E. Stirpe*a (Dr), J. Koehla (Dr)

a Unit of Respiratory Dieases, Bolzano Hospital, Bolzano, ITALY

* emanuele.stirpe@sabes.it

Background: Multiloculated pleural effusion or trapped lungs often occur in patients with malignant pleural effusions. These conditions limit the view during medical thoracoscopy (MT), making it difficult to perform pleural biopsies.

Clinical Case: in a 71-years old man with right complicated pleural effusion we observed a remarkable intrapleural fibrin deposition during MT. We attempted to breakdown mechanically the fibrin networks, but it was not possible to see the parietal pleura. Therefore, we reconstituted 100,000 IU urokinase in 50 mL of 0.9% saline solution and instilled into the pleural cavity using a syringe connected to the MADmagic® (Teleflex Medical, Morrisville, NC, US), normally used to instill local anesthetics on the laryngo-tracheal mucosa. The MADmagic® was passed with the thoracoscope through the trocar, making it possible to see in real time where the solution was directed. In the meanwhile, we checked the action of the urokinase under vision. After about 10 minutes, we observed that the network of septa had significantly decreased and that some portions of the parietal pleura were visible. No bleeding was observed. We then identified where to take pleural biopsies in different points in the parietal pleura. MT ended without any complications. The diagnosis was pleural localization of squamous lung cell carcinoma.

Conclusions: Our case shows that the direct instillation of intrapleural urokinase during thoracoscopy could expand the therapeutic capacity of the MT and fibrinolysis and expand the diagnostic capacity of MT. In addition, direct vision of the jet of solution containing fibrinolytic may further reduce the risk of bleeding in patients with malignant pleural effusions.


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  2. British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010 Aug;65 Suppl 2:ii54-60.
  3. Khemasuwan D et al. Chest. 2018 Sep;154(3):550-556.

Disclosure of funding source(s): none