Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema

Cameron, Robert; Davies, HR

doi:10.1002/14651858.cd002312.pub2

Cited by 58 publications

(56 citation statements)

References 37 publications

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“…In addition, a small-bore catheter placed with the Seldinger technique, when used for an initial thoracentesis, can be left in place for continued drainage or removed after complete drainage if the fluid is nonpurulent and the pH is 17.30. Intrapleural fibrinolytics. In 2004, The Cochrane Database Review stated that, although the evidence suggests that intrapleural fibrinolysis can be considered an important adjunctive therapy to tube drainage on the basis of evidence from randomized, controlled trials alone, routine use was not recommended for the management of CPPE and empyema, because the number of cases was too small [33]. They opined that streptokinase (no longer available as a result of a lack of market demand) and urokinase were equally efficacious and that lifethreatening complications were not reported in any of the randomized, controlled trials.…”

Section: Managementmentioning

confidence: 99%

Diagnosis and Management of Parapneumonic Effusions and Empyema

2007

Clinical Infectious Diseases

176

144

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Approximately 1 million patients develop parapneumonic effusions (PPEs) annually in the United States. The outcome of these effusions is related to the interval between the onset of clinical symptoms and presentation to the physician, comorbidities, and timely management. Early antibiotic treatment usually prevents the development of a PPE and its progression to a complicated PPE and empyema. Pleural fluid analysis provides diagnostic information and guides therapy. If the PPE is small to moderate in size, free-flowing, and nonpurulent (pH, 17.30), it is highly likely that antibiotic treatment alone will be effective. Prolonged pneumonia symptoms before evaluation, pleural fluid with a pH !7.20, and loculated pleural fluid suggest the need for pleural space drainage. The presence of pus (empyema) aspirated from the pleural space always requires drainage. Fibrinolytics are most likely to be effective during the early fibrinolytic stage and may make surgical drainage unnecessary. If pleural space drainage is ineffective, video-assisted thoracic surgery should be performed without delay.Parapneumonic effusion (PPE; i.e., pleural fluid that results from pneumonia or lung abscess) is the most common cause of an exudative pleural effusion. PPE may be the consequence of either community-acquired or nosocomial pneumonia. Between 20% and 57% of the 1 million patients hospitalized yearly in the United States with pneumonia develop a PPE [1][2][3]. Although PPEs are relatively common, empyema (i.e., the accumulation of pus in the pleural space) is less common, occurring in 5%-10% of patients who experience PPE [4]. In a review of 14 studies of empyema that involved a total of 1383 patients, 70% of PPEs were secondary to pneumonia (figure 1) [4]. CLASSIFICATIONA practical, clinical classification of PPE is as follows: (1) an uncomplicated parapneumonic effusion (UPPE) resolves with antibiotic therapy alone, without pleural space sequelae; (2) a complicated parapneumonic effusion (CPPE) requires pleural space drainage to resolve pleural sepsis and prevent progression to an empyema; and (3) empyema, the end stage of a PPE, occurs. Empyema is defined by its appearance; it is an opaque, whitish-yellow, viscous fluid that is the result of serum coagulation proteins, cellular debris, and fibrin deposition. Empyemas develop primarily because of delayed presentation by the patient with advanced pneumonia and progressive pleural infection and, less often, from inappropriate clinical management. Early antibiotic treatment prevents progression of pneumonia and the development of a PPE. Early antibiotic treatment will prevent development of an UPPE and progression to empyema. Risk factors for empyema include age (empyemas occur most frequently among children and elderly persons), debilitation, male sex, pneumonia requiring hospitalization, and comorbid diseases, such as bronchiectasis, chronic obstructive pulmonary disease, rheumatoid arthritis, alcoholism, diabetes, and gastroesophageal reflux disease [5]. Bacterial pneumonia, pneumon...

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Section: Managementmentioning

confidence: 99%

Diagnosis and Management of Parapneumonic Effusions and Empyema

2007

Clinical Infectious Diseases

176

144

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“…Streptokinase has been associated with febrile reactions but has been generally well tolerated, as reported in a number of studies. Intrapleural streptokinase, as commonly used for intrapleural administration, does not induce systemic fibrinolysis and is relatively free of hemorrhagic risk 4,5 . Intrapleural urokinase has likewise been reported to be well-tolerated 6 .…”

Section: Discussionmentioning

confidence: 99%

Intrapleural Fibrinolytics- A review

Dandagi¹

2013

IOSR-JDMS

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“…However, no significant radiological or functional differences were observed between the groups during the followup of more than 6 months. A meta-analysis evaluating four of these trials [4,5,9,24] concluded that although fibrinolytics reduce hospital stay and the duration of fever, and provide radiological improvements, the trials were not sufficiently powered to determine the true efficacy of fibrinolytics such as in terms of mortality and the need for surgery [6]. In the following year, a double-blind trial comparing intrapleural streptokinase with placebo in 454 adult patients with pleural infection did not show any benefit of streptokinase in terms of mortality, rate of surgery, radiological outcomes or length of hospital stay [17].…”

Section: Discussionmentioning

confidence: 99%

Intrapleural streptokinase treatment in children with empyema

Aydoğan

Özcan

et al. 2007

Eur J Pediatr

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Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.

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Intra-pleural fibrinolytic therapy versus conservative management in the treatment of parapneumonic effusions and empyema

Cited by 58 publications

References 37 publications

Diagnosis and Management of Parapneumonic Effusions and Empyema

Diagnosis and Management of Parapneumonic Effusions and Empyema

Intrapleural Fibrinolytics- A review

Intrapleural streptokinase treatment in children with empyema

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