DOI: http://dx.doi.org/10.18203/2349-2902.isj20202871

To lyse or not to lyse? Use of intrapleural tissue plasminogen activator and DNase in the management of parapneumonic effusions and empyema

Oluwasegun Afolaranmi, Oreoluwa Arowojolu

Abstract


Despite a range of management options, pleural effusions and empyema continue to present therapeutic challenges in the clinical setting. With treatment options ranging from simple use of antibiotics to more complex surgical procedures, several important considerations need be made as to what type of treatment is best for each patient on a case by case basis. One treatment modality of increasing interest is the use of intrapleural fibrinolytics to facilitate drainage of effusions. This presents a viable option especially in patients in whom surgery is not preferred. But, as with many therapeutic approaches, the use of intrapleural fibrinolytics is laden with significant controversies and has been a subject of considerable debate over the last couple of years. With accruing evidence for and against this modality of treatment, the ensuing discussion has been whether or not it should be a routine treatment choice and which group of patients should this consideration be made for. This paper gives a background on the epidemiology and etiology of parapneumonic effusions and empyema and briefly outlines the available options of management. Furthermore, we extensively discuss available evidence on the use of intrapleural fibrinolytics as a management option for parapneumonic effusions and empyema, with particular emphasis on use of tissue plasminogen activator (tPA) and DNase.

 


Keywords


DNase, Empyema, Intrapleural fibrinolytics, Parapneumonic effusion, Tissue plasminogen activator

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References


Grijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. 2011:2-7.

Light RW. Parapneumonic effusions and empyema. 2005;3(1):75-80.

Corcoran JP, Rahman NM. point: should fibrinolytics be routinely administered intrapleurally for management of a complicated parapneumonic effusion? Chest. 2014;145(1):14-7.

Farjah F, Symons RG, Krishnadasan B, Wood DE, Flum DR. Management of pleural space infections: a population-based analysis. J Thorac Cardiovasc Surg. 2007;133(2):38.

Bender JM, Ampofo K, Sheng X, Pavia AT, Albright CL, Byington CL. Parapneumonic empyema deaths during past century, Utah. Emerg Infect Dis. 2009;15(1):44-8.

Hasley B, Albaum MN, Li Y. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia? Arch Intern Med. 1996;156:2206-12.

Lim WS, Lewis S, Macfarlane JT. Severity prediction rules in community acquired pneumonia: a validation study. Thorax. 2000;55(3):219-23.

Andrews N, Parker E, Shaw R. Management of nontuberculous empyema. Am Rev Respir Dis. 1962;85:935-6.

Light R, Girard W, Jenkinson S, George R. Parapneumonic effusions. Am J Med. 1980;69:507-12.

Light R. A new classification of parapneumonic effusions and empyema. Chest. 1995;108:299-301.

Colice G, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000;118:1158-71.

Davies C, Gleeson F, Davies R. BTS guidelines for the management of pleural infection. Thorax. 2003;58(2):18-28.

Brook I, Frazier EH. Aerobic and anaerobic microbiology of empyema: a retrospective review in two military hospitals. Chest. 1993;103(5):1502-7.

Maskell NA, Davies CW, Nunn AJ. U.K. controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005;352:865-74.

Chapman SJ, Davies RJO. The management of pleural space infections. Respirology. 2004;9(1):4-11.

Tillet WS, Sherry S. The effect in patients of streptococcal fibrinolysin (streptokinase) and streptococcal desoxyribo- nuclease on fibrinous, purulent, and san- guinous pleural exudations. J Clin Invest. 1949;5:173-90.

Bergh N, Ekroth R, Larsson S. Intrapleural streptokinase in the treatment of hemothorax and empyema. Scand J Cardiovasc Surg. 1977;11:265-8.

Moulton JS, Moore PT, Mencini RA. Treatment of loculated pleural effusions with transcatheter intracavitary urokinase. Am J Roentgenol. 1989;153(5):941-5.

