Comparative Analysis of Intrapleural Alteplase-Tyloxapol vs Intrapleural Alteplase-DNase in Pleural Infection (ALTON-PI)
Conditions: Pleural Infection
Sponsor: National University of Malaysia

1 
Comparative Analysis of Intrapleural Alteplase-Tyloxapol vs Intrapleural Alteplase-DNase in 
Pleural Infection (ALTON-PI) 
UNIVERSITI KEBANGSAAN MALAYSIA 
KUALA LUMPUR 
VERSION 1.0 
DATE : 1.1.2026
RESEARCH ID : FF 2026-033

2 
CONTENTS 
Pages 
CHAPTER 1 : INTRODUCTION        
3-4
CHAPTER 2: PROBLEM STATEMENT
4
CHAPTER 3 : RESEARCH OBJECTIVES & HYPOTHESIS         
5
CHAPTER 4 : METHODOLOGY
6-12
4.1 Study Design 
4.2 Study Population 
4.3 Sample Size and Power of Study 
4.4 Inclusion and Exclusion Criteria 
4.5 Recruitment/Data Collection 
4.6 Study Protocol /Flow Chart  
4.7 Statistical Analysis 
4.8 Estimated Cost of Study  
4.9 Research Ethics  
CHAPTER 5: GANTT CHART
 12 
CHAPTER 6: REFERENCES
13-14
APPENDIX 1   Drug Administration Protocol
15-22

3 
CHAPTER 1: INTRODUCTION 
Pneumonia, thought to be the chief aetiological process in the development of pleural space 
infection, is defined as an infection of the lung parenchyma with an estimated annual incidence rate of 
5–11 cases per 1000 population, with around 50,000 hospital admissions in the U.K. per year (1). 
Parapneumonic effusions caused by an infection of the pleural membranes occur in 40–57% of cases 
of pneumonia. A variable percentage (10–20%) of parapneumonic effusions progresses to empyema 
(pus) and/or abscess formation (encapsulation). Pleural infection is associated with significant 
morbidity and mortality, which may be as high as 20–35% in immunocompromised patients. (1) 
Standard treatment of these collections in adults involves antibiotic therapy, adequate 
drainage of infected fluid, and surgical intervention if conservative management fails. Appropriate 
treatment is adequate drainage via an intercostal catheter (ICC) with antibiotic therapy for 
parapneumonic effusions requiring clearance. Frequently, simple ICC drainage is ineffective due to 
the presence of loculations, formed predominantly by fibrinous material deposited in the 
fibrinopurulent phase of empyema, preventing free drainage of infected pleural fluid (2). The presence 
of fibrinous septae in the pleural space, known as loculations, may result in inadequate drainage of 
effusions and, therefore, nonresolution of infection and systemic sepsis. Surgical intervention (VATS 
or open) is usually required to clear loculations and resolve infection without adequate intercostal 
catheter drainage. 
Nonsurgical treatment options to reduce the impact of adhesions and loculi include (in 
addition to appropriate antibiotic therapy) single and multiple thoracocentesis, or single and multiple 
intercostal tube thoracostomies, with or without intrapleural fibrinolytic agents. Surgical options 
include direct vision and VATS adhesiolysis, limited and full thoracotomy with adhesiolysis, and 
decortication for severe pleural thickening (3). 
Although the success rate of surgical intervention remains high, the morbidity and mortality 
of both VATS and open thoracotomy are of concern, particularly in a cohort of patients who may be 
older and with significant comorbidity. Less invasive therapies, which promote pleural space drainage 
and effective resolution of pleural infection, are therefore likely to be of considerable clinical utility. 
Intrapleural fibrinolytic therapy (IPFT) in the management of complex parapneumonic 
effusions and thoracic empyema has been employed for over 50 years, with a mixture of agents 
including streptokinase/streptodornase, urokinase, alteplase, and a combination of streptodornase and 
alteplase (4-12).   These medications are administered into the pleural space via an ICC. 
Fibrinolytic agents, including streptokinase, urokinase, alteplase, and recombinant tissue 
plasminogen activator (rTPA), have been used safely and effectively intrapleurally for complicated 
pleural effusion and empyema (12-14). During the fibrinopurulent-purulent stage of empyema, there 
is an imbalance between fibrin activators and fibrin inhibitors, with elevated levels of plasminogen 
activator inhibitor (PAI-1) resulting from the presence of inflammation-induced tumour necrosis 
factor alpha, interleukin-8, and transforming growth factor beta, as well as lower levels of endogenous 
tissue plasminogen activator (tPA). This results in a profibrotic state, causing deposition of fibrin-
forming loculations within the infected pleural space. Fibrinolytic agents activate plasmin, lysing 
fibrinous septations, thereby improving pleural fluid drainage and clearing infection without surgical 
intervention. (15, 16) 

