Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Fibrinolytics for pleural infection in Australian practice

  Pleural infection ranges from an uncomplicated parapneumonic effusion to septated empyema with sepsis. It can progress quickly, and antibiotics alone do not provide source control when infected fluid remains in the pleural space. Decisions about drainage therefore drive both recovery and the risk of invasive treatment.

  Managing pleural infections with intrapleural fibrinolytics means instilling medicines through a chest drain to improve drainage. Alteplase breaks down fibrin, while dornase alfa digests DNA-rich material that makes infected pleural fluid thick and sticky. Used together, they may open loculations and reduce the need for thoracic surgery, but they complement rather than replace antibiotics and adequate drainage.

  The clinical questions are practical: which patients benefit, when should treatment begin, and how should a hospital manage bleeding risk and drug access? Geography adds another layer. Patients in metropolitan Melbourne, Sydney, Brisbane, Perth or Adelaide may have rapid access to respiratory, thoracic and radiology services, while clinicians in rural and remote Australia often manage the initial phase before transfer.

  APSR 2022, organised in connection with APSR and KATRD, brings these decisions into a respiratory medicine forum shared by physicians, surgeons, intensivists, microbiologists, pharmacists and nurses. The congress programme and invited-speaker discussions provide a valuable opportunity to compare approaches to pleural infection and translate them into safe local care.

  Comparing drainage and lysis strategies

  Pleural infection requires an ultrasound-guided assessment of fluid volume, loculation, drain position and the clinical picture. Microbiological sampling should occur where possible without delaying treatment. Pleural pH, glucose, lactate dehydrogenase and culture results help guide management, although no single laboratory result should override the need for drainage in a septic patient.

  Medical and surgical drainage should be viewed as a sequence rather than competing slogans. A patient may start with a drain, receive intrapleural treatment, and still require theatre if sepsis, fluid recurrence or organised infection persists. The aim is timely source control with the least invasive effective procedure.

  Approach	Typical role	Advantages	Limitations
  Chest-tube drainage with antibiotics	Initial source control for drainable infected fluid	Widely available; supports culture-directed treatment	May leave loculated collections unresolved
  Intrapleural alteplase and dornase alfa	Adjunct for loculated or persistent infection after drainage	Targets fibrin and fluid viscosity; may reduce surgical intervention	Bleeding risk, protocol variation and off-label use
  Surgical washout or decortication	Source control for failed drainage or organised empyema	Direct clearance and removal of infected tissue	Theatre access, anaesthesia and postoperative recovery

  How intrapleural fibrinolytics fit into care

  The strongest use is usually as an adjunct in a loculated or refractory pleural infection, once a drain has been placed and the team has confirmed that fluid can be drained. It is less useful for a tiny, freely mobile effusion or an organised, thick pleural peel requiring surgical assessment. A respiratory physician or thoracic surgeon should review patients with persistent sepsis despite appropriate antibiotics.

  The usual workflow is ultrasound-guided drain placement, collection of diagnostic specimens, instillation of the agreed medicines, temporary clamping, and reopening the drain under an institutional protocol. Drain output, blood loss, vital signs and respiratory status need close observation. Physiotherapy and mobilisation should accompany treatment when the patient is stable, because clearing loculations is only one part of restoring lung expansion.

  Timing matters. Repeated courses may be used when fluid remains infected or drainage is inadequate, but each episode needs reassessment. Persistent positive cultures, ongoing rigors, rising inflammatory markers or failure to improve should prompt a broader review of the drain, antibiotics, microbiology and need for surgery.

  Evidence, safety and patient selection

  Randomised evidence supports the combined approach in selected patients with pleural infection. The MIST2 trial reported improved pleural drainage and fewer surgical procedures with intrapleural alteplase plus dornase alfa than placebo, although the trial was not powered to establish a mortality benefit. Observational studies also associate treatment with fewer operations, but protocols and patient groups vary.

  Safety depends on careful selection. Review anticoagulants, thrombocytopenia, coagulopathy, recent surgery or trauma, and other bleeding risks before instillation. Active bleeding may preclude treatment. Drug preparation, doses, dwell time and clamping should follow a written, multidisciplinary protocol; they should not be improvised at the bedside.

  Documentation should make the next decision easier. Record the drain site, output and fluid characteristics, drugs and doses given, complications, culture results and the reason for any repeat treatment. A daily ward-round review allows clinicians to stop treatment when it is no longer helping and involve thoracic surgery early enough to avoid prolonged ineffective drainage.

  Building a reliable Australian hospital protocol

  Australia’s public hospital system, Medicare and the Medicare Benefits Schedule divide responsibility for admitted, outpatient and elective care, while private hospitals operate under their own clinical and funding arrangements. A protocol must fit local pharmacy pathways, microbiology services and theatre access. The language used on Australian medical units—intercostal drain, pleural aspirate and ward round—should be paired with plain instructions for patients and families.

  Geography is part of quality planning. In regional New South Wales, Queensland, Western Australia or the Northern Territory, a local team may stabilise a patient, obtain fluid cultures and insert a drain before retrieval through local services or the Royal Flying Doctor Service. Telehealth links can support this process, but transfer plans should be triggered early. For Aboriginal and Torres Strait Islander patients, decisions should include the local Aboriginal health service and the patient’s chosen family where appropriate.

  • Confirm with ultrasound that the collection is drainable and the drain is positioned correctly.
  • Send pleural fluid for Gram stain, culture and susceptibility testing, with blood cultures when sepsis is present.
  • Define eligible patients, bleeding exclusions, prescribing authority and review times in one protocol.
  • Specify pharmacy preparation, instillation, dwell time, clamping, drainage and complication checks.
  • Pair each treatment episode with nursing observations, physiotherapy and a documented surgical review trigger.
  • Audit drain-free days, surgery, complications, readmissions and outcomes by hospital and referral pathway.

  From congress discussion to bedside practice

  At APSR 2022, the focus should be shared decision-making across disciplines rather than advocacy for a single drug. Respiratory physicians can coordinate medical source control, thoracic surgeons can define when surgery is needed, microbiology colleagues can refine antibiotics, and nurses can make drain care and early warning signs consistent.

  The concrete next step is a 30-minute local pathway review in which the respiratory lead, thoracic surgeon, pharmacist, microbiologist and bedside nurse agree who approves intrapleural fibrinolytics, which bleeding exclusions apply, and where the protocol and emergency drug access will be held.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)