Intra-pleural fibrinolytic therapy versus 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 and treatments have included surgical drainage and the use of intra-pleural 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 para pneumonic effusions and empyema.

SEARCH STRATEGY: The Cochrane Controlled Trials Register was initially searched for relevant RCT's. Trial authors were contacted for further information and details regarding the possibility of unpublished trials was requested. The most recent search was conducted in July 2003.

SELECTION CRITERIA: All studies in the review were Randomised Controlled Trials in adult patients with empyema or complicated para pneumonic effusions who had not had prior surgical intervention or trauma. The intervention was an intrapleural fibrinolytic agent (streptokinase or urokinase) versus 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: Four studies were included, one which directly compared the fibrinolytics streptokinase and urokinase. Three small RCTs (total 104 patients) compared streptokinase or urokinase versus normal saline control. The pooled data showed significant 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 observed.

REVIEWERS' CONCLUSIONS: The numbers of patients in the controlled trials are small. In meta-analysis of these trials, intrapleural fibrinolytic therapy confers significant benefit when compared with normal saline control. Although lesser levels of evidence suggest that intrapleural fibrinolysis can be considered as an important adjunctive therapy to intercostal tube drainage in these conditions, on the basis of RCT evidence alone, we cannot recommend the routine use of fibrinolysis in their management as the trial numbers are too small. Both streptokinase and urokinase are equally efficacious but streptokinase has a slightly higher non-fatal complication rate. Life-threatening complications are rare and were not seen in the RCTs.