Management Of Complicated Parapneumonic Effusions Research Articles

Management of complicated parapneumonic effusions.

Approximately 36-57% of cases of pneumonia are associated with a parapneumonic effusion (PPE). It begins as sterile effusion, which can quickly evolve to a fibrinopurulent stage with evidence of infection called complicated parapneumonic effusions (CPPE). Marked fibrinous organization then follows. This study focuses on literature synthesis on management of CPPE. Ultrasound has become an indispensable tool in the identification and treatment of CPPE. Prompt antibiotic administration remains the universal standard of care. Decision to drain the fluid is based on fluid staging, characterization and assessment of risk of poor outcomes vs. risk of complications. There is growing evidence to support use of intrapleural fibrinolytic therapy (IPFT) in case of loculated effusions. Newer areas of research include antibodies against plasminogen activator inhibitors and stratification scores that can identify patients at an increased risk. Lastly, timing of surgical referral is an important area under study. Evolution of medical therapy over recent years has increased treatment success rates. Use of IPFT in conjunction to thoracostomy is now the standard of care for loculated effusions. Understanding available therapeutic options, both medical and interventional, can ensure evidence-based practice and improve patient-centred outcomes.

Comparison of Clinical Efficacy between Alteplase 0.1 mg/kg and 4 mg for Complicated Parapneumonic Effusion in Children

Background: Intrapleural alteplase for the treatment of complicated parapneumonic effusion has been shown to reduce the surgical rate, duration of hospitalization, and time to defervescence, and improve pleural fluid drainage. However, there are various regimens of alteplase administration. Objective: To compare the efficacy and safety between intrapleural alteplase 0.1 mg/kg and 4 mg in the management of complicated parapneumonic effusion. Materials and Methods: An observational historical cohort study was conducted in patients aged between three months and 15 years diagnosed with complicated parapneumonic effusion or empyema thoracis. The patients were divided into two groups. The first group was patients enrolled between January 2012 and December 2019 and receiving alteplase 4 mg/dose. The second group was patients were enrolled between April 2020 and March 2021 and receiving alteplase 0.1 mg/kg/dose with a maximum of 4 mg. Intrapleural alteplase was given once a day for three consecutive days. Baseline characteristic, clinical outcome, adverse effect, and treatment costs were recorded. The data were statistically analyzed. Results: Thirty patients were enrolled with 20 in the 4 mg group and 10 in the 0.1 mg/kg group. There were no significant differences between the two groups with regards to treatment success rate, time to defervescence, and total pleural fluid drainage. One patient in the 0.1 mg/kg group required surgical treatment. Patients in the 0.1 mg/kg group had significantly shorter duration of hospitalization at 10 versus 13 days (p=0.03) and lower costs of treatment compared with the 4 mg group at 15,388.50 versus 22,214.75 Baht (p=0.03). Intrapleural bleeding was found in one patient in the 4 mg/dose group. Conclusion: Intrapleural alteplase in the dose of 0.1 mg/kg and that of 4 mg have good clinical efficacy for treatment of complicated parapneumonic effusion. The 0.1 mg/kg group is safe and associated with lower cost of treatment, and shorter hospital stays. Keywords: Intrapleural alteplase; Tissue plasminogen activator; Complicated parapneumonic effusion

Percutaneous management of complicated parapneumonic effusion and empyema after surgical tube thoracostomy failure in children: a retrospective study

We aimed to evaluate the results of percutaneous management of complicated parapneumonic effusions (PPE) and empyema after surgical tube thoracostomy failure in children. A total of 84 children treated percutaneously after surgical tube thoracostomy failure between 2004 and 2019 were included to this retrospective study. Technical success was defined as appropriate placement of the drainage catheter. Clinical success was defined as complete resolution of infection both clinically and radiologically. Management protocol included imaging-guided pigtail catheter insertion, fibrinolytic therapy, serial ultrasonographic evaluation, catheter manipulations as necessary (revision, exchange, or upsizing), and appropriate antibiotherapy. All patients were followed up at least 6 months. Technical success rate was 100%. Unilateral single, unilateral double, and bilateral catheter insertions were performed in 73, 9, and 2 patients, respectively. Inserted catheter sizes ranged from 8 F to 16 F. Streptokinase, urokinase, and tissue plasminogen activator were used as fibrinolytic agent in 29 (34%), 14 (17%), and 41 (49%) patients, respectively. In order to maintain effective drainage, 42 additional procedures (catheter exchange, revision, reposition, or additional catheter placement) were performed in 20 patients (24%). Clinical success was achieved in 83 of 84 patients (99%). Median catheter duration was 8 days (4-32 days). Median hospital stay during percutaneous management was 11.5 days (7-45 days). Factors affecting the median catheter duration were the presence of necrotizing pneumonia (p < 0.001) and bronchopleural fistulae (p < 0.001). Percutaneous imaging-guided catheterization with fibrinolytic therapy should be the method of choice in pediatric complicated PPE and empyema patients with surgical tube thoracostomy failure. Percutaneous treatment is useful in avoiding more aggressive surgical options.

