Intrapleural fibrinolysis for parapneumonic effusion and empyema in children

Radiology. 2003 Aug;228(2):370-8. doi: 10.1148/radiol.2282020486.


Purpose: To assess the safety and efficacy of urokinase and alteplase for intrapleural fibrinolysis in children with parapneumonic pleural fluid collections.

Materials and methods: A retrospective review was performed of 71 children with parapneumonic pleural fluid accumulations who were treated with thoracostomy tube placement and intrapleural instillation of either urokinase or alteplase. The procedures were performed with urokinase between September 2, 1995, and March 27, 1998, and with alteplase between March 30, 1998, and January 2, 2002. The medical records and daily chest radiographs were reviewed by a pediatric radiologist to ascertain demographic information, signs and symptoms, laboratory results, thoracostomy tube output, treatment details, and radiographic pleural thickness and lung opacification. Multiple variables were compared for the alteplase and urokinase groups by using univariate and multivariate statistics. We defined primary treatment success as resolution of signs and symptoms at the time of discharge, without surgical intervention.

Results: Primary treatment success was 98% for alteplase and 100% for urokinase, with no major complications. Greater pleural fluid drainage occurred with alteplase than urokinase during the 1st (P =.001) and 2nd (P =.002) days of fibrinolytic therapy, and for the duration of thoracostomy drainage (P <.001). Multivariate models showed greater total drainage with alteplase (P <.001), greater patient age (P <.001), larger tube size (P =.002), and greater volume of drainage during the 24 hours prior to fibrinolysis (P <.001).

Conclusion: Intrapleural fibrinolysis with urokinase or alteplase facilitates thoracostomy tube drainage of parapneumonic pleural fluid. With the dosing regimen used in this study, alteplase produces greater thoracostomy tube output than does urokinase.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Empyema, Pleural / complications*
  • Empyema, Pleural / diagnostic imaging
  • Empyema, Pleural / drug therapy*
  • Female
  • Fibrinolytic Agents / administration & dosage
  • Fibrinolytic Agents / therapeutic use*
  • Humans
  • Infant
  • Instillation, Drug
  • Least-Squares Analysis
  • Male
  • Pleural Effusion / complications*
  • Pleural Effusion / diagnostic imaging
  • Pleural Effusion / drug therapy*
  • Pleurodesis / methods
  • Radiography
  • Retrospective Studies
  • Statistics, Nonparametric
  • Thoracostomy
  • Tissue Plasminogen Activator / therapeutic use*
  • Treatment Outcome
  • Urokinase-Type Plasminogen Activator / therapeutic use*


  • Fibrinolytic Agents
  • Tissue Plasminogen Activator
  • Urokinase-Type Plasminogen Activator