adverse events have been noted.

In our practice, 10 mg of t-PA in 50 ml of saline is instilled through the chest catheter, followed by 20 ml of a saline flush. If possible, the patients position is every 10 min for1hbefore the catheter is connected to suction.

complications of intrapleural fibrinolysis hemorrhage,

allergic reactions,

transient chest pain

promotion of bronchopleural fistula formation.

intrapleural instillation of thrombolytic agents may alter systemic coagulation parameters, many studies have shown that this effect does not occur.

Contraindications to thrombolytic therapy

Absolute contraindications include:

Recent head trauma or caranial tumor

Previous hemorrhagic shock

Stroke

Active internal bleeding

Major surgery within two weeks

Relative contraindications include:

Active peptic ulcer, diabetic retinopathy, pregnancy, uncontrolled hypertension

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