Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions.

OBJECTIVE The management of parapneumonic effusions in children is controversial. The objective of this study was to evaluate the effectiveness and safety of intrapleural tissue plasminogen activator (tPA) in children who require tube thoracostomy for drainage of a complicated parapneumonic effusion. METHODS An observational cohort study was used to compare children who were treated with intrapleural tPA (either early or late administration) with children who were treated with thoracostomy tube drainage alone. RESULTS Over a 6-year period, 12 children received early tPA (within 24 hours of diagnosis), 18 children received late tPA (>24 hours after diagnosis), and 23 children received thoracostomy tube drainage alone for the management of a complicated parapneumonic effusion. Total pleural fluid drainage was highest for the late tPA group (691 mL vs 360 mL in the control group); however, the rate of pleural fluid drainage was highest for the early tPA group (7 mL/h vs 3 mL/h in the control group). The duration of chest tube placement was 84 hours for the early tPA group, 209 hours for the late tPA group, and 130 hours for the control group. There was a significant difference in duration of chest tube placement between the early and late tPA groups. No child who was treated with tPA developed local or systemic bleeding. CONCLUSIONS Early administration of intrapleural tPA seems to be a safe and potentially effective treatment in children with complicated parapneumonic effusions. Randomized controlled trial evidence is needed to confirm this finding.