4 
 
 The MIST 2 trial has established intrapleural therapy as the mainstay of CPEE treatment, 
hence avoiding surgery and decreasing the length of hospitalization; however, little is known about 
the correct dosage needed for tPA and Dornase Alfa/Deoxyribonuclease (DNase) (8). Dose and 
duration of intrapleural therapy based on MIST 2 involve multiple dosing and can be time-consuming 
for health care providers(8, 17). Nevertheless, treatment of pleural infection with fibrinolytic therapy 
has been incorporated in the British Thoracic Society guideline 2023. (18)   
Another study in 2022 by Cheong et al. used a modified regimen of intrapleural alteplase 
16 mg t-PA with 5 mg DNase for three doses administered sequentially within 24 h. In this study, a 
modified regimen of t-PA and DNase offers an alternative therapeutic option for patients who are 
unfit or refuse surgical intervention but have persistent pleural infection (19). They have demonstrated 
similar treatment success comparable to other studies, as evidenced by improved pleural fluid 
drainage and reduced pleural opacity on day 7 chest x-ray, approximately 50% from the baseline (8, 
20, 21). The mechanism of action of t-PA and DNase in the pleural cavity remains unclear. Studies 
suggested that IPFT may trigger the monocyte chemoattractant protein 1 (MCP-1) pathway, which 
promotes pleural fluid formation and subsequently causes a therapeutic lavage effect that increases 
pleural fluid drainage(22).  
The respiratory unit in Hospital Canselor Tuanku Muhriz (HCTM) Universiti Kebangsaan 
Malaysia (UKM) has used intrapleural fibrinolysis therapy with varying doses since 2017. Tyloxapol 
was also explored in managing pleural infection, as DNase is not readily available in certain centres.       
 
Tyloxapol (Tacholiquin) is a synthetic mucolytic surfactant traditionally used to aid the 
clearance of bronchopulmonary secretions. (23) Unlike DNase, its intrapleural use for pleural 
infection is not established; to date, Provan et al. provide the only published report, describing 
intrapleural tyloxapol—used with chloramphenicol—for empyema. (24) Limited case-series 
experience with adjunctive saline irrigation appears promising but remains preliminary. (25) 
 
In 2024,  Mohamad Jailaini et al first reported cases on the combination of intrapleural saline 
irrigation and intrapleural tyloxapol as an alternative treatment for pleural infection, apart from 
parenteral antibiotics as the pillar of the treatment. These two cases were then referred to decortication. 
A good treatment outcome was shown in both cases upon follow-up, evidenced by clinical cure, 
biochemical recovery, and radiological improvement. (25) 
This study retrospectively compares outcomes between tPA(alteplase)+DNase and 
tPA+Tyloxapol across two centres. Given the scarce evidence in the literature, this study was 
conducted to support further the evidence on the safety and efficacy of IP tacholiquin as an alternative 
treatment for pleural infection. 
 
 
 
 
CHAPTER 2: PROBLEM STATEMENT 
 
Pleural infection carries substantial morbidity, and standard chest-tube drainage often fails due to 
septations and viscous pus. While intrapleural alteplase+DNase improves drainage, its cost, bleeding 
concerns, and availability limit universal adoption; alteplase combined with the surfactant-mucolytic 
tyloxapol (Tacholiquin) is increasingly used but supported only by small case series. Robust, real-
world head-to-head data comparing alteplase(t-PA)+DNase versus alteplase (t-PA)+tyloxapol are 

