Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial

• Published in: Chest Vol. 161; no. 3; pp. 710 - 727
• Main Authors: Barrett, Christopher D, Moore, Hunter B, Moore, Ernest E, Wang, Janice, Hajizadeh, Negin, Biffl, Walter L, Lottenberg, Lawrence, Patel, Purvesh R, Truitt, Michael S, McIntyre, Jr, Robert C, Bull, Todd M, Ammons, Lee Anne, Ghasabyan, Arsen, Chandler, James, Douglas, Ivor S, Schmidt, Eric P, Moore, Peter K, Wright, Franklin L, Ramdeo, Ramona, Borrego, Robert, Rueda, Mario, Dhupa, Achal, McCaul, D Scott, Dandan, Tala, Sarkar, Pralay K, Khan, Benazir, Sreevidya, Coimbatore, McDaniel, Conner, Grossman Verner, Heather M, Pearcy, Christopher, Anez-Bustillos, Lorenzo, Baedorf-Kassis, Elias N, Jhunjhunwala, Rashi, Shaefi, Shahzad, Capers, Krystal, Banner-Goodspeed, Valerie, Talmor, Daniel S, Sauaia, Angela, Yaffe, Michael B
• Format: Journal Article
• Language: English
• Published: United States American College of Chest Physicians. Published by Elsevier Inc 01.03.2022
• Subjects: Adolescent; Adult; Aged; COVID-19 - blood; COVID-19 - complications; COVID-19 - epidemiology; Critical Care: Original Research; Cross-Sectional Studies; Female; Fibrinolytic Agents - administration & dosage; Follow-Up Studies; Humans; Male; Middle Aged; Pandemics; Partial Thromboplastin Time; Respiratory Insufficiency - blood; Respiratory Insufficiency - drug therapy; Respiratory Insufficiency - etiology; Retrospective Studies; SARS-CoV-2; Thrombosis - blood; Thrombosis - complications; Thrombosis - drug therapy; Tissue Plasminogen Activator - administration & dosage; Treatment Outcome; Young Adult; COVID-19; fibrinolysis; tissue plasminogen activator (tPA); pulmonary failure; ARDS
• ISSN: 1931-3543; 0012-3692; 1931-3543
• DOI: 10.1016/j.chest.2021.09.024

Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients. Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe? Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao to Fio ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao to Fio ratio improvement of > 50% or Pao to Fio ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality. Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao to Fio ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao to Fio ratio at 48 h (16.9% control [interquartile range (IQR), -8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit. The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality. ClinicalTrials.gov; No.: NCT04357730; URL: www. gov.