North Texas Research Forum 2024



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North Texas


Medical City Weatherford


Internal Medicine

Document Type


Publication Date



hemoptsis, tPA, congestive heart failure


Internal Medicine | Medicine and Health Sciences


Introduction: Congestive heart failure is a morbid condition with a myriad of pathologic sequelae. Recurrent accumulations of fluid in the pleural space serve as a nidus for infection. The combination of CHF-induced pleural effusions and concomitant pneumonia are a recipe for disaster as bacteria can translocate to form parapneumonic effusions with empyemas as potential complications. Empyemas are one of many etiologies of exudative pleural effusions and are treated with complete drainage of the infected pleural fluid; however, loculations create a barrier for thoracostomy drainage. Since the MIST2 trial in 2011, intrapleural alteplase and dornase alfa have been utilized as fibrinolytic therapy to break up loculations for aid in drainage of loculated parapneumonic effusions. Here we present a case of immediate hemoptysis after intrapleural fibrinolytic therapy. Case presentation: A 56-year-old female with history of CHF, COPD, and recurrent pleural effusions s/p Pleurx catheter placement presented for evaluation of dyspnea and was found to have recurrent pleural effusion. Her effusion was initially managed with chest tube insertion but CT of the chest showed a loculated effusion and intrapleural fibrinolytic therapy was instilled. Immediately after her second dose, she had hemoptysis of 50 to 75 cc of bright red blood. She required transfer for cardiothoracic surgery with thoracotomy and decortication and was ultimately diagnosed with an empyema. Discussion: Hemoptysis and intrapleural hemorrhage are 2 serious adverse events that are associated with intrapleural fibrinolytic therapy. Intrapleural hemorrhage is a more common adverse event than hemoptysis with an occurrence rate of 4.2% in the MIST2 trial. A proposed solution to this adverse event is decreasing the instilled alteplase dose which has been trialed in the ADAPT and ADAPT-2 trials utilizing an alteplase dose of 5 mg and 2.5 mg respectively. The ADAPT and ADAPT-2 trials showed a 93.4% and 88.4% success rate with a pleural bleeding event rate of 4.9% and 2.9% respectively. Intrapleural fibrinolytic therapy is an important therapeutic modality to prevent thoracic surgery and may be the only option in patients who are not surgical candidates. Current studies for evaluation of other tissue plasminogen activators are underway and optimal medication and dosing of intrapleural fibrinolytics are important future studies to investigate.

Original Publisher

HCA Healthcare Graduate Medical Education

Stop That Bloody Cough: A Case of Hemoptysis After Intrapleural tPA Administration



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