5 
lacking, prompting this two-centre retrospective study to evaluate their comparative effectiveness and 
safety. 
CHAPTER 3: RESEARCH OBJECTIVES & HYPOTHESIS 
3.1 Research Questions: 
•
Is there a difference in efficacy and safety between a combination of intrapleural alteplase (5
mg + tacholiquin, with intrapleural alteplase 5mg and DNase (Pulmozyme) 5mg in managing
pleural infection?
3.2 Primary Objective: 
•
To compare the reduction of pleural opacity (in percentage) on chest radiograph from baseline
(0-24 hours pre-intervention) to day 7 post-intervention between group A (alteplase + DNase)
and group B (alteplase + tacholiquin)
3.3 Secondary Objectives: 
•
To compare the absolute and percentage change in inflammatory markers (WBC/CRP) from
baseline (0-24 hours pre-intervention)  to day 7 between the two groups
•
To compare the volume of pleural effusion drainage (in mL) 72 hours following post-
intervention between the two groups
•
To compare the outcome between the two groups:
-
Length of hospital stay (in days) after the intervention for each group
-
The need for surgical intervention within 30 days
-
Adverse effects following alteplase/DNase and talteplase +Tacholiquin
-
Mortality rate at 30 days
3.4 Study Hypothesis 
•
The mean reduction in pleural opacity (%) from baseline (0–24 h pre-intervention) to day 7 is
the same in both groups.
•
The mean change in WBC/CRP from baseline to day 7 is the same in both groups.
•
The mean pleural effusion drainage volume in both groups over the first 72 hours post-
intervention is the same.
•
The mean length of hospital stay (days) post-intervention is the same in both groups.
•
The proportion requiring surgical intervention within 30 days is the same in both groups.
•
The proportion experiencing adverse effects is the same in both groups.
•
The 30-day mortality proportion is the same in both groups.

6 
 
 
 
 
 
 
CHAPTER 4: METHODOLOGY 
 
4.1  
Study Design 
Retrospective, observational cohort; on patients with pleural infection exposure defined by 
intrapleural regimen received (Alteplase+DNase vs Alteplase+Tyloxapol) DNase from June 2023 to 
June 2025 in HCTM UKM and University Malaya Medical Centre. 
 
4.2  
Study Population 
Adult patients with pleural infection (complex pleural effusion or empyema) with poor outflow (≤ 150 
cc) from chest drain after 24 Hours of insertion in medical and non-medical wards, HCTM UKM, and 
UMMC from June 2023 to June 2025. 
 
4.3  
Sample Size and Power of Study 
Following the guidance of the UH Bristol and Weston Clinical Audit Team (Version 5), a pragmatic 
snapshot sample of 40 cases for each arm was deemed sufficient to measure current practice against 
the pre-defined standard, prioritizing feasibility over formal statistical representativeness. 
 
Sampling Method 
All cases (universal sampling) that fulfill the inclusion criteria will be included from 2023 to 2025. 
 
 
4.4 
 Inclusion and Exclusion Criteria  
Inclusion Criteria 
1. Adult patient aged ≥ 18 years old 
2. Patients with pleural infection (complex parapneumonic effusion or empyema) with poor 
pleural fluid drainage of ≤ 150 ml after 24 hours of chest drain insertion received either t-PA-
DNAse or t-PA/Tyloxapol. 
3. Clinical features consistent with pleural infection; fulfilling ≥ 2 of the following 
characteristics: 
i) 
Clinical evidence of infection, such as fever and or elevated C-reactive protein (CRP) 
or total white blood count (TWBC) 
ii) 
Complex pleural effusion proven by thoracic ultrasound is defined as the presence of 
fibrin strands or septations within the pleural cavity 
iii) 
Pleural fluid that fulfils at least one of the characteristics:  

7 
 
• 
Frank Pus, 
• 
Exudative type of pleural effusion (according to light’s criteria) 
• 
Gram stain or culture positive 
• 
Lactate dehydrogenase (LDH) > 900U/L 
• 
Acidic with pH < 7.2  
• 
Glucose level < 3.3 mmol/L 
 
Exclusion criteria 
1. Incomplete data. 
2. Medical records that cannot be retrieved. 
 
4.5  
Recruitment/Data Collection 
 
Data sources: Electronic medical records, chest drain charts, medication/pharmacy logs, radiology 
PACS (for Day 0 and Day 7 CXR), ultrasound notes. 
 • Outcome assessment: Radiographic % opacity measured by two blinded readers using a 
standardized digital polygon/planimetry method; discrepancies resolved by consensus; drainage 
volume calculated net of any volume infused 
 