Dual intracavitary therapy for pleural infections: leaving reluctance behind

Intrapleural tPA/DNase therapy is cost-effective for the management of complicated parapneumonic effusions and empyemashttp://bit.ly/2Lv0Kg9

Real-time ultrasound-guided pigtail catheter chest drain for complicated parapneumonic effusion and empyema in children \u2013 16-year, single-centre experience of radiologically placed drains

BackgroundChest tube drainage with fibrinolytics is a cost-effective treatment option for parapneumonic effusion and empyema in children. Although the additional use of ultrasound (US) guidance is recommended, this is rarely performed in real time to direct drain insertion.ObjectiveTo evaluate the effectiveness and safety of real-time US-guided, radiologically placed chest drains at a tertiary university hospital.Materials and methodsThis was a retrospective review over a 16-year period of all children with parapneumonic effusion or empyema undergoing percutaneous US-guided drainage at our centre.ResultsThree hundred and three drains were placed in 285 patients. Treatment was successful in 93% of patients after a single drain (98.2% success with 2 or 3 drains). Five children had peri-insertion complications, but none was significant. The success rate improved with experience. Although five patients required surgical intervention, all children treated since 2012 were successfully treated with single-tube drainage only and none has required surgery.ConclusionOur technique for inserting small-bore (≤8.5 F) catheter drains under US guidance is effective and appears to be a safe procedure for first-line management of complicated parapneumonic effusion and empyema.

Repeated therapeutic thoracentesis to manage complicated parapneumonic effusions.

In complicated parapneumonic effusion (CPPE), antibiotics and evacuation of the infected pleural fluid are mandatory. The first-line evacuation treatment is still controversial. The aim of this article is to highlight the usefulness of repeated therapeutic thoracentesis (RTT) as a first-line treatment. In the most recent study on RTT in CPPE, disposable pleural needles were used and the median number of thoracentesis was 3. The success rate was 81%, and only 4% of the patients were referred for thoracic surgery. The 1-year survival rate was 88%. On multivariate analysis, the observation of microorganisms in the pleural fluid after Gram staining and first thoracentesis volume at least 450 ml was associated with a higher risk of RTT failure. RTT is less invasive and can target different loculated pleural collections. Patients are less confined to beds between each procedure, and could even be ambulatory managed. The use of intrapleural fibrinolytics in association with DNase could most likely enhance the efficacy of RTT. RTT is efficient and well tolerated in the management of CPPE, including pleural empyema, and could be proposed as a first-line therapy for CPPE. This technique could be used in association with intrapleural fibrinolytics and DNase.

Prise en charge des épanchements parapneumoniques compliqués : état des lieux des pratiques en France

There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for this condition. A questionnaire was sent by email to the 1500members of the Société de Pneumologie de Langue Française (SPLF) between 15thNovember and 15thDecember2012. There were 92responders, i.e. a response rate of 6%. Of these, 87physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous. The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.

Iterative Thoracentesis as First-Line Treatment of Complicated Parapneumonic Effusion

RationaleOptimal management of complicated parapneumonic effusions (CPPE) remains controversial.Objectivesto assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital.MethodsPatients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death.ResultsSeventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44–40.67] and 6.97 [95% CI, 1.86–26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed.ConclusionsAlthough not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness.

Diagnostic utility of soluble triggering receptor expression on myeloid cells-1 in complicated parapneumonic pleural effusion

