Should tissue-type plasminogen activator (tPA) and dornase alfa be used to treat a hemothorax?

Should tPA and Dornase Alfa Be Used for Hemothorax?

No, tPA and dornase alfa should NOT be used for hemothorax—these agents are indicated specifically for pleural infection (empyema/complicated parapneumonic effusions), not for traumatic or non-infectious hemothorax.

Key Distinction: Infection vs. Blood

The fundamental issue is that hemothorax and pleural infection are entirely different pathologies requiring different treatments:

For Pleural Infection (NOT Hemothorax):

• Combination tPA and DNase is recommended when initial chest tube drainage fails to clear infected pleural collections 1
• The mechanism works by breaking down fibrin deposits (tPA) and degrading extracellular DNA from inflammatory cells (DNase) that contribute to fluid viscosity in infected effusions 2
• Standard dosing: 10 mg tPA twice daily + 5 mg DNase twice daily for 3 days 1, 2
• Single agent tPA or DNase should NOT be used as they are ineffective alone 1, 2

For Hemothorax (The Question at Hand):

• No guideline support exists for using tPA/DNase in hemothorax 1
• The British Thoracic Society guidelines specifically address pleural infection, not traumatic hemothorax 1
• Hemothorax lacks the DNA-rich inflammatory exudate that DNase targets, making the rationale for DNase questionable 3

Limited Evidence in Hemothorax

The available research on tPA ± DNase for retained hemothorax shows:

Retrospective Data Suggests No Benefit from Adding DNase:

• A 6-year trauma center study (50 patients) found no difference in treatment failure rates between tPA alone versus tPA + DNase for retained hemothorax 3
• DNase addition did not improve chest tube output, hemothorax reduction, or bleeding rates 3
• The study concluded DNase may be inappropriate for hemothorax 3

Small Case Series Show Variable Results:

• Some case reports describe successful use of tPA alone or tPA/DNase for retained hemothorax 4, 5
• However, these are low-quality evidence (case reports/small series) without controls 4, 5
• One study showed tPA alone appeared safe and efficacious without requiring DNase 5

Critical Safety Concern

Bleeding risk is a major concern when using tPA in hemothorax:

• Patient consent must be obtained due to potential bleeding complications 1, 2
• Reduced tPA doses should be considered in higher bleeding risk patients 1, 2
• Using fibrinolytics in a space already containing blood carries inherent risk of rebleeding

Appropriate Management of Retained Hemothorax

When chest tube drainage fails for hemothorax:

First-Line Approach:

• Ensure adequate chest tube size and positioning
• Consider image-guided drain placement if initial tube is malpositioned 5

Second-Line Options:

• Video-assisted thoracoscopic surgery (VATS) is the preferred surgical approach over thoracotomy 1
• VATS allows direct visualization, clot evacuation, and hemostasis confirmation
• Surgical consultation should occur if drainage remains inadequate 6

If Considering Fibrinolytics (Off-Label):

• tPA alone (without DNase) may be reasonable based on limited trauma data 3, 5
• Typical dosing in case series: 6-10 mg per treatment 3, 5
• This remains off-label use without guideline support

Common Pitfalls to Avoid

• Do not extrapolate empyema guidelines to hemothorax—the pathophysiology is fundamentally different 1
• Do not use DNase for hemothorax—there is no mechanistic rationale or evidence of benefit 3
• Do not delay surgical consultation if medical drainage fails—VATS is definitive treatment 1
• Do not confuse hemothorax with hemopneumothorax or infected hemothorax (empyema), which would require different management 6