Medication Regimen: 
t-PA (Alteplase) 5mg and DNase (Pulmozyme) 5mg 
t-PA (Alteplase), which is available in our pharmacy, is 50mg per ampoule, and DNase (Pulmozyme) 
is 2.5mg per ampoule  
The number of intrapleural t-PA/DNase installations depends on the treating physician's discretion (at 
least 6 hours apart between doses). 5mg of alteplase (t-PA) and 5mg DNase are diluted in each 50ml 
of 0.9% sodium chloride solution. T-PA and DNase are not mixed in one syringe. The detailed 
method of t-PA/DNase therapy administration is described in Appendix 1. In brief, both medications 
are administered sequentially, with t-PA first instilled intrapleurally, and the chest tube is then 
clamped for 45 minutes, then unclamped to allow free drainage for 45 minutes. The same procedure is 
then repeated for DNase. Selection of the timing of treatment and removal of the chest tube depends 
on the chest physician’s judgment. 
Patients who received t-PA/Tyloxapol (Tacholiquin) will be given 5-10 mg alteplase + 200 mg 
Tyloxapol—the detailed method as described in Appendix 2.  
Both groups received standard care of treatment, which includes regular flushing of the chest drain to 
maintain patency using 20 mL of normal saline. 
The primary outcome was to evaluate the percentage reduction in ipsilateral pleural opacity on chest 
radiograph at Day 7 compared with baseline (preintervention), quantified as % hemithorax occupied 
by effusion. The area of pleural opacity and the location of the ipsilateral hemithorax will be 
measured digitally by two radiologists using Horos Project Software, v3.2.1, as described previously 
in Multicentre Intrapleural Sepsis Trial 2 (MIST-2). 

8 
 
The secondary outcomes are measuring net pleural fluid drainage within 72 hours post first 
intrapleural dose (mL), change in inflammatory markers (CRP, WBC) from baseline to Day 7, length 
of stay (days) from first intrapleural dose to discharge, and the need for surgical intervention 
(VATS/open decortication) within 30 days. Adverse events: pleural/systemic bleeding, Hb drop ≥10%, 
chest pain requiring escalation, hemoptysis, hemodynamic instability, and 30 day all cause mortality 
and readmission for pleural infection. 
 
Monitoring Parameters: 
a. TPA-Tacholiquin Group 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Parameter 
Day0 
Day1 
Day2 
Day3 
Day7 
Day30 
Investigations 
• 
Full blood count (FBC)  
o  WBC 
o Hemoglobin  
√ 
 
 
 
√ 
 
• 
C C-reactive protein (CRP)  
√ 
 
 
 
√ 
 
• 
Chest X-ray  
√ 
 
 
 
√ 
 
• 
Ultrasound Thorax 
√ 
√ 
√ 
√ 
 
 
Adverse effects  
• 
Chest pain requires 
escalation of analgesics.  
 
√ 
√ 
√ 
 
 
• 
Gastrointestinal bleed 
 
√ 
√ 
√ 
 
 
• 
Bleeding from the chest 
drain site 
 
√ 
√ 
√ 
 
 
• 
Intrapleural hemorrhage 
 
√ 
√ 
√ 
 
 
• 
Hemoptysis  
 
√ 
√ 
√ 
 
 
• 
Clinical deterioration – 
hypotension, dyspnea 
 
√ 
√ 
√ 
 
 
• 
Hb drop >10% requires 
transfusion of blood.  
 
√ 
√ 
√ 
 
 
• 
Death related to intrapleural 
saline irrigation. 
 
√ 
√ 
√ 
 
 
Others Outcome 
 
• 
Mortality 
 
 
 
 
 
 
• 
Surgical intervention 
 
 
 
 
 
 
Net volume of pleural fluid drained (ml) 
post pleural irrigation 
Baseline 
Day 1 
Day 2 
Day 3 
√ 
√ 
√ 
√ 
Cumulative pleural fluid drained post-
pleural irrigation. 
 
 
 
√ 

9 
 
 
 
b. Intrapleural fibrinolytic group  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Operational Definition:  
• 
Treatment success will be assessed at two predefined time points: day 7 and day 30. At day 7, 
success is defined as adequate pleural drainage post-intervention with resolution of septations on 
thoracic ultrasound, a reduction in chest radiograph opacity by more than 50%, and resolution of 
inflammatory markers. On day 30, success is defined as no surgical intervention.  
• 
Treatment failure:  
Parameter 
Day0 
Day1 
Day2 
Day3 
Day7 
Day30 
Investigations 
• 
Full blood count (FBC)  
o  WBC 
o Hemoglobin  
√ 
√ 
√ 
√ 
√ 
 
• 
C C-reactive protein (CRP)  
√ 
 
 
 
√ 
 
• 
Chest X-ray  
√ 
 
 
 
√ 
 
• 
Ultrasound Thorax 
√ 
√ 
√ 
√ 
 
 
Adverse effects  
• 
Chest pain requires 
escalation of analgesics.  
 
