Intrapleural fibrinolytic therapy in complicated parapneumonic effusion and empyema: present status

Pneumonia remains one of the commonest community- and hospital-acquired infection despite the advent of potent antimicrobial agents. A significant number of patients with pneumonia develop parapneumonic effusions. The parapneumonic effusion may be "simple" consisting of free-flowing, clear exudative fluid which almost resolves completely with antibiotics alone. In case of delayed or inappropriate treatment, some of these simple effusions progress to complicated parapneumonic effusions and empyema. The management of these types of effusions with intercostal tube drainage and antibiotics fails most of the time due to the presence of thick viscous fluid and multiple pleural space loculations. The various therapeutic options available at this stage include intrapleural instillation of fibrinolytic agents, breaking down of loculations or decortication either by video-assisted thoracosopic surgery (VATS) or thoracotomy and open drainage procedures. Video-assisted thoracic surgery is a better option but it is neither easily available nor affordable by majority of patients in developing countries, like India. Intrapleural instillation of fibrinolytic agents has been found to be a useful adjunctive therapy in various small uncontrolled and randomised trials. After a recent and first large multicentre trial which showed that this therapy does not have any significant effect in reducing mortality and need for surgery in patients with pleural infection, the role of intrapleural fibrinolytics has become more controversial. In view of this, there is a need to re-define its role especially in the developing countries.