Intrapleural agents for pleural infection: fibrinolytics and beyond

Intrapleural use of urokinase and DNase in pleural infections managed with repeated thoracentesis: A comparative cohort study

Introduction

Evacuation of infected fluid in pleural infections is essential. To date, the use of an intrapleural fibrinolytic agent such as urokinase and DNase has not yet been assessed in infections managed by repeated therapeutic thoracentesis (RTT).

Methods

We performed a retrospective comparative study of two successive cohorts of consecutive patients with pleural infections from 2001 to 2018. Between 2001 and 2010, patients had RTT with intrapleural urokinase (RTT-U). After 2011, patients received intrapleural urokinase and DNase with RTT (RTT-UD). Data were collected through a standardized questionnaire.

Results

One hundred and thirty-three patients were included: 93 were men and the mean age was 59 years (standard deviation 17.2). Eighty-one patients were treated with a combination of intrapleural urokinase and DNase, and 52 were treated with intrapleural urokinase only. In the RTT-UD, RTT failure occurred in 14 patients (17%) compared to 10 (19%) in the RTT-U group (P = 0.82). There was no difference between the two groups in intensive care unit admission, surgical referrals or in-hospital mortality. RTT-UD was associated with faster time to apyrexia (aOR = 0.51, 95%CI [0.37–0.72]), a reduced length of hospital stay (aOR = 0.61, 95%CI [0.52–0.73]) and a higher volume of total pleural fluid retrieved (aOR = 1.38, 95%CI [1.02–1.88]). Complications were rare with only one hemothorax in the RTT-UD group and no pneumothorax requiring drainage in either group.

Conclusion

Compared to urokinase only, intrapleural use of urokinase and DNase in RTT was associated with quicker defervescence, shorter hospital stay and increased volumes of pleural fluid drained. Randomized controlled trials evaluating urokinase and DNase with RTT technique would be required to confirm these results.

Chronic empyema: importance of preventing complications in the management of pleural effusions

We report a case of chronic empyema in a 63-year-old man with a history of asbestos exposure and alcohol overconsumption. In 2009, he presented with dyspnoea, exudative pleurisy on the right side with no symptoms of infection or malignancy. In 2013, the patient presented with increased dyspnoea and a massive chronic empyema had evolved. Culture of the pleural fluid was positive for Escherichia coli and anaerobic bacteria, and he was treated with antibiotics, chest drainage as well as surgical evacuation. After surgery, as the lung failed to expand, growth of opportunistic bacteria and rising C reactive protein obliged long-time treatment with broad-spectrum antibiotics as well as chest drainage with daily saline flushes. The patient still suffers from fatigue, poor nutritional status and anaemia, and further treatment with chest drainage and antibiotics is planned. Advanced chronic empyema is a difficult condition with poor response to treatment, and diagnostic delay is the main cause of complications.

Emergencies in pleural diseases

A parapneumonic effusion should be drained if it is large (≥ 1/2 of the hemithorax), loculated, frank pus is obtained, if the fluid is non-purulent fluid but has a low pH (< 7.20) or if the culture is positive. Instillation of fibrinolytics and DNase thorough the chest catheter in locutated effusions and empyemas is currently recommended. Management of spontaneous pneumothorax is fundamentally influenced by the patient's symptoms. Insertion of a chest catheter is mandatory if there is significant dyspnea, hemodynamic instability or large pneumothoraces (≥ 2 cm). Pleural ultrasonography confirms the presence of air or fluid in the pleural space and serves to guide any pleural procedure (e.g., thoracentesis, chest tubes). The use of small-bore 12F catheters inserted via the percutaneous Seldinger technique under ultrasonography guidance is a safe and effective procedure in complicated parapneumonic effusions/empyema and most pneumothoraces.