The treatment of complex parapneumonic effusions in children remains controversial, with some advocating less invasive, strictly medical management and others supporting a more aggressive approach of thoracotomy with or without decortication. Recent advances, including video-assisted thoracoscopic surgery and intrapleural fibrinolytic therapy, offer new options for effective treatment. We report the first case of successful resolution of a complex parapneumonic effusion in a 16-month-old girl with the use of tissue plasminogen activator (alteplase), infused via a catheter in the pleural space.
Copyright © 2003 by the American Academy of Pediatrics
2003
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Bishop et al describe the previously untried use of intrapleural Alteplase to treat a 16 month old child with a complex parapneumonic effusion. While I recognise that they may have been unaware of the randomised placebo controlled trial of intrapleural urokinase in the management of empyema, published last year1. This trial showed convincing evidence of benefit from urokinase, with few adverse effects. The median length of stay in the treatment group was 7.4 days, which compares favourably to the reported case. The best results have been found using smaller pigtail catheters (e.g. 12 French)(1,2) rather than the 16 French catheter used by Bishop. While it is important to try new treatments for conditions where treatment is ineffective, it is also crucial that these innovations are compared to effective treatments which have been undergone adequate clinical trial.
References 1. Thomson A, Hull J, Kumar M, Wallis C, Balfour Lynn I, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57:343-7. 2. Pierrepoint M, Evans A, Morris S, Harrison S, Doull I. Pigtail catheter drain in the treatment of empyema thoracis. Archives of Disease in Childhood 2002;87:331-2.