√ 
√ 
√ 
 
 
• 
Gastrointestinal bleed 
 
√ 
√ 
√ 
 
 
• 
Bleeding from the chest 
drain site 
 
√ 
√ 
√ 
 
 
• 
Intrapleural hemorrhage 
 
√ 
√ 
√ 
 
 
• 
Hemoptysis  
 
√ 
√ 
√ 
 
 
• 
Clinical deterioration – 
hypotension, dyspnea 
 
√ 
√ 
√ 
 
 
• 
Hb drop >10% requires 
transfusion of blood.  
 
√ 
√ 
√ 
 
 
• 
Death related to intrapleural 
therapy.  
 
√ 
√ 
√ 
 
 
Others Outcome 
 
 
 
• 
Mortality 
 
 
 
 
 
 
• 
Surgical intervention 
 
 
 
 
 
 
Net volume of pleural fluid drained (ml) 
post IPFT 
Baseline 
Day 1 
Day 2 
Day 3 
√ 
√ 
√ 
√ 
Cumulative pleural fluid drained post IPFT 
 
 
 
√ 

10 
 
o Poor drainage from chest drain, failure of resolution of pleural effusion or empyema, at 
least 50% reduction in opacity on chest x-ray, and clinical evidence of ongoing infection 
that requires surgical intervention within 30days post-intervention or death before 
discharge.  
 
   Data will be collected retrospectively by reviewing patient demographics, clinical data on length of 
hospital stay, pleural fluid analysis, intrapleural therapy, radiographic characteristics, and adverse 
events.  
 
 
 
4.6  
 
Study protocol /flow chart 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assessed for eligibility 
n= 
Recruited, n= 
Demographic data-age, gender, comorbidities 
t-PA-DNAse , n= 
 t-PA/Tyloxapol n= 
Excluded, n= 
Incomplete data, n= 
Medical records cannot be 
retrieved, n= 
Procedureal characteristics and 
outcomes  
Complications during and after 
procedure 
Procedureal characteristics and 
outcomes  
Complications during and after 
procedure 
Analysed, n= 
Missing data, n= 

11 
 
 
 
 
 
4.7  
Statistical Analysis   
• Descriptive statistics by arm; normality via Shapiro-Wilk. 
• Primary endpoint: two sample t- test (or Mann-Whitney U) on % reduction Day 7; report 
mean/median difference and 95% CI. Sensitivity analysis using ANCOVA, adjusting for baseline % 
opacity and matched/weighted cohorts. 
 • Secondary endpoints: 
✓ Net drainage 72h: t-test/Mann-Whitney; linear regression with adjustment. 
✓ Change in CRP/WBC Day7: t-test/Mann-Whitney. 
✓ LOS: Mann-Whitney; competing risk sensitivity if death before discharge. 
✓ Surgery within 30 days: chisquare/Fisher’s exact; logistic regression to adjust confounders; 
time to event via Kaplan-Meier and Cox model. 
 •   • Adverse events & 30-day mortality: chisquare/Fisher’s exact. 
 • Multiplicity: secondary outcomes interpreted as exploratory; p<0.05 (two sided) for primary 
endpoint. 
 
4.8  
Estimated cost of study 
Not applicable 
 
4.9 
 Research ethics 
Ethics: To be submitted to the UKM Research Ethics Committee and the UMMC MREC. 
Retrospective design with minimal risk; request for informed consent waiver and data use agreement; 
strict de-identification; secure storage on institutional servers. 
 
 
 
 
 
 
 
 
 
 

12 
 
 
 
 
 
CHAPTER 4: GANTT CHART 
Progression / 
Timeline 
July 2025- 
September 
2025 
November 
2025- 
December 
2025 
January 
2026-
December 
2026 
January 
2027- June 
2027 
July 2027-
December 
2027 
January 
2028-July 
2028 
Formulating a 
research title 
and literature 
review 
 
 
 
 
 
 
Proposal write-
up and editing. 
 
 
 
 
 
 
Proposal 
presentation and 
modification 
 
 
 
 
 
 
Proposal 
submission and 
ethics 
committee 
approval 
 
 
 
 
 
 
Commencement 
of study and 
data collection 
 
 
 
 
 
 
Data analysis 
 
 
 
 
 
 
Thesis write-up 
/ Dissertation 
preparation. 
 
