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, ...

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 th...