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formation of fibrinous septa in the interior of the effusion can be observed in up to 14&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> This is the result of procoagulant activity and the decline of fibrinolytic activity of MPEs&#44; which contributes to the deposit of fibrin in the pleural space&#44; creating septa that make it difficult to perform pleural effusion drainage in the patient&#39;s home&#46; The benefit of urokinase instillation in these cases has been reported by several authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> some of whom opt for high doses over prolonged periods&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Hsu et al&#46;&#44; in 2006&#44; recommended repeated instillations of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase daily for at least 3 days &#40;up to a maximum of 9 days and 900<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a>&#59; in contrast&#44; other authors such as Mishra et al&#46;&#44; in 2018&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> used 3 doses of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase instilled at 12-h intervals for a total dose of 300<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU&#44; with monitoring 24<span class="elsevierStyleHsp" style=""></span>h after the last dose&#44; but reported no significant benefit in the urokinase group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present a clinical case treated according to our hospital protocol for septated MPEs that are not effectively drained&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This was a 61-year-old man&#44; referred to the respiratory medicine outpatient department for generalized constitutional symptoms&#44; dyspnea on minimal effort and recurrent pleural effusion&#46; He underwent 2 thoracenteses in the emergency department&#44; for diagnosis and evacuation&#59; a total of 2700<span class="elsevierStyleHsp" style=""></span>ml lymphocytic exudate was extracted&#44; and cytology was negative for malignancy&#46; In the respiratory medicine clinic&#44; we performed a chest ultrasound which revealed pleural thickening&#46; A computed tomography &#40;CT&#41; scan of the chest was requested&#44; showing grade III&#47;IV right pleural effusion causing right lower lobe atelectasis that contained a 2<span class="elsevierStyleHsp" style=""></span>cm nodular image and multiple foci of tumor-like pleural nodular thickening&#46; The abdomen was significant for a pathological retroperitoneal lymphadenopathy measuring 2<span class="elsevierStyleHsp" style=""></span>cm in its greatest diameter&#46; A right pleural ultrasound-guided biopsy was performed and thoracentesis for drainage was repeated &#40;the third within a week&#44; extracting 2000<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; The pathology study reported renal cell carcinoma metastasis as a primary neoplasm&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A diagnosis of MPE due to stage IV kidney cancer was made&#44; and in view of the persisting pleural effusion&#44; we decided&#44; after explaining the different therapeutic alternatives to the patient&#44; to place a TPD catheter &#40;IPC&#8482; Rocket Medical&#169;&#44; Watford&#44; United Kingdom&#41;&#44; and both the patient and his family members were instructed how to perform drainage at home&#46; About 30 days after TPD placement&#44; the patient attended the clinic with dyspnea on minimal effort &#40;visual analog scale &#91;VAS&#93;&#58; 8&#47;10&#44; modified Medical Research Council dyspnea grade&#58; III&#41;&#44; with ineffective TPD draining&#46; Chest X-ray revealed grade II&#47;IV right pleural effusion&#44; unchanged from previous studies&#44; with the catheter placed correctly in the right hemithorax&#46; A chest ultrasound showed grade II&#47;IV effusion containing multiple septa and detritus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; An intrapleural instillation of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase was administered and left to act for 2<span class="elsevierStyleHsp" style=""></span>h&#44; after which chest ultrasound was repeated&#44; according to our protocol&#59; this showed total lysis of the septa and persistent pleural effusion with detritus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; This effusion was drained&#44; obtaining 750<span class="elsevierStyleHsp" style=""></span>ml of serosanguineous fluid&#59; no associated complications were reported&#44; and the patient showed significant symptomatic relief&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In October 2017&#44; we implemented our protocol for home-managed MPE that does not drain after connecting the TPD tube to the vacuum bottle&#46; This protocol consists of an initial chest X-ray and pleural ultrasound and&#44; if intrapleural septa are observed on the latter&#44; a single dose of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase is instilled and the patient is reevaluated at 2<span class="elsevierStyleHsp" style=""></span>h by repeating the ultrasound to visualize the effect of the urokinase &#40;lysis of the septa&#41;&#44; and then immediately performing drainage through the tunneled catheter&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> A third pleural ultrasound is performed to confirm the reduction of the pleural effusion and the absence of immediate complications&#46; The procedure takes less than 10<span class="elsevierStyleHsp" style=""></span>min from the time of the initial ultrasound to the intrapleural administration of the fibrinolytic agent&#44; and another 10<span class="elsevierStyleHsp" style=""></span>min between subsequently visualizing septal lysis and draining the effusion&#46; On discharge&#44; the patient is given a contact telephone number to report any possible complications &#40;effusion becoming hemorrhagic&#44; principally&#44; or onset of dyspnea or