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Intrapleural fibrinolysis for parapneumonic effusion and empyema in children
Robert G Wells1, Peter L Havens
1Department of Radiology, MS 721, Children's Hospital of Wisconsin, 9000 W Wisconsin Ave, Milwaukee, WI 53226, USA. rwells@chw.org
Insights
Alteplase and urokinase effectively treat pediatric parapneumonic effusions. Alteplase demonstrated greater pleural fluid drainage compared to urokinase, with both agents showing high success rates and safety.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Pharmacology
Background:
- Parapneumonic pleural fluid collections are common in children.
- Intrapleural fibrinolysis is a treatment option to facilitate pleural fluid drainage.
- Urokinase and alteplase are commonly used fibrinolytic agents.
Purpose of the Study:
- To compare the safety and efficacy of urokinase and alteplase for intrapleural fibrinolysis in pediatric patients with parapneumonic pleural fluid collections.
- To evaluate the impact of these agents on thoracostomy tube drainage and treatment success.
Main Methods:
- Retrospective review of 71 children treated with thoracostomy tubes and intrapleural urokinase or alteplase.
- Analysis of demographic data, clinical signs and symptoms, laboratory results, and radiographic findings.
- Comparison of treatment success, defined as resolution of signs and symptoms without surgery, and pleural fluid drainage between the two groups.
Main Results:
- Both urokinase and alteplase demonstrated high primary treatment success rates (98% for alteplase, 100% for urokinase) with no major complications.
- Alteplase resulted in significantly greater pleural fluid drainage during the first two days and over the entire duration of thoracostomy drainage compared to urokinase.
- Multivariate analysis indicated that alteplase, older patient age, larger tube size, and higher pre-fibrinolysis drainage volume were associated with greater total drainage.
Conclusions:
- Intrapleural fibrinolysis with either urokinase or alteplase is an effective method for managing parapneumonic pleural fluid collections in children.
- Alteplase, under the dosing regimen used in this study, led to superior thoracostomy tube output compared to urokinase.
- Both agents are safe and effective, but alteplase may offer advantages in terms of drainage efficiency.
Purpose:
To assess the safety and efficacy of urokinase and alteplase for intrapleural fibrinolysis in children with parapneumonic pleural fluid collections.
Materials And Methods:
A retrospective review was performed of 71 children with parapneumonic pleural fluid accumulations who were treated with thoracostomy tube placement and intrapleural instillation of either urokinase or alteplase. The procedures were performed with urokinase between September 2, 1995, and March 27, 1998, and with alteplase between March 30, 1998, and January 2, 2002. The medical records and daily chest radiographs were reviewed by a pediatric radiologist to ascertain demographic information, signs and symptoms, laboratory results, thoracostomy tube output, treatment details, and radiographic pleural thickness and lung opacification. Multiple variables were compared for the alteplase and urokinase groups by using univariate and multivariate statistics. We defined primary treatment success as resolution of signs and symptoms at the time of discharge, without surgical intervention.
Results:
Primary treatment success was 98% for alteplase and 100% for urokinase, with no major complications. Greater pleural fluid drainage occurred with alteplase than urokinase during the 1st (P =.001) and 2nd (P =.002) days of fibrinolytic therapy, and for the duration of thoracostomy drainage (P <.001). Multivariate models showed greater total drainage with alteplase (P <.001), greater patient age (P <.001), larger tube size (P =.002), and greater volume of drainage during the 24 hours prior to fibrinolysis (P <.001).
Conclusion:
Intrapleural fibrinolysis with urokinase or alteplase facilitates thoracostomy tube drainage of parapneumonic pleural fluid. With the dosing regimen used in this study, alteplase produces greater thoracostomy tube output than does urokinase.