Intrapleural Fibrinolytic Therapy in Loculated Pleural Effusions

About 36% to 57% of bacterial pneumonias develop parapneumonic effusion. When the chest tube is correctly positioned as evidenced by postero-anterior and lateral chest radiographs and there is a significant amount of pleural fluid, the major reasons for failed drainage are multiple pleural space loculations or tube obstruction by thick and viscous fluid. The various modalities of treatment available for loculated pleural effusion are: saline flushes, placing one or more catheters in loculi under image guidance, video assisted thoracoscopic surgery (VATS), standard thoracotomy with drainage of empyema and decortication. The first two modalities are not so effective in improving drainage. The last two surgical modalities are more invasive, not easily available and, if available, are not affordable by majority of patients in the developing countries like India. The fibrinolytic agents, if used early in loculated pleural effusions, break loculations and early pleural peel thereby facilitating pleural space drainage.