Taylor R F, Rubens M B, Pearson M C, Barnes N C
London Chest Hospital, UK.
Thorax. 1994 Sep;49(9):856-9. doi: 10.1136/thx.49.9.856.
Significant morbidity and mortality result from the ineffective evacuation of empyema. Failure of conventional first line treatment with closed intercostal tube drainage and antibiotic therapy may result in fibrin deposition and loculated empyema. Enzymatic debridement using intrapleural instillation of streptokinase is a non-invasive therapeutic option which may obviate the need for surgical intervention.
Eleven adults with multiloculated post-pneumonic empyemas who had failed to respond satisfactorily to intercostal tube drainage and antibiotic therapy were treated with intrapleural streptokinase between November 1992 and January 1994. A small catheter was inserted under ultrasound guidance into a loculation within the pleural space. Aliquots of 250,000 units of streptokinase in 100 ml normal saline were instilled into the pleural cavity and the tube clamped for four hours. Response was assessed by clinical outcome, measurement of drain output after unclamping, and subsequent pleural ultrasound, chest radiography, or both.
Streptokinase enhanced drainage in all patients. Complete resolution of the empyema with re-expansion of the underlying lung was effected in eight patients, all of whom remain well. Further resolution of minimal pleural thickening was shown on subsequent chest radiographs. Two patients with considerably thickened visceral pleura following empyema drainage underwent successful decortication. The other, with myocarditis and a pyopneumothorax, underwent surgery for non-resolution of the pneumothorax but died perioperatively from cardiac failure. The number of streptokinase instillations per patient ranged from two to six (median three), and the volume of empyema fluid drained per patient ranged from 100 ml to 4870 ml (median 900 ml). Streptokinase was well tolerated in all patients.
Intrapleural streptokinase is an effective adjunct in the management of complicated empyema and may reduce the need for surgery.
脓胸引流不畅会导致严重的发病率和死亡率。传统的一线治疗方法，即肋间闭式引流和抗生素治疗失败，可能会导致纤维蛋白沉积和局限性脓胸。通过胸腔内注入链激酶进行酶促清创是一种非侵入性治疗选择，可能无需手术干预。
1992年11月至1994年1月期间，对11例多房性肺炎后脓胸患者进行了治疗，这些患者对肋间引流和抗生素治疗反应不佳。在超声引导下，将一根小导管插入胸膜腔内的一个分隔中。将25万单位链激酶溶于100ml生理盐水中，注入胸腔，然后夹闭导管4小时。通过临床结果、夹闭后引流液量的测量以及随后的胸膜超声、胸部X线检查或两者来评估反应。
链激酶使所有患者的引流量增加。8例患者的脓胸完全消退，肺复张，所有患者情况良好。随后的胸部X线片显示胸膜增厚进一步减轻。2例脓胸引流后脏层胸膜明显增厚的患者成功进行了剥脱术。另一例患有心肌炎和气胸的患者因气胸未缓解接受了手术，但在围手术期死于心力衰竭。每位患者链激酶的注入次数为2至6次（中位数为3次），每位患者排出的脓胸液体量为100ml至4870ml（中位数为900ml）。所有患者对链激酶耐受性良好。
胸腔内注入链激酶是治疗复杂性脓胸的有效辅助方法，可能减少手术需求。
