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Point/Counterpoint Editorials |

Counterpoint: Should Fibrinolytics Be Routinely Administered Intrapleurally for Management of a Complicated Parapneumonic Effusion? NoFibrinolytics for Effusion? No

Gene L. Colice, MD, FCCP; Steven Idell, MD, PhD, FCCP
Author and Funding Information

From The George Washington University School of Medicine & Health Sciences (Dr Colice); Pulmonary, Critical Care and Respiratory Services (Dr Colice), Washington Hospital Center; and School of Medical Biological Sciences (Dr Idell), The University of Texas Health Science Center at Tyler.

Correspondence to: Gene L. Colice, MD, FCCP, Washington Hospital Center, 110 Irving St, NW, Washington, DC 20010; e-mail: Gene.Colice@Medstar.net


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Idell is the unpaid Chief Scientific Officer of Lung Therapeutics, Inc, serves on its board of directors, and has an equity position in the company, which was created to develop and commercialize single chain urokinase and other agents for use in lung and pleural disease. His work on single chain urokinase and pleural injury has been supported by grants from the National Institutes of Health and philanthropy. Dr Colice has reported no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


Chest. 2014;145(1):17-20. doi:10.1378/chest.13-2356
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Extract

In this debate, the question involves three key terms: fibrinolytics, routine administration intrapleurally, and complicated parapneumonic effusion (PPE). Fibrinolytics promote lysis of fibrin by generating plasmin. The only currently available fibrinolytic in the United States is tissue plasminogen activator (tPA). Routine use implies that administration of intrapleural fibrinolytic therapy represents a standard approach. Complicated PPE is a term introduced by Light1 to describe a PPE that evolved into the fibropurulent stage with a higher pleural fluid lactate dehydrogenase level, a lower pleural fluid glucose level, and a higher likelihood of a positive pleural fluid Gram stain. Light1 suggested that complicated PPE would not resolve with antibiotic treatment but would require drainage. Instead of the term complicated PPE, we prefer the approach adopted by the American College of Chest Physicians consensus panel for the management of PPE for identifying those PPEs in need of effective drainage.2 This consensus panel divided PPE into four different groups with varying risks for poor outcomes based on pleural space anatomy, pleural fluid bacteriology, and pleural fluid chemistry criteria (Table 1). The groups at increased risk for poor outcomes, such as those with large or loculated effusions, empyema, or a pleural fluid pH < 7.20, would benefit from drainage.

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