What is the use of Cathflo (Alteplase) for chest tube?

From the Guidelines

Cathflo (alteplase) is not recommended for routine use in chest tubes, as its primary indication is for clearing occluded central venous catheters, not chest tubes. When considering the use of fibrinolytics for chest tube occlusions, it's essential to note that the standard protocol typically involves a different approach, such as using 10-20 mg of tPA (alteplase) diluted in 50-100 mL of saline instilled into the chest tube, or streptokinase 250,000 IU 1. After instillation, the chest tube should be clamped for 1-4 hours before reconnecting to drainage, allowing the fibrinolytic agent to break down fibrin clots that may be causing the occlusion. Some key points to consider when using fibrinolytics for chest tube occlusions include:

• Ensuring the chest tube isn't kinked or positioned improperly, as mechanical issues are common causes of poor drainage
• Being aware that fibrinolytic use carries bleeding risks and should be avoided in patients with active bleeding, recent surgery, or coagulopathy
• Consulting with a pulmonologist or thoracic surgeon before administering fibrinolytics through chest tubes It's also important to note that the use of alteplase for catheter occlusion has been well-studied, with the Cathflo Activase Pediatric Study reporting a cumulative rate of restoration of catheter function after serial administration of a maximum of two doses of alteplase of 82.9% (95% CI, 78.2e86.9%) 1. However, this data is specific to central venous catheters, not chest tubes. In terms of the mechanism of action, fibrinolytics work by converting plasminogen to plasmin, which degrades fibrin clots, and have been shown to be effective in restoring catheter patency in various studies, including the COOL and COOL-2 trials 1. Overall, while Cathflo (alteplase) may not be the primary choice for chest tube occlusions, fibrinolytic therapy can be an effective treatment option when used appropriately and with caution.

From the FDA Drug Label

Cathflo® Activase® (Alteplase) is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood. The FDA drug label does not answer the question.

From the Research

Cathflo for Chest Tube

• Cathflo, also known as alteplase, is a medication used to break up blood clots and other blockages in the chest tube 2, 3.
• The efficacy and safety of intrapleural instillation of alteplase have been investigated in several studies, with results showing that it can be an effective treatment for complicated pleural effusion or empyema 2, 3.
• The use of alteplase via tube thoracostomy has been shown to have a success rate of 86.4% in treating complex pleural processes, with a bleeding incidence of 8.5% 3.
• Studies have also investigated the risk factors associated with bleeding after alteplase administration, including recent major surgery, international normalized ratio above 1.7, and one or more risk factors for bleeding 4, 5.
• The safety profile of intrapleural alteplase has been reported to be relatively low, with a bleeding incidence of 5.3% in patients receiving intrapleural alteplase for nondraining indwelling tunneled pleural catheters 6.

Administration and Dosage

• Alteplase can be administered through a chest tube, with doses ranging from 10 to 100 mg daily 2.
• The number of doses required can vary, with most patients requiring 3 to 4 doses of alteplase 2.
• The use of alteplase via indwelling tunneled pleural catheters has been shown to be effective, with a low incidence of complications 6.

Risks and Complications

• Bleeding is a potential complication of alteplase administration, with a reported incidence of 8.5% in one study 3.
• Other potential complications include chest pain, with a reported incidence of 6% in one study 2.
• The risk factors associated with bleeding after alteplase administration include recent major surgery, international normalized ratio above 1.7, and one or more risk factors for bleeding 4, 5.