What guides your decision whether to complete a full course of intrapleural alteplase-dornase versus proceeding to surgical decortication when a patient continues to worsen or does not adequately improve with intrapleural therapy?

This decision is typically individualized, based on the patient's clinical trajectory and radiographic findings. My practice is to initiate treatment with a lower dose of tPA, as supported by current literature. If the patient does not demonstrate an adequate response within the first 1 to 2 doses, I escalate to a higher dose. However, if radiographic evidence of inadequate response after 1 to 2 doses of 10 mg tPA/5 mg DNase, I generally advocate for surgical intervention, but continue with lyti...

Based on the MIST trials (Maskell et al., PMID 15745977, Rahman et al., PMID 21830966, and Bedawe et al., PMID 37820359), I typically complete a three-day course of intrapleural therapy before proceeding to surgical decortication. It's only three days, and the decision to proceed to surgery after that is based on chest tube output, follow-up imaging to see if there is residual fluid in the chest that requires drainage, and the patient's clinical response, including temperature, other vital signs...