BackgroundThe differentiation between complicated parapneumonic effusions (CPPE) or empyema, which require chest tube drainage, and uncomplicated parapneumonic effusions (UCPPE), which respond to antibiotic therapy alone, is sometimes unclear. Delay in diagnosis results in substantial delay in the commencement of treatment and may contribute to the high mortality of this infection. The aim of the studyEvaluation of the utility of soluble triggering receptor expression on myeloid cells-1 (sTREM-1) as an early marker in the diagnosis and management of complicated parapneumonic effusions and empyema. Patients and methodsThis study included 58 patients who were diagnosed as having PPE and admitted to the Chest Department, Zagazig University Hospitals during the period from March 2012 to March 2013. Patients were diagnosed PPE if they had a pleural effusion and showed one or more clinical manifestations typical of pneumonia, including acute febrile illness, sputum production, chest pain, leukocytosis and infiltrate(s) on chest X-ray. They were divided into two groups. Group (1)Complicated parapneumonic effusion (22 patients), according to at least one of the following criteria on pleural fluid examination: macroscopic pus, presence of organisms on Gram-stain or culture, fluid pH<7.2 with normal peripheral blood pH, or fluid glucose concentrations <40mg/dL. Group (2)Uncomplicated parapneumonic effusion (36 patients), according to the following criteria: pleural effusion associated with a non purulent pleural fluid, negative fluid microbiological studies; fluid pH>7.2 with normal peripheral blood pH and fluid glucose >40mg/dL. Exclusion criteriaA history of pleural disease or any underlying disease that could potentially cause pleural effusions, such as tuberculosis, malignancy, heart failure, systemic lupus erythematosus and chronic renal failure, were excluded. Pleural fluid samples were examined for level of sTREM-1, pH, LDH and glucose. The sTREM-1 levels were expressed as pg/mL. Microbiological studies included: Gram and Ziehl–Neelsen stains and cultures on conventional media for aerobic and anaerobic micro-organisms in the pleural fluid samples. ResultsThe median sTREM-1 level in pleural fluid was significantly higher in the bacterial PPE (688±398pg/mL) than in the non-bacterial PPE (45±79pg/mL). The cut-off value of pleural fluid sTREM-1 for diagnosis of bacterial PPE was 130pg/mL with 93% sensitivity and 92% specificity, while it was 7.237 for pleural fluid pH with 91% sensitivity and 96% specificity and 640mg/L for pleural fluid glucose with 92% sensitivity and 86% specificity and 800IU/L for pleural fluid LDH with 81% sensitivity and 90% specificity. In conclusionCombination of classical criteria with pleural fluid sTREM-1 could be useful in discrimination between nonpurulent complicated and non complicated parapneumonic pleural effusions and hence early pleural drainage in patients with complicated parapneumonic effusions which may affect disease outcome.

Intrapleural hemorrhage due to alteplase use in a 6-year-old boy with pleural effusion

BackgroundIntrapleural fibrinolytics have been used successfully worldwide for the management of complicated pleural effusions and empyema. Bleeding complications are usually mentioned as rare side effects, but there is no clear information in the literature addressing the alarming outcome that might result following the use of alteplase as a fibrinolytic in the management of complicated parapneumonic effusions. We present a rare, if not unique, case of intrapleural hemorrhage requiring transfusion after alteplase use as a fibrinolytic in a 6-year-old male with complicated parapneumonic effusion.MethodsA search of the PubMed database was carried out, using a combination of the following terms: alteplase, fibrinolytic, intrapleural hemorrhage, and side effects.ResultsThe majority of studies found in the search concentrated on the efficacy of intrapleural fibrinolytics in the management of pleural effusion, but very few of the reports addressed the bleeding complications which may be caused by the treatment.ConclusionAlthough intrapleural and systemic hemorrhage are rare side effects of intrapleural fibrinolytic use, the health care provider must be watchful for these potentially life-threatening complications. Further studies are needed to understand not only the efficacy of fibrinolytics but also their safety, especially in children.

Intrapleural streptokinase for the treatment of complicated parapneumonic effusion and empyema in 2 newborns

The management of complicated parapneumonic effusions by conventional first-line treatment with closed intercostal tube drainage and antibiotic therapy may fail because of thick viscous fluid and multiple pleural space loculations. Intrapleural fibrinolytic treatment is a non-invasive therapeutic option. In this report, we present successful use of intrapleural streptokinase for complicated parapneumonic effusion and empyema in 2 newborns. Intrapleural fibrinolytic therapy with streptokinase appears to be a safe and effective adjunctive therapy of choice and may have significant benefit even in newborns with complicated parapneumonic effusion and empyema, and thus, it can obviate surgical intervention.