chest pain&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fifteen patients have been included in this protocol to date&#44; 53&#46;8&#37; men&#44; with an average age &#40;standard deviation&#44; SD&#41; of 68&#46;5 &#40;13&#46;9&#41; years&#44; and an average &#40;SD&#41; of 584 &#40;199&#41; cc drained after the procedure&#46; Clear symptomatic relief &#40;reduction of &#62;2 points on VAS&#41; was obtained in 73&#46;3&#37; of cases&#44; and no complications have been observed so far&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The dose of urokinase required in MPE is not clearly established&#44; and in our experience a high success rate is achieved in septal lysis with a single dose&#46; As previously mentioned&#44; recent studies published in the literature support the instillation of fibrinolytic agents over several consecutive days with subsequent assessments&#59; however&#44; this approach requires several visits and increases costs&#44; and the patient is obliged to spend more time in the hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> Since most patients with advanced disease are receiving palliative care&#44; one of the main objectives should be to prioritize the well-being of the patient and reduce the number of visits to the hospital&#46; With this systematic intervention&#44; effective septal fibrinolysis is achieved in a single visit&#44; without affecting the main objective of the procedure&#44; which is to optimize pulmonary reexpansion&#44; reduce pleural effusion&#44; and improve the patient&#39;s dyspnea&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Herrero Huertas J&#44; L&#243;pez Gonz&#225;lez FJ&#44; Garc&#237;a Alfonso L&#44; Enr&#237;quez Rodr&#237;guez AI&#46; Fibrin&#243;lisis ambulatoria en el manejo del derrame maligno multiseptado&#46; Arch Bronconeumol&#46; 2019&#59;55&#58;594&#8211;596&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient&#44; 61 years of age&#44; with malignant pleural effusion due to stage IV kidney cancer&#44; presenting with non-draining tunneled catheter&#46; Chest ultrasound showing abundant septa preventing drainage of pleural fluid &#40;A&#41;&#46; A single dose of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase was instilled and left to act for 2<span class="elsevierStyleHsp" style=""></span>h&#59; the thoracic ultrasound was then repeated&#44; revealing pleural effusion containing detritus and lysis of the septa &#40;B&#41;&#46; The effusion was than drained&#44; obtaining 750<span class="elsevierStyleHsp" style=""></span>ml of serosanguineous pleural fluid and subsequent symptomatic improvement&#46;</p>"
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Scientific Letter
Ambulatory Fibrinolysis in the Management of Septated Malignant Effusions
Fibrinólisis ambulatoria en el manejo del derrame maligno multiseptado
Julia Herrero Huertasa,
Corresponding author
herrerohuertas@gmail.com

Corresponding author.
, Francisco Julián López Gonzáleza, Lucía García Alfonsob, Ana Isabel Enríquez Rodrígueza
a Servicio de Neumología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
b Servicio de Neumología, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
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formation of fibrinous septa in the interior of the effusion can be observed in up to 14&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> This is the result of procoagulant activity and the decline of fibrinolytic activity of MPEs&#44; which contributes to the deposit of fibrin in the pleural space&#44; creating septa that make it difficult to perform pleural effusion drainage in the patient&#39;s home&#46; The benefit of urokinase instillation in these cases has been reported by several authors&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">6&#44;7</span></a> some of whom opt for high doses over prolonged periods&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Hsu et al&#46;&#44; in 2006&#44; recommended repeated instillations of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase daily for at least 3 days &#40;up to a maximum of 9 days and 900<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a>&#59; in contrast&#44; other authors such as Mishra et al&#46;&#44; in 2018&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> used 3 doses of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase instilled at 12-h intervals for a total dose of 300<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU&#44; with monitoring 24<span class="elsevierStyleHsp" style=""></span>h after the last dose&#44; but reported no significant benefit in the urokinase group&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">We present a clinical case treated according to our hospital protocol for septated MPEs that are not effectively drained&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This was a 61-year-old man&#44; referred to the respiratory medicine outpatient department for generalized constitutional symptoms&#44; dyspnea on minimal effort and recurrent pleural effusion&#46; He underwent 2 thoracenteses in the emergency department&#44; for diagnosis and evacuation&#59; a total of 2700<span class="elsevierStyleHsp" style=""></span>ml lymphocytic exudate was extracted&#44; and cytology was negative for malignancy&#46; In the respiratory medicine clinic&#44; we performed a chest ultrasound which revealed pleural thickening&#46; A computed tomography &#40;CT&#41; scan of the chest was requested&#44; showing grade III&#47;IV right pleural effusion causing right lower lobe atelectasis that contained a 2<span class="elsevierStyleHsp" style=""></span>cm nodular image and multiple foci of tumor-like pleural nodular thickening&#46; The abdomen was significant for a pathological retroperitoneal lymphadenopathy measuring 2<span class="elsevierStyleHsp" style=""></span>cm in its greatest diameter&#46; A right pleural ultrasound-guided biopsy was performed and thoracentesis for drainage was