 
 
 
 
 
Dissertation 
presentation and 
submission 
 
 
 
 
 
 
 
 
 
 

13 
 
 
 
 
 
 
CHAPTER 5: REFERENCES 
 
1. 
Committee BTSSoC. BTS guidelines for the management of community acquired pneumonia 
in adults. Thorax. 2001;56(Suppl 4):IV1-IV64. 
2. 
LeMense GP, Strange C, Sahn SA. Empyema thoracis: therapeutic management and outcome. 
Chest. 1995;107(6):1532-7. 
3. 
Scarci M, Abah U, Solli P, Page A, Waller D, Van Schil P, et al. EACTS expert consensus 
statement for surgical management of pleural empyema. European journal of cardio-thoracic 
surgery. 2015;48(5):642-53. 
4. 
Tillett WS, Sherry S, Read CT. The use of streptokinase-streptodornase in the treatment of 
postpneumonic empyema. Journal of Thoracic Surgery. 1951;21(3):275-97. 
5. 
Davies R, Traill ZC, Gleeson FV. Randomised controlled trial of intrapleural streptokinase in 
community acquired pleural infection. Thorax. 1997;52(5):416-21. 
6. 
Diacon AH, Theron J, Schuurmans MM, Van de Wal BW, Bolliger CT. Intrapleural 
streptokinase for empyema and complicated parapneumonic effusions. American journal of 
respiratory and critical care medicine. 2004;170(1):49-53. 
7. 
Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R, et al. UK Controlled trial of 
intrapleural streptokinase for pleural infection. New England Journal of Medicine. 2005;352(9):865-
74. 
8. 
Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, et al. Intrapleural use of 
tissue plasminogen activator and DNase in pleural infection. New England Journal of Medicine. 
2011;365(6):518-26. 
9. 
Bouros D, Schiza S, Tzanakis N, Chalkiadakis G, Drositis J, Siafakas N. Intrapleural urokinase 
versus normal saline in the treatment of complicated parapneumonic effusions and empyema: a 
randomized, double-blind study. American Journal of Respiratory and Critical Care Medicine. 
1999;159(1):37-42. 
10. 
Thommi G, Shehan J, Robison K, Christensen M, Backemeyer L, McLeay M. A double blind 
randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of 
alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions. 
Respiratory medicine. 2012;106(5):716-23. 
11. 
Idell S. Update on the use of fibrinolysins in pleural disease. Clinical Pulmonary Medicine. 
2005;12(3):184-90. 
12. 
Thommi G, Shehan C, Bell A, Coughlin N, McLeay M. Intrapleural instillation of TPA in the 
management of complicated pleural effusions. Chest. 2000;118(4):164S-S. 
13. 
Walker CA, Shirk MB, Tschampel MM, Visconti JA. Intrapleural alteplase in a patient with 
complicated pleural effusion. Annals of Pharmacotherapy. 2003;37(3):376-9. 
14. 
Idell S, Fair S. Abnormalities of Pathways of Fibrin Turnover in the Human Pleural Space1-3. 
Am Rev Respir Dis. 1991;144:187-94. 
15. 
Chung C-L, Chen C-H, Sheu J-R, Chen Y-C, Chang S-C. Proinflammatory cytokines, 
transforming growth factor-β1, and fibrinolytic enzymes in loculated and free-flowing pleural 
exudates. Chest. 2005;128(2):690-7. 

14 
 
16. 
Komissarov AA, Idell S. PAI-1 drives septation and clinical outcomes in pleural infection. 
American Thoracic Society; 2023. p. 653-5. 
17. 
Majid A, Kheir F, Folch A, Fernandez-Bussy S, Chatterji S, Maskey A, et al. Concurrent 
intrapleural instillation of tissue plasminogen activator and DNase for pleural infection. A single-
center experience. Annals of the American Thoracic Society. 2016;13(9):1512-8. 
18. 
Roberts ME, Rahman NM, Maskell NA, Bibby AC, Blyth KG, Corcoran JP, et al. British thoracic 
society guideline for pleural disease. Thorax. 2023;78(Suppl 3):s1-s42. 
19. 
Cheong XK, Ban AY-L, Ng BH, Nik Abeed NN, Nik Ismail NA, Nik Fuad NF, et al. Modified 
regimen intrapleural alteplase with pulmozyme in pleural infection management: a tertiary teaching 
hospital experience. BMC Pulmonary Medicine. 2022;22(1):199. 
20. 
Piccolo F, Pitman N, Bhatnagar R, Popowicz N, Smith NA, Brockway B, et al. Intrapleural 
tissue plasminogen activator and deoxyribonuclease for pleural infection. An effective and safe 
alternative to surgery. Annals of the American Thoracic Society. 2014;11(9):1419-25. 
21. 
Mehta HJ, Biswas A, Penley AM, Cope J, Barnes M, Jantz MA. Management of intrapleural 
sepsis with once daily use of tissue plasminogen activator and deoxyribonuclease. Respiration. 
2016;91(2):101-6. 
22. 
Lansley SM, Cheah HM, Varano della Vergiliana JF, Chakera A, Lee YG. Tissue plasminogen 
activator potently stimulates pleural effusion via a monocyte chemotactic protein-1–dependent 
mechanism. American Journal of Respiratory Cell and Molecular Biology. 2015;53(1):105-12. 
23. 
(MD) IB. National Library of Medicine (US), National Centre for Biotechnology Information; 
2004-. PubChem Compound Summary for, Tyloxapol; [cited 2024 June 21] Available from: 
https://pubchemncbinlmnihgov/compound/Tyloxapol. 
24. 
Provan J. The management of postpneumonectomy empyema. The Journal of Thoracic and 
Cardiovascular Surgery. 1971;61(1):107-9. 
25. 
Mohamad Jailaini MF, Saini NA, Che Rahim MJ, Abdul Hamid MF. A potential prospect: The 
novel treatment of intrapleural saline irrigation with intrapleural tyloxapol in treating thoracic 
empyema. Respirol Case Rep. 2024;12(8):e70000. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