Management of complicated parapneumonic effusion and empyema using different treatment modalities

To evaluate the efficacy of the 3 treatment modalities (intrapleural instillation of streptokinase, video-assisted thoracoscopic surgery, thoracotomy and decortication) in the management of complicated parapneumonic effusion and empyema, a prospective study was conducted between January 2008 and June 2010. The 69 patients (52 men and 17 women, aged 18-50 years) were divided into 3 groups: 20 patients underwent intrapleural administration of streptokinase, 25 underwent video-assisted thoracoscopic surgery, and 24 had thoracotomy and decortication. Perioperative variables, mortality, and procedure success were compared among groups. In all groups, preoperative variables were well matched for age, sex, and clinical stage according to Light's classification. No allergic or hemorrhagic complication occurred. Operative time was significantly shorter in patients undergoing video-assisted thoracoscopic surgery. There was no intraoperative complication in the 2 surgically treated groups. Length of hospital stay and duration of chest drainage were significantly shorter after video-assisted thoracoscopic surgery. Procedure success was 50% after streptokinase, 92% after video-assisted thoracoscopic surgery, and 100% after thoracotomy and decortication. There was no perioperative mortality in any group. Video-assisted thoracoscopic surgery is a safe and effective treatment modality for complicated parapneumonic effusion and pleural empyema. Earlier intervention with video-assisted thoracoscopic surgery may produce better clinical results.

Intrapleural therapy in management of complicated parapneumonic effusions and empyema

Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.

The effectiveness of urokinase in treatment of pleural effusion in children

Purpose : Pleural effusion is a common complications of pediatric bacterial pneumonia. Intrapleural administration of fibrinolytic agents such as urokinase have been used in the management of complicated parapneumonic effusions. But the safety and effectiveness of intrapleural urokinase instillations in children has not been confirmed. The aim of this study is to evaluate the safety and effectiveness of intraperitoneal urokinase in children. Methods : We reviewed a total of 29 children diagnosed as parapneumonic effusion with septation by chest CT or chest ultrasonography. We divided them into two groups. Fourteen children treated with urokinase after thoracostomy (Group A) were compared with 15 children treated only with thoracostomy (Group B). The urokinase, 3,000 IU/kg/day, was injected into the pleural cavity twice a day. Results : There was no statistical difference in sex and age between the two groups. Total drainage volume during thoracostomy in group A and B was 375.5 mL and 350.0 mL, respectively. It was not statistically significant. But the amounts of pleural fluid of group A on day 1, day 2 and day 3 were 102.5 mL, 100.0 mL, and 70.0 mL respectively and those of group B on day 1, day 2 and say 3 were 120.0 mL, 50.0 mL and 15.0 mL respectively. To compare group A with group B in the amounts of drainage volume on day 1 was not statistically significant, but the amounts of drainage volumes on day 2 and day 3 in group A were statistically more significant than group B (Day 1 P=0.371, Day 2 P=0.049, Day 3 P=0.048, respectively). The duration of fever, antibiotics, thoracostomy and total hospital days. Were not statistically significant between the two groups. But the frequency of complications in Group A was statictically significantly lower than in group B. Conclusion : Intrapleural instillation of urokinase facilitates the drainage of loculated pleural effusions, especially during the first 3 days, and it could reduce complications, such as pleural thickening, surgical managements, re-positioning of tube and re-thoracostomy. So intrapleural urokinase injection was and effective and safe treatment of pleural effusion in children (P=0.014).

ADHERENCE TO ACCP GUIDELINE IMPROVES OUTCOMES IN COMPLICATED PARAPNEUMONIC EFFUSION AND EMPYEMA THORACIS

PURPOSE: Complicated parapneumonic effusion (CPE) and empyema thoracis are significant complications of pneumonia. There is ongoing debate regarding the best strategy to manage CPE and empyema thoracis, particularly regarding the role of intrapleural fibrinolysis and surgical intervention. Guideline on the management of complicated parapneumonic effusion have been published by the American College of Chest Physicians (ACCP), but it is not certain whether adherence to management guidelines will improve the outcomes of CPE and empyema thoracis.

Management of Parapneumonic Effusions:Current Practice and Controversies

The incidence of complicated parapneumonic effusions in children has been increasing over the past decade despite the increasing use of protein-conjugate vaccines against Streptococcus pneumoniae, the most common cause of complicated pneumonia in children in the developed world. Despite the fact that this condition is increasingly common in hospitalized children, the management of this condition remains controversial, in large part due to the small number of prospective, controlled trials evaluating therapies. This review will highlight the epidemiology, diagnosis and management of complicated parapneumonic effusions. The role for intrapleural fibrinolytic therapy and early videoassisted thorascopic surgery in the management of this condition will be emphasized as will the questions that need to be answered with future inquiry.

Intrapleural urokinase treatment in children with complicated parapneumonic effusion.

