Chest
Volume 109, Issue 6, June 1996, Pages 1514-1519
Journal home page for Chest

Clinical Investigations: The Pleura
Intrapleural Fibrinolysis With Streptokinase as an Adjunctive Treatment in Hemothorax and Empyema: A Multicenter Trial

https://doi.org/10.1378/chest.109.6.1514Get rights and content

To test the efficacy of intrapleural fibrinolytic therapy in patients with loculated pleural effusions, we conducted an open, prospective, and multicenter trial among five hospitals in Mexico. We enrolled patients with hemothorax or empyema, clotted and/or loculated, that was not resolved through conventional pleural drainage with chest tube and antibiotics in patients with empyema. All patients received repeated doses of 250,000 IU of streptokinase through chest tube. Effectiveness criteria were before and after intrapleural streptokinase (IPSK) drainage, and poststreptokinase radiographic and respiratory function test improvement. Forty-eight patients were studied; there were 30 patients with empyemas, 14 with hemothorax, and 4 patients with malignant pleural effusions without lung trapping. Successful fibrinolysis was obtained in 44 patients, with complete resolution of the pleural collection and adequate radiologic and spirometric improvement. In three of four patients with multiloculated malignant hemothorax with high-yielding pleural drainage, IPSK allowed successful lysis of loci and an adequate pleurodesis was achieved. Only four patients required surgical treatment. The overall success rate in our series was 92%, similar to previous reports. The results in this first prospective and multicentric trial suggest that intrapleural fibrinolysis is an effective and safe adjunctive treatment in patients with heterogeneous pleural coagulated and loculated collections to restore the pulmonary function assessed by respiratory function tests and can obviate surgery in most cases.

Section snippets

Primary End Point

To evaluate the role of intrapleural fibrinolysis in clotted or loculated pleural collections, and to investigate if major surgical procedures can be avoided, a prospective, open, and multicenter trial was carried out in five hospitals in Mexico.

Inclusion and Exclusion Criteria

Patients were included if they had clotted hemothorax or loculated empyema, or malignant loculated pleural effusion without lung trapping that did not resolve after pleural drainage with closed thoracotomy. Patients were also included if they had

RESULTS

From October 1993 to April 1995, 49 consecutive patients were enrolled. One patient with chronic renal failure and empyema was excluded owing to bronchopleural fistula on the second day of IPSK. The remaining 48 patients represent the basis of our report.

Patients' demographic data, etiology, pleural drainage, number of loci, length of treatment, and complications are depicted in Table 1. Regarding pleural space management, in cases of empyema (30/48), diagnosis was supported by aspiration of

DISCUSSION

The results in this multicentric trial suggest that intrapleural fibrinolysis is useful in the treatment of persistent, loculated hemothorax and empyema. A significant increase in the drainage of chest tube and/or loci lysis with improvement from the clinical, radiologic, and pulmonary function point of view was demonstrated early and after approximately 6 months. Administration of IPSK avoided surgical decortication in a significant number of patients as did other aggressive, prolonged, and

CONCLUSION

Our results in this multicenter trial suggest that intrapleural fibrinolysis appears to be an effective and safe adjunctive therapy in patients with heterogeneous pleural proteinaceous retained collections, loci lysis, and can obviate surgery in most cases. Although the standard streptokinase regimen was effective, a new IPSK-controlled, randomized regimen should be tested in other trials.

REFERENCES (15)

There are more references available in the full text version of this article.

Cited by (157)

  • Pleural Infection

    2021, Encyclopedia of Respiratory Medicine, Second Edition
  • Lytic Therapy for Retained Traumatic Hemothorax: A Systematic Review and Meta-analysis

    2019, Chest
    Citation Excerpt :

    No heterogeneity was noted in the pooled studies (Q = 0.311, df = 2, P = .86, I2 = 0%). The remaining seven studies were pooled to evaluate non-TPA fibrinolytic agents.3-5,11-13,17 These agents included a combination of streptokinase and urokinase.

  • Thoracic irrigation prevents retained hemothorax: A pilot study

    2016, Journal of Surgical Research
    Citation Excerpt :

    We chose not to use warmed sterile water due to the theoretical concern for electrolyte derangements after a large volume hypotonic irrigation. Although literature has demonstrated the use of tissue plasminogen activator (t-PA) and streptokinase effective in the management of retained HTx, no previous studies have evaluated its utility in prophylactic use due to potential risks for bleeding shortly after trauma.25-27 Similar to the initial suction irrigation data, no safety concerns with early intervention were noted.19

  • Pleural Effusion and Empyema

    2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases
View all citing articles on Scopus
View full text