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Original Research |

Intrapleural Fibrinolytic Therapy for Treatment of Adult Parapneumonic Effusions and EmpyemasIntrapleural Fibrinolytic Therapy: A Systematic Review and Meta-analysis

Surinder Janda, MD; John Swiston, MD, FCCP
Author and Funding Information

From the University of British Columbia, Vancouver, BC, Canada.

Correspondence to: John Swiston, MD, FCCP, Division of Respiratory Medicine, University of British Columbia, Vancouver General Hospital, 2775 Laurel St, 7th Floor, Vancouver, BC, V5Z 1M9, Canada; e-mail: swiston@interchange.ubc.ca


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Funding/Support: The authors have reported to CHEST that no funding was received for this study.


Chest. 2012;142(2):401-411. doi:10.1378/chest.11-3071
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Background:  The purpose of our study was to conduct a systematic review and meta-analysis of all randomized controlled trials to date comparing fibrinolytics with placebo to clarify their current role in the management of parapneumonic effusions and empyemas.

Methods:  MEDLINE, EMBASE, PapersFirst, and the Cochrane Collaboration and the Cochrane Register of controlled trials were searched. All searches were inclusive as of October 2011. Two investigators independently reviewed articles and extracted data. Quality was assessed with the Cochrane concealment of allocation approach and the Jadad criteria.

Results:  Seven randomized controlled studies (total number of patients, 801) comparing fibrinolytic therapy with placebo were included in the meta-analysis. Fibrinolytic therapy was beneficial for the outcomes of treatment failure (surgical intervention or death) (risk ratio [RR], 0.50; 95% CI, 0.28-0.87) and surgical intervention alone (RR, 0.61; 95% CI, 0.45-0.82). There was no difference in mean duration of hospital stay (standard mean difference, −0.69; 95% CI, −1.54-0.16) or death (RR, 1.14; 95% CI, 0.74-1.74).

Conclusions:  This meta-analysis does reveal that fibrinolytic therapy is potentially beneficial in the management of parapneumonic effusions and empyemas in the adult population. Although there is insufficient evidence to support the routine use of this therapy for all parapneumonic effusions/empyemas, fibrinolytic therapy may be considered in patients with loculated pleural effusions, because it may prevent the need for surgical intervention. Further randomized controlled trials with adequate power are needed to definitively address the effect of fibrinolytics and the combination of fibrinolytics and deoxyribonuclease on the clinical outcomes outlined in this analysis in patients with parapneumonic effusions/empyemas.

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