Intrapleural Thrombolytics for Parapneumonic Effusion: A Network Metaanalysis

Area of Science:

• Pulmonology
• Critical Care Medicine
• Pharmacology

Background:

• Complicated parapneumonic effusion often requires pleural fluid drainage.
• Intrapleural thrombolytics are used to facilitate drainage and avoid surgery.
• Evidence on the comparative efficacy and safety of different thrombolytics is limited.

Purpose of the Study:

• To conduct a network meta-analysis of randomized clinical trials (RCTs).
• To evaluate the therapeutic effect of intrapleural thrombolytics in patients with complicated parapneumonic effusion.
• To compare outcomes including mortality, surgical referral, and adverse events.

Main Methods:

• Systematic search of electronic databases (Medline, Cochrane CENTRAL, Google Scholar) for relevant RCTs.
• Inclusion of 16 RCTs evaluating thrombolytics for complicated parapneumonic effusion.
• Random-effects model for pooled estimates of odds ratios (OR) with 95% confidence intervals (CI) for mortality, surgical referral, and adverse events.

Main Results:

• No significant difference in mortality was observed among thrombolytic groups.
• Streptokinase, urokinase, alteplase, and alteplase + DNase significantly reduced surgical referral compared to normal saline.
• Alteplase + DNase showed the lowest proportion of patients referred for surgery (OR 0.2, 95% CI 0.1-0.7).
• DNase alone increased surgical referral risk (OR 3.4, 95% CI 1.5-7.6).
• Streptokinase was associated with increased serious adverse events (OR 2.8, 95% CI 1.1-7.1 vs. normal saline; OR 6.7, 95% CI 1.1-39.9 vs. alteplase).
• Evidence quality was moderate for streptokinase vs. normal saline regarding surgical referral, and low/very low for other comparisons.

Conclusions:

• Intrapleural thrombolytics, including streptokinase, urokinase, alteplase, and alteplase + DNase, reduce the need for surgical intervention in complicated parapneumonic effusion.
• Alteplase + DNase appears most effective in minimizing surgical referrals.
• Thrombolytics other than streptokinase are recommended due to its higher risk of serious adverse events, pending further evidence.