repeated &#40;the third within a week&#44; extracting 2000<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; The pathology study reported renal cell carcinoma metastasis as a primary neoplasm&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">A diagnosis of MPE due to stage IV kidney cancer was made&#44; and in view of the persisting pleural effusion&#44; we decided&#44; after explaining the different therapeutic alternatives to the patient&#44; to place a TPD catheter &#40;IPC&#8482; Rocket Medical&#169;&#44; Watford&#44; United Kingdom&#41;&#44; and both the patient and his family members were instructed how to perform drainage at home&#46; About 30 days after TPD placement&#44; the patient attended the clinic with dyspnea on minimal effort &#40;visual analog scale &#91;VAS&#93;&#58; 8&#47;10&#44; modified Medical Research Council dyspnea grade&#58; III&#41;&#44; with ineffective TPD draining&#46; Chest X-ray revealed grade II&#47;IV right pleural effusion&#44; unchanged from previous studies&#44; with the catheter placed correctly in the right hemithorax&#46; A chest ultrasound showed grade II&#47;IV effusion containing multiple septa and detritus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; An intrapleural instillation of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase was administered and left to act for 2<span class="elsevierStyleHsp" style=""></span>h&#44; after which chest ultrasound was repeated&#44; according to our protocol&#59; this showed total lysis of the septa and persistent pleural effusion with detritus &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; This effusion was drained&#44; obtaining 750<span class="elsevierStyleHsp" style=""></span>ml of serosanguineous fluid&#59; no associated complications were reported&#44; and the patient showed significant symptomatic relief&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In October 2017&#44; we implemented our protocol for home-managed MPE that does not drain after connecting the TPD tube to the vacuum bottle&#46; This protocol consists of an initial chest X-ray and pleural ultrasound and&#44; if intrapleural septa are observed on the latter&#44; a single dose of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase is instilled and the patient is reevaluated at 2<span class="elsevierStyleHsp" style=""></span>h by repeating the ultrasound to visualize the effect of the urokinase &#40;lysis of the septa&#41;&#44; and then immediately performing drainage through the tunneled catheter&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">11</span></a> A third pleural ultrasound is performed to confirm the reduction of the pleural effusion and the absence of immediate complications&#46; The procedure takes less than 10<span class="elsevierStyleHsp" style=""></span>min from the time of the initial ultrasound to the intrapleural administration of the fibrinolytic agent&#44; and another 10<span class="elsevierStyleHsp" style=""></span>min between subsequently visualizing septal lysis and draining the effusion&#46; On discharge&#44; the patient is given a contact telephone number to report any possible complications &#40;effusion becoming hemorrhagic&#44; principally&#44; or onset of dyspnea or chest pain&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fifteen patients have been included in this protocol to date&#44; 53&#46;8&#37; men&#44; with an average age &#40;standard deviation&#44; SD&#41; of 68&#46;5 &#40;13&#46;9&#41; years&#44; and an average &#40;SD&#41; of 584 &#40;199&#41; cc drained after the procedure&#46; Clear symptomatic relief &#40;reduction of &#62;2 points on VAS&#41; was obtained in 73&#46;3&#37; of cases&#44; and no complications have been observed so far&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The dose of urokinase required in MPE is not clearly established&#44; and in our experience a high success rate is achieved in septal lysis with a single dose&#46; As previously mentioned&#44; recent studies published in the literature support the instillation of fibrinolytic agents over several consecutive days with subsequent assessments&#59; however&#44; this approach requires several visits and increases costs&#44; and the patient is obliged to spend more time in the hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> Since most patients with advanced disease are receiving palliative care&#44; one of the main objectives should be to prioritize the well-being of the patient and reduce the number of visits to the hospital&#46; With this systematic intervention&#44; effective septal fibrinolysis is achieved in a single visit&#44; without affecting the main objective of the procedure&#44; which is to optimize pulmonary reexpansion&#44; reduce pleural effusion&#44; and improve the patient&#39;s dyspnea&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Herrero Huertas J&#44; L&#243;pez Gonz&#225;lez FJ&#44; Garc&#237;a Alfonso L&#44; Enr&#237;quez Rodr&#237;guez AI&#46; Fibrin&#243;lisis ambulatoria en el manejo del derrame maligno multiseptado&#46; Arch Bronconeumol&#46; 2019&#59;55&#58;594&#8211;596&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient&#44; 61 years of age&#44; with malignant pleural effusion due to stage IV kidney cancer&#44; presenting with non-draining tunneled catheter&#46; Chest ultrasound showing abundant septa preventing drainage of pleural fluid &#40;A&#41;&#46; A single dose of 100<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>IU urokinase was instilled and left to act for 2<span class="elsevierStyleHsp" style=""></span>h&#59; the thoracic ultrasound was then repeated&#44; revealing pleural effusion containing detritus and lysis of the septa &#40;B&#41;&#46; The effusion was than drained&#44; obtaining 750<span class="elsevierStyleHsp" style=""></span>ml of serosanguineous pleural fluid and subsequent symptomatic improvement&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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