Ahmed Alaeldin H, Yacoub Tariq E
Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan.
Clin Pharmacol. 2010;2:213-21. doi: 10.2147/CPAA.S14104. Epub 2010 Nov 22.
Empyema thoracis causes high mortality, and its incidence is increasing in both children and adults. Parapneumonic effusions (PPEs) develop in about one-half of patients hospitalized with pneumonia, and their presence increases mortality by about four-fold. PPEs can be divided into simple PPEs, complicated PPEs, and frank empyema. Two guideline statements on the management of PPEs in adults have been published by the British Thoracic Society (BTS) and the American College of Chest Physicians; a third guideline statement published by the BTS focused on management of PPEs in children. The two adult guideline statements recommend drainage of the pleural space in complicated PPEs and frank empyema. They also recommend the use of intrapleural fibrinolysis in those who do not show improvement. The pediatric guideline statement recommends adding intrapleural fibrinolysis to those treated by tube thoracostomy if they have loculated pleural space or thick pus. Published guideline statements on the management of complicated PPEs and empyema in adults and children recommend the use of intrapleural fibrinolysis in those who do not show improvement after pleural space drainage. However, published clinical trial reports on the use of intrapleural fibrinolysis for the treatment of pleural space sepsis suffer from major design and methodologic limitations. Nevertheless, published reports have shown that the use of intrapleural fibrinolysis does not reduce mortality in adults with parapneumonic effusions and empyema. However, intrapleural fibrinolysis enhances drainage of infected pleural fluid and may be used in patients with large collections of infected pleural fluid causing breathlessness or respiratory failure, but a proportion of these patients will ultimately need surgery for definite cure. Intrapleural streptokinase and urokinase seem to be equally efficacious in enhancing infected pleural fluid drainage in adults. In most of the published studies in adults, the use of intrapleural fibrinolysis was not associated with serious side effects. There is emerging evidence that the combination of intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) is significantly superior to tPA or DNase alone or placebo in improving pleural fluid drainage in patients with pleural space infection. In children, intrapleural fibrinolysis has not been shown to reduce mortality, but has been shown to enhance drainage of the pleural space and was safe. In addition, two prospective, randomized trials have shown that intrapleural fibrinolysis is as effective as video-assisted thoracoscopic surgery for the treatment of childhood empyema and is a more cost-effective treatment and therefore should be the primary treatment of choice.
脓胸可导致高死亡率，其在儿童和成人中的发病率均呈上升趋势。约一半因肺炎住院的患者会出现类肺炎性胸腔积液（PPE），其存在会使死亡率增加约四倍。PPE可分为单纯性PPE、复杂性PPE和真性脓胸。英国胸科学会（BTS）和美国胸科医师学会已发表了两份关于成人PPE管理的指南声明；BTS发表的第三份指南声明聚焦于儿童PPE的管理。这两份成人指南声明建议对复杂性PPE和真性脓胸进行胸腔引流。它们还建议对病情无改善的患者使用胸腔内纤维蛋白溶解疗法。儿科指南声明建议，如果接受胸腔闭式引流术治疗的儿童存在包裹性胸腔积液或浓稠脓液，则在治疗中加入胸腔内纤维蛋白溶解疗法。已发表的关于成人和儿童复杂性PPE及脓胸管理的指南声明建议，对胸腔引流后病情无改善的患者使用胸腔内纤维蛋白溶解疗法。然而，已发表的关于使用胸腔内纤维蛋白溶解疗法治疗胸腔感染的临床试验报告存在重大设计和方法学缺陷。尽管如此，已发表的报告表明，胸腔内纤维蛋白溶解疗法并不能降低成人类肺炎性胸腔积液和脓胸的死亡率。然而，胸腔内纤维蛋白溶解疗法可增强感染性胸腔积液的引流，可用于因大量感染性胸腔积液导致呼吸困难或呼吸衰竭的患者，但这些患者中有一部分最终需要手术才能彻底治愈。胸腔内链激酶和尿激酶在增强成人感染性胸腔积液引流方面似乎同样有效。在大多数已发表的成人研究中，使用胸腔内纤维蛋白溶解疗法未出现严重副作用。有新证据表明，在改善胸腔感染患者的胸腔积液引流方面，胸腔内组织型纤溶酶原激活剂（tPA）与脱氧核糖核酸酶（DNase）联合使用明显优于单独使用tPA或DNase或安慰剂。在儿童中，胸腔内纤维蛋白溶解疗法未显示可降低死亡率，但已证明可增强胸腔引流且安全。此外，两项前瞻性随机试验表明，胸腔内纤维蛋白溶解疗法在治疗儿童脓胸方面与电视辅助胸腔镜手术效果相同，且是一种更具成本效益的治疗方法，因此应作为首选的主要治疗方法。
