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National University of Singapore, Singapore
Correspondence to: Tow K. Lim, MBBS, Department of Medicine, National University of Singapore, 5 Lower Kent Ridge Rd, Singapore 119074; e-mail: mdclimtk@nus.edu.sg
To the Editor:
In his editorial comment on the management of fibrino-purulent parapneumonic effusions and empyema (March 1999),1 Dr. Yim recommended that those pleural fluid collections that do not resolve after 2 days of chest-tube drainage should be evacuated by video-assisted thoracic surgery (VATS). We are disappointed that he did not cite recent evidence from prospectively controlled studies on the management of empyema and parapneumonic effusions. This might have led him to a slightly different conclusion.
Bouros et al,2 in a randomized, double-blind study of 31 patients, showed that a 3-day regimen of intrapleural urokinase (compared with normal saline solution) significantly reduced the length of hospital stay (13 days vs 18 days, respectively) and the need for further intervention (13.5% vs 37.5%, respectively, of all patients). The results of adjunctive treatment with intrapleural streptokinase, however, have been less impressive. In two controlled studies with a total of 76 patients, streptokinase failed to significantly reduce the duration of hospitalization or the need for surgical drainage.3 4 Moreover, Wait et al,5 in a randomized, controlled study of 20 patients with multiloculated parapneumonic effusions and empyema, showed that primary treatment with VATS resulted in significantly shorter hospital stays and lower costs than intrapleural streptokinase therapy.
Thus, the evidence suggests that VATS is, indeed, cost-effective if employed without delay as a primary treatment. If, however, as suggested by Dr. Yim, a trial of chest-tube drainage is to be attempted in the first 2 to 3 days, probably it should be augmented by a fibrinolytic agent such as urokinase. Unless the pleural sepsis resolves clinically and radiologically, more aggressive methods such as VATS should be employed without further delay.2 Lim and Chin6 have shown in a controlled study of 82 consecutive patients that an empirical treatment strategy that combined intrapleural fibrinolysis with early surgical intervention resulted in shorter hospitalizations (15 days vs 22 days, respectively) and lower mortality rates (3% vs 15%, respectively).
References
The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
Correspondence to: Anthony P.C. Yim, MD, FCCP, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong, SAR, China; E-mail:yimap@cuhk.edu.hk
To the Editor:
I thank Dr. Lim for his comments. I agree that early surgical intervention should be considered in the management of complicated effusions and empyemas, and that was indeed the message of my editorial. The role of a fibrinolytic agent, used either as primary therapy or in combination with surgery in the management of this condition, however, remains to be better defined.
The nice study by Bouros and colleagues1 was published after I wrote the editorial; hence, I did not have an option to refer to it earlier. The authors found intrapleural urokinase to be effective in 13 of 15 patients (87%), which is far better than the reported success with streptokinase.2 However, in the control group, which received intrapleural saline solution, success was encountered in 4 of 16 patients (25%), suggesting that for some patients, fibrinolytic treatment was unnecessary. Also of note is that of the 12 patients in the control group who subsequently switched over to receive urokinase, only half of them were successfully treated, suggesting that urokinase is not always effective either. In comparison, all of the patients who failed conservative therapy had success with video-assisted thoracoscopic (VATS) drainage.
I have reservations about recommending intrapleural fibrinolytics to be used routinely outside of a study protocol setting. First, it is costly, not always effective, and sometimes unnecessary. Second, although it does not seem to affect coagulation parameters, there have been anecdotal reports of associated major local bleeding.3 4 The possibility remains that prior fibrinolytic treatment could interfere with subsequent management. Third, and what I worry about the most, is that it would delay the patients from getting surgical drainage,5 resulting in the progression of disease to stages increasingly more difficult to treat.
On the other hand, although VATS is highly effective, it is not necessary for every patient with empyema. Using it indiscriminately will not only subject some patients to an unnecessary operation, but it will also raise the overall hospital cost in treating this condition. I do not agree with Dr. Lim that an initial trial of chest tube drainage constitutes a delay in management. Rather, I believe that it helps to select the right patients for VATS. Although it is refreshing to have a pulmonologist ask for immediate surgery, the temptation to use VATS nonselectively6 without a trial of conservative therapy should be resisted.
References
This article has been cited by other articles:
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  M. H. Brutsche, G.-F. Tassi, S. Gyorik, M. Gokcimen, C. Renard, G. P. Marchetti, and J.-M. Tschopp Treatment of Sonographically Stratified Multiloculated Thoracic Empyema by Medical Thoracoscopy Chest, November 1, 2005; 128(5): 3303 - 3309. [Abstract] [Full Text] [PDF]
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