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

Background: Effusions and empyema may complicate lower respiratory tract infections. Loculation of fluid is a major problem with this condition so treatments have included surgical drainage and the use of intra-pulmonary fibrinolysis to break down fibrin bands that may cause loculation.
Objectives: To conduct a systematic review of the benefit of adding intrapleural fibrinolytic therapy to intercostal tube drainage in the treatment of complicated parapneumonic effusions and empyema.
Search Strategy: The Cochrane Controlled Trials Register was initially searched for relevant RCT's. The search terms were Streptokinase OR Urokinase AND Pleural Effusion OR Intrapleural OR Pleur* OR Parapneumonic Or Empyema. Bibliographies and review articles identified herein were searched for further citations and RCT's. MEDLINE, EMBASE were searched and, where relevant, Index Medicus was hand searched. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested.
Selection Criteria: Types of Studies All studies in the review were Randomised Controlled Trials in adult patients empyema or complicated parapneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) vs control or a comparison of the two.
Data Collection and Analysis: All identified studies were reviewed independently by two reviewer and all data collected. Reviews were scored according to the Cochrane assessment of allocation concealment and the Jadad scale of methodological quality. Disagreements between reviewers were referred to a third reviewer. Where further information was required, authors of trial papers were contacted for further details.
Main Results: Three studies were identified, one which directly compared the fibrinolytics streptokinase and urokinase. Two small RCTs (total 58 patients) compared streptokinase or urokinase vs normal saline control. The pooled data showed small benefits in terms of hospital stay, time to defervescence, improvement in chest radiograph, requirement for surgery, but the results were not always consistent across studies. Complications attributable to therapy were not seen.
Reviewer's Conclusions: There is currently insufficient evidence to support routine use of intrapleural fibrinolytic therapy in the treatment of parapneumonic effusion and empyema. The results of a large multi-centre study, currently underway, are awaited.