15 
 
 
 
 
 
 
 
 
APPENDIX 1 : 
 
 
DRUG ADMINISTRATION OF INTRAPLEURAL t-PA (ALTEPLASE) & DNase 
(PULMOZYME) 
 
 
Drugs dosage   
Intrapleural t-PA 5mg per dose 
Intrapleural DNase 5mg (2 ampoules of 2.5mg) per dose 
at least 6 hrs apart 
Timing of administration: 8-9 am, 4-5 pm & next day, 8-9 am.  
Patient undergoing 
hemodialysis 
No dosage adjustment provided. Suggest heparin-free dialysis while receiving t-PA and 
DNase. 
Patient on 
anticoagulant  
 
No standard guideline. Physician to assess patient‘s thrombotic risk & bleeding risk 
and decide if need to withhold anticoagulant. 
 
Elimination half-life 
Warfarin 
20-60 hours 
Rivaroxaban 5-9 hrs; Elderly: 11-13 hrs; renal impairment: 8.7-9.5 hrs; hepatic 
impairment: 10.1-10.4 hrs) 
Apixaban 
~12 hrs (8-15 hrs) 
Dabigatran 
12 -17 hrs; Elderly: 14-17 hrs; Mild-to-moderate renal impairment: 
15-18 hrs; Severe renal impairment: 28 hrs 
 
 
MATERIAL REQUIREMENT:  
1. 
Drugs as prescribed 
2. 
Dressing pack 
3. 
Sterile gloves 
4. 
Povidone iodine 10% or Chlorhexidine in 70% alcohol or alcohol swab 
5. 
2 x 50ml leur lock syringes (for Alteplase & Pulmozyme) 
6. 
2 x 10ml syringes (to flush) 
7. 
2 x Blunt-ended drawing up needles 
8. 
0.9% NaCl total 750ml 
9. 
3-way tap connector  
10. 
Rubbish bag 
11. 
Dressing trolley 
 
 
 
 
1. PREPARATION CHART  t-PA (ALTEPLASE)/ACTILYSE®:  
A) Reconstitution  
1) Wipe the top of the vial with a 60-70% alcohol swab. 
2) Insert cannula into Sterile Water Vial (provided in the box).  
 

16 
 
3) Empty water into Actilyse® 50mg Vial. 
 
 
 
 
4) Mix by gentle swirling/ slow inversion. DO NOT shake. Allow to stand if foam is present. 
Final concentration = 1mg/mL (50mL). 
 
 
 
 
 
 
     
B) Administration 
STEP 1 
Syringe out dose required (eg, if 16 mg = 16 ml) 
 
 
 
 
 
Reconstituted Alteplase solution 
         
50mL Syringe 
                        1mg/mL (50mL) 
 
 
STEP 2 
 
 
 
 
 
2. PREPARATION CHART – DNase  (PULMOZYME)_: 
▪ 
DNase (Pulmozyme) must be stored in the refrigerator at 2-8ºC and protected from light 
& heat.  
▪ 
Do not use the medicine if it has been at room temperature for more than 24 hours. 
▪ 
The solution should be discarded if it is cloudy or discoloured. 
▪ 
DNase (Pulmozyme) contains no preservative; the entire ampoule must be used or 
discarded once opened. 
 
a) Open the foil pouch and remove only two ampoules (2x2.5mg=5mg) of DNase (Pulmozyme) 
from its pouch each time before instillation. Keep the other ampoules back in the fridge.  
 
