What is the typical duration of intrapleural lytics (intrapleural fibrinolytic therapy) treatment?

Duration of Intrapleural Fibrinolytic Therapy

Intrapleural fibrinolytics should be administered for 3 days as the standard treatment duration, regardless of which agent is used. 1, 2, 3

Standard Treatment Protocols by Agent

tPA/DNase Combination (Preferred Regimen)

• Administer tPA 10 mg combined with DNase 5 mg twice daily for 3 days 3
• This combination is significantly more effective than either agent alone and represents the current standard of care per the American College of Chest Physicians 3
• Clamp the chest tube for 1 hour after each instillation 3

Streptokinase (Not Recommended)

• If used, give 250,000 IU twice daily for 3 days 1, 2
• The British Thoracic Society now recommends against streptokinase due to lack of beneficial effect and higher complication rates compared to other fibrinolytics 3
• Patients receiving streptokinase must be given an exposure card and should receive urokinase or tPA for any future systemic indications 2

Urokinase (Limited Availability)

• Administer 100,000 IU once daily for 3 days 1, 2
• No longer available in North America and shows inferior efficacy compared to alteplase 3

Clinical Assessment Timeline

Evaluate treatment effectiveness at 5-8 days after initiating chest tube drainage and antibiotics 2

Key indicators of successful therapy:

• Resolution of fever and sepsis 2
• Adequate pleural drainage 2
• Radiographic improvement 2

When to Escalate Care

Discuss with a thoracic surgeon if effective pleural drainage has not been achieved by the 5-8 day assessment point 2

Critical Pitfall to Avoid

• Do not continue fibrinolytic therapy beyond the standard 3-day course without reassessment 2
• The 3-day protocol should prompt clinical evaluation, not automatic continuation 2
• Do not delay surgical consultation beyond 5-8 days if drainage remains inadequate despite fibrinolytic therapy 2

Pre-Treatment Checklist

Before attributing poor drainage to loculations:

• Ensure the chest tube is patent by flushing with 20-50 mL normal saline if blockage is suspected 2
• Check for tube kinking at the skin, particularly with smaller drains 1
• Consider contrast-enhanced CT scanning to identify undrained locules and confirm accurate tube placement 1

Administration Technique

For all fibrinolytic agents:

• Instill through the existing chest tube after initial drainage has slowed 3
• Clamp the chest tube after instillation (1 hour for tPA/DNase, 2-3 hours for other agents) 1, 3
• Resume suction drainage after the clamping period 1
• Obtain patient consent due to potential bleeding risk 3