Intrapleural Fibrinolytic Therapy versus Early Medical Thoracoscopy for Treatment of Pleural Infection. Randomized Controlled Clinical Trial

Abstract

Rationale: Pleural infection is a frequent diagnosis encountered in clinical practice associated with high morbidity and mortality. Limited evidence exists regarding the optimal treatment. Although both early medical thoracoscopy (MT) and tube thoracostomy with intrapleural instillation of tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) are acceptable treatment for patients with complicated pleural infection, there is a lack of comparative data between these modes of management. Objectives: The aim of this study was to compare the safety and efficacy of early MT versus intrapleural fibrinolytic therapy (IPFT) in selected patients with multiloculated pleural infection and empyema. Methods: This was a prospective multicenter randomized control trial of patients who underwent MT or IPFT for pleural infection. The primary outcome was the length of hospital stay following either intervention. Secondary outcomes included total length of hospital stay, treatment failure, 30-day mortality and adverse events. Results: 32 patients with pleural infection were included in the study. The median length of stay following intervention was 4 days in IPFT arm as compared to 2 days in MT (p=0.026). The total length of hospital stay was 6 days in IPFT arm and 3.5 days in MT arm (p=0.12). There was no difference in treatment failure, mortality or adverse events between treatment groups, and no serious complications related to either interventions were recorded. Conclusion: Medical thoracoscopy when used early in the course of a complicated parapneumonic effusion or empyema is safe and might shorten hospital stay in selected patients with as compared with IPFT therapy. Multicenter trial with larger sample size is needed to confirm such findings. Clinical trial registered with ClinicalTrials.gov (NCT02973139)