A comparative study of three therapeutic modalities in loculated tuberculous pleural effusions

Abstract

Although most of the patients with tuberculous pleural effusions completely reabsorbed their effusions and became asymptomatic within 2 to 4 months, later surgical procedures such as decortication is needed in some patients because of dyspnea caused by pleural loculations and thickening despite anti-tuberculous chemotherapy. It is obligatory to secure adequate drainage to prevent the development of complications. But, the best methods for treating loculated tuberculous pleural effusions remain debatable. Recent several reports revealed that intrapleural instillation of fibrinolytic agents is an effective adjunct in the management of complicated empyema and may reduce the need of surgery. Purpose: The effects of catheterization with intrapleural urokinase instillation were prospectively evaluated in the patients with septated tuberculous pleural effusion, and compared with other therapeutic effects of different modalities of therapy such as repeated thoracentesis and small-bored catheterization. Methods: Forty-eight patients diagnosed with tuberculous pleurisy were randomly separated into three groups: control group (n=13), catheter group (n=12), urokinase group (n=22). In urokinase group, dose of 100,000 U urokinase was instilled into the pleural cavity via a percutaneous drainage catheter for complete drainage or total dose of 700,000 U of urokinase. After two hours clamping, the catheter was opened and intermittently irrigated. The early and late effectiveness of therapies was assessed by radiographically and by measuring the volume of fluid drained from the catheter. Results: There was statistically significantly better result in the urokinase group in respect of frequency of catheterization, frequency of catheter obstruction and the duration of catheterization in early effectiveness (p < 0.05). There were no difference in radiologic improvement of follow-up in later phase chest X-ray between urokinase group and catheter group in later phase (p > 0.05). But there were more failure rates in control group especially honeycomb septa in pleural effusion sonographically than former two groups. And there were no complications of urokinase such as fever or hemorrhage. Conclusion: In the treatment of septated tuberculous pleurisy, there were better results in urokinase than those of catheterization alone in early effectiveness. And there was no difference in radiographic improvement between urokinase group and catheter group. Intrapleural instillation of urokinase is an effective and safe mode of treatment for septated tuberculous pleural effusions and alleviates the need for thoracotomy.