What is the key question?

• What is the safety and efficacy of early medical thoracoscopy (MT) versus intrapleural fibrinolytic therapy (IPFT) for the treatment of multiloculated pleural infection and empyema?

What is the bottom line?

• Despite treatment with antibiotics and chest tube drainage, it is estimated that 30% of patients with pleural infection and empyema experience difficulty in fluid drainage owing to loculations, septations, and increased viscosity of the pleural fluid, and about 20% will need a surgical intervention to adequately treat their pleural infection. The more recent introduction of intrapleural therapy with tissue plasminogen activator (tPA) and human recombinant deoxyribonuclease (DNase) reduced the frequency of surgical referral but this treatment is still viewed as being associated with long hospital stays.
• In this prospective multicenter randomized controlled trial, the investigators aimed at evaluating the safety and efficacy of early MT versus intrapleural fibrinolytic therapy (IPFT) in selected patients with multiloculated pleural infection and empyema. They chose their primary outcome as the duration of hospital stay after each intervention.
• A total of 32 patients with pleural infection were randomized 1:1 to MT versus IPFT. The median length of stay after an intervention was 4 days in the IPFT arm and 2 days in the MT arm (P = 0.026) but the total length of hospital stay was not statistically different between the two groups (6 days in the IPFT arm and 3.5 days in MT arm with a p = 0.12). There was no difference in treatment failure, mortality, or adverse events between the treatment groups. There were no serious complications related to either intervention.
• Some of the limitations included a small sample size, a potential bias towards MT since IPFT is typically a longer-therapy procedure (3 days) compared to MT. Also, the investigators targeted a highly selected patient population who had early-stage pleural infection, were hemodynamically stable, and were treated in centers with good expertise in MT and in management of pleural infection, all of which can affect the generalizability of the findings.

Why read on?

• MT is a minimally invasive procedure that is safe and effective for the treatment of early pleural infection in a selected patient population, and may shorten hospital stays as compared with IPFT when performed in high-volume pleural centers by experienced interventional pulmonologists.
• A multicenter trial with a larger sample size is needed to confirm the findings.