Role of Medical Interventions in Complicated Parapneumonic Pleural Effusion and Empyema

Background Complicated parapneumonic effusion (PPE) and empyema require intercostal drainage (ICD), failure of which usually leads to surgery. Intrapleural instillation of fibrinolytic agents (IFT) enhance pleural drainage and reduce the need for surgery. This study aimed to evaluate the role of medical interventions (ICD and IFT) in complicated PPE and empyema. Methods In a prospective, cohort study conducted at National Academy of Medical Sciences, Bir Hospital. Patients aged >18 years with complicated PPE and empyema were included. ICD was placed in all. In those with significant residual effusion and loculations after ICD, intrapleural Streptokinase was instilled and daily drain output recorded. Outcomes were measured as complete, partial response and treatment failure. The duration of ICD tube in situ, length of hospital stay and need for surgical interventions was evaluated at three-month follow up. Results A total of 51 patients were enrolled into the study. Commonest symptoms were dyspnea, cough, chest pain and fever with a median duration of 14 days (IQR = 7-28). The etiologies of effusions were presumed or proven bacterial infection in 36 (70.5%), tuberculosis in 8 (15.7%) and parasitic infection in 2 (3.9%). ICD was successful in achieving a complete drainage in 22 (43.1%) patients. In the remaining 29 (56.9%), intrapleural Streptokinase was instilled which led to increase in drain output by 760.34 ± 283.90 ml. Post Streptokinase instillation; 18 (62.1%), 4 (15.8%) and 7 (24.2%) patients met the predefined criteria of "complete" response, "partial" response and treatment failure respectively. The mean duration of ICD tube in situ and hospital stay was 10.98 ± 3.56 and 13.51 ± 3.92 days respectively. Conclusions In patients with complicated parapneumonic effusion and empyema, intercostal drainage and intrapleural fibrinolytic have high success rates and a potential to significantly reduce the need for surgical interventions. These results are relevant to us as thoracic surgery and VATS services are limited and only available at few centers in Nepal.