Chest
Volume 110, Issue 1, July 1996, Pages 102-106
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Clinical Investigations: The Pleura
Intrapleural Fibrinolytics in Management of Empyema Thoracis

https://doi.org/10.1378/chest.110.1.102Get rights and content

Study objective

To determine the success and complication rates of fibrinolytic therapy (FL) in the treatment of thoracic empyema.

Design and patients

Between December 1992 and November 1994, all patients referred with empyema thoracis (ET) were offered FL. FL consisted of streptokinase (275,000± 170,000 IU) or urokinase (121,000±57,000 IU) daily for a mean of 6.2±2.1 days.

Setting

The University of New Mexico Health Sciences Center and the Albuquerque Veterans Affairs Medical Center.

Results

Twenty-six patients were treated. Sixty-two percent (16/26) had complete resolution (CR) of symptoms, near or complete normalization of chest radiographic findings, and required no surgery or empyema tubes. Eight percent (2/26) had relief of symptoms and partial resolution (PR) of radiographic abnormalities and were discharged from the hospital with empyema tubes in place. All patients with PR had empyema tubes removed within 30 days of hospital discharge. Thirty-one percent (8/26) of patients failed to completely improve clinically or radiographically (nonresponse) and were treated with decortication or empyema tubes for greater than 30 days. Bleeding occurred in a single patient (4%). There was no mortality associated with FL use.

Conclusions

The use of FL is associated with resolution of ET in 69% (18/26) of patients. This modality is safe, effective, and spares most patients with empyema the morbidity and mortality of thoracotomy.

Section snippets

MATERIALS AND METHODS

All patients referred for decortication for ET between December 1992 and November 1994 were considered for FL. ET was defined as the presence of documented infection by Gram's stain or culture, the presence of grossly purulent pleural fluid, complicated parapneumonic effusion (two of the following: pH<7.20, lactate dehydrogenase [LDH]>400 IU/L, or glucose <40 mg/dL), or pleural effusion and clinical septicemia without other etiology. All patients had failed to respond to antibiotic therapy and

RESULTS

A total of 26 patients are described. Nineteen patients were treated with streptokinase, 7 with urokinase. Mean age was 41.8±17.1 years. Twelve percent (3/26) were female, and the remainder (23/26) were male.

The mean duration of ET symptoms prior to treatment was 2.9±2.6 weeks. The mean temperature maximum immediately prior to treatment was 38.4 ±1.2°C, the mean WBC count prior to initiating FL was 15.0±5.3×l03 cells/mm3.

Empyema fluid had a mean pH of 6.96±0.34, a mean glucose level of

DISCUSSION

ET is thought to proceed through several well-described stages during maturation. In the exudative stage, a parapneumonic effusion develops and becomes secondarily infected. As infection progresses, the initially serous fluid becomes thick and purulent with organisms, fibrin, and WBCs. Loculations develop: the fibropurulent stage. Additional time and inadequate treatment result in organization with fibroblasts and scar encasing the empyema, lung, and pleural space.

The therapy for ET is

ACKNOWLEDGMENT

Biostatistical support for this work was provided by Dr. Clifford Qualls, biostatistician for General Clinical Research Center, University of New Mexico.

REFERENCES (10)

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