Intrapleural instillation of fibrinolytic agent such as urokinase has been shown to be effective as an adjunctive therapy for children with complicated parapneumonic effusion and empyema. In this study, we described our experience with the use of intrapleural urokinase in the management of complicated parapneumonic effusion in children. We collected 13 patients with a mean age of 50.8 months with parapneumonic pleural effusion or empyema; all were treated with intrapleural urokinase after poor response to appropriate antibiotics and simple tube drainage. We also reviewed another 13 patients with a mean age of 45.8 months from the clinical records of children hospitalized with the same conditions prior to urokinase introduction as a control group. The mean fluid drained during the first 24 hours and the first 72 hours after urokinase instillation were significantly greater than those during 24 hours before instillation, p=0.002 and p<0.001, respectively. The total volume of fluid drained was also greater in the urokinase group than that in the control group (p<0.001). The mean duration of chest tube drainage was significantly shorter in the urokinase group (8.7 +/- 2.8 days vs. 14.7 +/- 6.1 days, p<0.02). The mean length of hospitalization was also significantly shorter in the urokinase group (15.5 +/- 5.3 days vs. 24.4 +/- 6.9 days, p=0.002). All 13 patients were managed successfully with urokinase treatment without further surgical procedures. None of the patients experienced any side effect or adverse event after urokinase instillation. Two patients of the control group finally underwent surgical debridement. In conclusion, the use of intrapleural urokinase treatment in children with complicated parapneumonic effusion is an effective and safe therapy.

Echo-guided management of complicated parapneumonic effusion in children

The optimal management of parapneumonic effusion and empyema in children remains controversial; currently there is insufficient evidence to give clear guidance on therapy. The aims of this study were to delineate the biochemical characteristics and to examine the effect of different therapeutic strategies on ultrasound staging of parapneumonic effusion. The ultrasonic appearances were classified according to the deposition of fibrin or formation of fibrin septations. A total of 81 patients were enrolled in the present study. Chest ultrasound was performed and results were stratified into anechoic fluid (stage 1, n = 23), with floating fibrin strands (stage 2, n = 30), and with septated fibrin (stage 3, n = 28). The mean days of fever elapsed before detection of these stages appeared to be higher at advanced stages (7.3 +/- 2.1 vs. 8.5 +/- 2.7 vs. 9.7 +/- 4.2, respectively; P = 0.03). Univariate analysis revealed that WBC, platelet count in hemogram and pH, glucose, protein, LDH in pleural effusion were significantly associated with the stages of parapneumonic effusion. Multivariate logistic analysis revealed that pH (less than 7.27) in pleural fluid was the only significant factor for the formation of fibrin with/without fibrin septations. The rate of successful tube drainage decreased as the advancement of stages of parapneumonic effusion, especially in patients using chest tube for drainage initially (P = 0.001). Total duration of fever and hospital stay was significantly shorter for those children who had initial video-assisted thoracic surgery (VATS) compared to those who had initial chest tube drainage (P < 0.001). Chest sonography can well discriminate the progressive stages of bacterial parapneumonic effusion. In children with a progressive parapneumonic effusion with fibrin formation, early aggressive tube drainage may avoid a subsequent surgical intervention. In children with a fibrin septated parapneumonic effusion, an initial VATS is recommended to shorten the duration of fever and hospital stay.

Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study

A prospective randomized study was conducted in order to analyze the role of fibrinolytics in the treatment of complicated parapneumonic effusion. From 2001 to 2004, 127 consecutive patients were managed for thoracic empyema. In all cases the cause was bacterial pneumonia. Seventy patients were managed with sole tube thoracostomy (group A) and 57 with combination of tube thoracostomy and streptokinase instillation (group B). Groups were statistically compared for the age, gender, duration of symptoms, quality of pleural fluid, chest imaging, complete drainage, length of hospital stay and mortality. Multivariate analysis was used in order to define the factors that affect outcome. Tube thoracostomy was successful in 47 (67.1%) cases (group A), while fibrinolysis led to a favorable outcome in 50 cases (87.7%) (P<0.05). The length of stay in thoracic surgical department was significantly longer for group A (P<0.001). Mortality rate in group A was significantly higher (P<0.001). Multiple regression analysis disclosed as sole independent favorable factor for pleural drainage, the use of fibrinolysis during the course of chest tube drainage (P=0.006, odds ratio 4.29, 95% CI 1.51-12.14). Fibrinolytic agents are a useful adjunct in the management of complicated parapneumonic effusions. Intrapleural fibrinolytics, if used early in the fibrinopurulent stage of a parapneumonic effusion, decrease the rate of surgical interventions (VATS or open decortcation) and the length of hospital stay with minor associated morbidity.

Treatment of Complicated Parapneumonic Pleural Effusion With Intrapleural Streptokinase in Children

To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children. Prospective comparative study. Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan. We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics. More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation. Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.