Temes RT, Follis F, Kessler RM, Pett SB, Wernly JA. Intrapleural fibrinolytics in management of empyema thoracis. Chest. 1996;110(1):102-6.

Laisaar T, Püttsepp E, Laisaar V. Early administration of intrapleural streptokinase in the treatment of multiloculated pleural effusions and pleural empyemas. Thorac Cardiovasc Surg. 1996;44(5):252-6.

Sánchez JC, Rivera RA, Elizalde JJ. Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema: a multicenter trial. Chest. 1996;109(6):1514-9.

Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Panagou P, Siafakas NM. Intrapleural streptokinase vs. urokinase in the treatment of complicated parapneumonlc effusions. Am J Respir Crit Care Med. 1997;155:291-5.

Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest. 1997;111(2):275-9.

Davies R, Traill ZC, Gleeson FV. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax. 1997;52(5):416-21.

Bouros D, Schiza S, Tzanakis N, Chalkiadakis G, Drositis J, Siafakas N. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. Am J Respir Crit Care Med. 1999;159(26):37-42.

Tuncozgur B, Ustunsoy H, Sivrikoz M, Dikensoy O, Topal M, Sanli M. Intrapleural urokinase in the management of parapneumonic empyema: a randomised controlled trial. Int J Clin Pr. 2001;55:658-60.

Diacon AH, Theron J, Schuurmans MM, Wal BW, Bolliger CT. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. Am J Respir Crit Care Med. 2004;170(1):49-53.

Cameron R, Davies H. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema (Review). Cochrane Database Syst Rev. 2008;2:CD002312.

Aleman C, Alegre J, Monasterio J. Association between inflammatory mediators and the fibrinolysis system in infectious pleural effusions. Clin Sci. 2003;105:601-7.

Skeete DA, Rutherford EJ, Schlidt SA, Abrams JE, Parker LA, Rich PB. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma Infect Crit Care. 2004;57(6):1178-83.

Weinstein M, Restrepo R, Chait PG, Connolly B, Temple M, Macarthur C. Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions. Pediatrics. 2004;113(3):10-5.

Thommi G, Shehan JC, Robison KL, Christensen M, Backemeyer LA, McLeay MT. A double blind randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions. Respir Med. 2012;106(5):716-23.

Simpson G, Roomes D, Heron M. Effects of streptokinase and deoxyribonuclease on viscosity of human surgical and empyema pus. Chest. 2000;117(6):1728-33.

Rahman N, Maskell N, West A, Teoh R, Arnold A, Mackinlay C. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365:518-26.

Piccolo F, Pitman N, Bhatnagar R. Intrapleural tPA and DNase for pleural infection: an effective and safe alternative to surgery. Ann Am Thorac Soc. 2014;11(9):1-30.

Bishwakarma R, Shah S, Frank L, Zhang W, Sharma G, Nishi SP. Mixing it up coadministration of tPA/DNase in complicated parapneumonic pleural effusions and empyema. J Bronchol Interv Pulmonol. 2017;24(1):40-7.

Mehta HJ, Biswas A, Penley AM, Cope J, Barnes M, Jantz MA. Management of intrapleural sepsis with once daily use of tissue plasminogen activator and deoxy- ribonuclease. Respiration. 2016;91(2):101-6.

Tan PSC, Badiei A, Fitzgerald DB, Kuok YJ, Lee YCG. Pleural empyema in a patient with a perinephric abscess and diaphragmatic defect. Respirol Case Reports. 2019;7(3):45-9.

Hart JA, Badiei A, Lee YCG. Successful management of pleural infection with very low dose intrapleural tissue plasminogen activator/deoxyribonuclease regime. Respirol Case Reports. 2019;7(3):408-12.

Idell S, Florova G. Precision-guided, personalized intrapleural fibrinolytic therapy for empyema and complicated parapneumonic pleural effusions. Case Fibrinolytic Potential. 2018;24(4):163-9.