Intrapleural Fibrinolytic Therapy for Pediatric Empyema: What Is the Proper Regimen?

INTRODUCTION: Intrapleural fibrinolytic therapy (IFT) with tissue plasminogen activator (tPA) has become the first-line treatment for pediatric empyema. However, the duration and timing of doses varies widely in the literature. We aimed to review patient outcomes managed with IFT and identify the most effective treatment regimen. METHODS: We reviewed the records of all patients with empyema who underwent chest tube (CT) placement followed by tPA installation at a single children's hospital from 2012 to 2024. Patients with pleural collections due to chylothorax, malignancy, or cardiac surgery were excluded. Patients were grouped by duration and timing of fibrinolytic therapy. The primary outcome was CT duration, while secondary outcomes included length of stay, treatment failure, and complications. RESULTS: A total of 113 chest tubes were placed in 106 patients, with a median age of 6.2 y. Sixty percent were male, 51% were admitted to the intensive care unit, and 30% required mechanical ventilation. Forty-four patients (38.9%) received fewer than 3 d of tPA, 44 (38.9%) received 3 d, and 25 (22%) received >3 d. Sixty-five patients (58%) received consecutive doses of tPA. Patients who received 3 d had the shortest CT duration (6 d) (P = 0.013). Consecutive therapy (back-to-back days) was associated with a shorter duration of CT (6 d) than selective (9.5 d) (P = 0.002). Three (2.7%) patients required operative decortication. CONCLUSIONS: IFT of any duration is a highly effective and safe therapy for pediatric empyema. Consecutive doses for 3 d are associated with the shortest duration of CT treatment.