 
 
 
 
 
Wrap the balance Alteplase solution with parafilm, label the date 
and time opened, and keep in the fridge. (stable for 24 hours)  
Further dilute with 
normal saline up 
to a final volume 
of 50ml 

17 
 
b) Hold the tab at the base of the ampoule of DNase (Pulmozyme) firmly, taking care not to 
squeeze the body of the ampoule, and twist off the top. 
 
 
 
c) Syringe out the full dose of the drug from 2 ampoules of DNase (Pulmozyme) (2 x 2.5ml) 
until the ampoule is empty.  
 
 
 
 
 
 
 
 
 
 
d) Wrap the 50ml syringe with diluted DNase (Pulmozyme) with parafilm, 
label the date and time of preparation. Do not use the medicine if it has 
been at room temperature for more than 24 hours. 
 
 
PROCEDURE OF INSTILLATION OF t-PA/DNase 
 
1. Premedication (Tramadol) for pain relief before each dose. Medication to be given at least 20 
minutes before the procedure. 
2. Draw up Alteplase & DNase as prescribed (Refer to Sections 6 & 7 of the protocol).  
Prepare 2 x 10ml 0.9% NaCl in syringes for flushing purposes.  
3. Check all connections are secure. 
4. Uncap the outer port.  
5. Clean the port thoroughly with Chlorhexidine, Povidone iodine 10% or alcohol swab.  
6. Turn the 3-way tap to the off position. 
7. Attach the 10cc syringe filled with NS to the outer port and turn the three-way tap towards the 
chest. 
8. Flush the drain with 5 mL NaCl (pre-Alteplase) to check patency. 
9. Turn the three-way tap to the off position on the chest. 
10. Attach a 50cc syringe containing diluted alteplase, turn back the three-way tap towards the 
chest, and inject slowly within 1-2 minutes. 
11. Disconnect and flush with 5ml NaCl towards the chest (post-Alteplase). 
12. After flushing, keep the 3-way tap turned off to the chest and clamp for 45 minutes.  
13. Attach a new bung to the outer port. 
14. After clamping, open the 3-way tap to drain towards the bottle for 45 minutes, and record 
drainage before the second instillation.  
15. After 45 minutes of drainage, repeat the process with DNase (Pulmozyme). Flush the drain 
with 5 ml NS (pre-Pulmozyme). 
16. Turn the 3-way tap to the off position. 
Turn the ampoule upside down and 
gently squeeze.  
 
 
Syringe the contents from 2 
ampoules (2x 2.5ml=5ml =5mg) 
into the syringe. 
 
50mL 
Syringe 
Further dilute with 
normal saline to a final 
volume of 50ml 
 

18 
 
17. Attach a 50cc syringe containing diluted DNase (Pulmozyme), turn back the 3-way tap 
towards the chest, and inject slowly within 1-2 minutes. Followed by a 5ml NS flush (post-
Pulmozyme). 
18. After flushing, keep the 3-way tap turned off to the chest.  
19. After 45 minutes of clamping, open the 3-way tap to drain towards the bottle and record the 
drainage until the next instillation.  
 
 
 
OBSERVATION AFTER ADMINISTRATION OF t-PA (ALTEPLASE) & DNase 
(PULMOZYME) 
 
1. 
Observe the patient for: 
a. deterioration in clinical condition 
b. tension pneumothorax 
c. hemorrhage from the site or excessive drainage (in excess of 1L per hour) in the 
drainage bottle 
 
2. 
Monitor for:  
a. Bedside ultrasound of thorax (by chest physician) daily with curvelinear probe 
(ultrasound Mindray, model Z5) by measuring the maximum distances between the 
parietal and visceral pleura. 
b. Serial chest x-ray (baseline x-ray, day 7 post t-PA/DNase and pleural irrigation) 
c. Serum CRP level (baseline, day 7 post t-PA/DNase and pleural irrigation) 
d. FBC (baseline, day 1- 3, day 7 post t-PA/DNase and pleural irrigation). A drop of 
hemoglobin by less than 10% from baseline is acceptable. 
e. Systemic bleeding/ Pleural bleeding 
f. Drainage of pleural effusion daily  
3. 
Stop the t-PA & DNase if there is a significant drop in haemoglobin (>10% drop in Hb) with 
clinical signs of shock or significant haemorrhagic fluids drained. Consider CTA and blood 
transfusion in those cases.