Pleural Irrigation With Normal Saline Versus Intrapleural Fibrinolytic

Problem Statement Retained complicated pleural effusion is associated with a risk of empyema and sepsis.IPFT is commonly used as the bridging therapy to surgery. The efficacy of saline irrigation is not known. However, the probable problem in this study is when failed saline irrigation, the patient will be given IPFT as part of the intention to treat. Research Questions: • Is the combination of intrapleural Alteplase (t-PA) 5mg and DNase (Pulmozyme) 5mg superior than pleural pleural irrigation in the management of pleural infection? Primary Objective: • comparison of the safety outcome between IPFT and intrapleural saline irrigation, such as clinical deterioration, chest pain requiring escalation of analgesics, gastrointestinal bleeding, bleeding from chest drain site, intrapleural hemorrhage, hemoptysis, Hemoglobin (Hb) drop \>10% from baseline requiring blood transfusion Secondary Objectives: * To determine the reduction of pleural opacity (in percentage) on chest radiograph from day 1 (randomization) to day 7 * To determine the change on inflammatory markers (WBC/CRP) from day 1 (randomization) to day 7 * To determine the outcome : * Length of hospital stay (in days) after randomization for each group * The need of surgical intervention in 30 days * Mortality rate at 30 days * To measure the volume of pleural effusion drainage (in mls) 48 hours following randomization Study Hypothesis 1. Subjects in the IPFT has more volume of pleural fluid drainage compared with pleural irrigation group 2. Subjects in the IPFT has greater reduction of inflammatory parameters compared with pleural irrigation group 3. Subjects in the IPFT has shorter length of hospital stay compared with pleural irrigation group 4. Subjects in the IPFT has less surgical referral rate compared pleural irrigation group 5. There is no difference of mortality rate between both groups Subjects with pleural infection (complex parapneumonic effusion or empyema) with poor outflow ≤150cc pleural fluid from chest drain over 24 hours of insertion with standard medical therapy who are eligible for this study will be offered to participate into this study. Patient will be informed that this is an 'off label' drugs and a written informed consent will be obtained. All patients will undergo chest tube/drain insertion. The decision to insert chest drain, the size of chest drain and when to initiate intrapleural t-PA/DNase is determined by the chest physician. Ultrasound of thorax and chest radiograph will be performed within 24hours before randomization. Ultrasound of thorax is performed by chest physician with curve probe (ultrasound Mindray, model Z5) for confirmation of complex pleural effusions and chest tube's position. Complex pleural effusion on ultrasound is defined as fibrin strands or septa within the pleural effusion along with presence of loculations in pleural cavity. A baseline chest radiograph will be performed within 24 hours prior to intrapleural fibrinolysis or pleural irrigation to ensure the chest tube position. Demographic data was collected prior to randomization, which consist of age,gender,ethnicity,BMI,comorbidities. Subjects will be randomized with a block of 4 (using sealed envelope) with random permutations of 2 groups : pleural irrigation group and intrapleural t-PA and DNase. All patients that prescribed intrapleural t-PA/DNase during the study period will receive a standard dose of medications as below (Appendix 1). Medication Regimen : t-PA (Alteplase) 5mg and DNase (Pulmozyme)5mg t-PA (Alteplase) that is available in our pharmacy is 50mg ampoule and DNase (Pulmozyme) is 2.5mg per ampoule The number of installation of intrapleural t-PA/DNase depends on the discretion of the treating physician (at least 6 hours apart between each dose). 5mg of Alteplase (t-PA) and 5mg DNase are diluted in each 50ml of 0.9% sodium chloride solution. t-PA and DNase are not mixed together in one syringe. The detailed method of t-PA/DNase therapy administration is described in Appendix 1. In brief , both medication are administered sequentially which t-PA is first instilled intrapleurally and the chest tube is then clamped for 45 minutes, then unclamped to allow free drainage for 45 minutes. The same procedure is then repeated for DNase. Selection of the timing of treatment and removal of chest tube are depending on the chest physician's judgement. However, as for patients who were randomized into pleural irrigation group, subjects were administered 250 ml of 0.9% sodium chloride via chest tube a three way tap from a drip stand which were allowed drainage freely over 1 hour. Pleural irrigation will be performed minimum of 3 installations and maximum of 9 installation (3 times per day). Both groups received standard care of treatment : which includes regular flushing of chest drain to maintain patency using 20mls of normal saline. The primary outcome was to evaluate the volume of pleural effusion drainage (in mls) 72 hours following randomization. The volume drained measured after subtracting the amount of volume administered as per protocol. The secondary outcome are measured by the change in the area of pleural opacity in chest x-ray (day 7 post t-PA/DNase compared to baseline), measured as the percentage of the ipsilateral hemithorax occupied by effusion. The area of pleural opacity and the area of the ipsilateral hemithorax will be measured digitally by two radiologists using Horos Project Software, v3.2.1 as described previously in Multicentre Intrapleural Sepsis Trial 2 (MIST-2) Other outcomes that will be monitored include : 1. Inflammatory markers including serum C-reactive protein (CRP) \& white blood count 2. Length of hospital stay in days 3. The need of surgical intervention within 30 days 4. Adverse effects : 1. Chest pain required escalation of analgesics 2. Systemic bleeding 3. Pleural bleeding During any point of treatment subjects will be allowed to cross-over and analysis will be done as per intention to treat. Subjects in the pleural irrigation group may be switched to IPFT group if there is poor response to treatment (poor drainage of effusion), or adverse effects of irrigation as per clinician's judgement. On the contrary, subjects in the IPFT group may be switched to pleural irrigation group if patient developed any adverse effects of IPFT (e.g hemothorax,haemoptysis). Those who failed both treatment will be referred for surgical intervention