Intrapleural Fibrinolytic Therapy in Loculated Effusions

Loculated pleural effusions are most commonly due to complicated parapneumonic effusions and empyema followed by tubercular pleural effusions and empyema, hemothorax and malignant effusions. Loculations develop due to delayed initiation and inappropriate use of antibiotics and, delayed initiation of pleural space drainage. The presence of loculations and thick viscous fluid leads to failed pleural space drainage in spite of tube being patent and correctly positioned. The management options in such cases consist of either use of minimally invasive video assisted thoracic surgery (VATS) or more invasive conventional thoracotomy. In spite of being effective, VATS is not easily accessible and affordable in developing countries like India. The use of intrapleural fibrinolytics is a safer, easier and cost effective option and various uncontrolled and small randomized studies have shown it to be a useful alternative. However, a recent large multicenter randomised trial using intrapleural streptokinase in cases of pleural infection and using mortality and need for surgery as primary outcomes found no significant difference between patients receiving streptokinase or placebo1. This study met with serious criticism with regard to the selection of primary outcomes and methodology. This article discusses the parapneumonic effusions, which are the most common cause of loculated effusions, rationale of this therapy, its indications and treatment protocols and the present status of this therapy especially in a developing country like ours.