Thoracic Kyung Soo Won Kyung

Lee, MD Bae, MD

#{149} Jung-Gi #{149} Byoung

Treatment Empyemas A Prospective The

Im, MD Ho Lee,

authors

prospectively treated 10 patients with multiloculated empyemas with intracavitary instillation of urokinase via a percutaneous drainage catheter. Urokinase (100,000 IU) in 100 mL of 5% dextrose in water was instilled into the pleural cavity via a percutaneous drainage catheter. After overnight clamping, the catheter was opened and the empyema drained with use of negative suction (20 cm H2O). Intermittent irrigation of the catheter with normal saline was performed to prevent clogging of the catheter. Complete drainage of multiloculated empyemas was accomplished in nine patients by means of intracavitary instillation of urokinase via a single 8-F catheter. One patient showed complete drainage of multiloculated empyema, but recurrent empyema appeared in the site of a previous tube thoracostomy. A total of 100,000-700,000 IU (mean, 400,000 IU) of urokinase were needed for complete drainage in all patients. Plasminogen and fibrin degradation product levels in empyema fluid were determined before instillation of urokinase to demonstrate any fibrinolytic action. No complications occurred. Index

terms:

Radiology

From

66.204, 1991;

Empyema, 66.76, 66.20, 66.21, 66.234 #{149} Urokinase,

66.201, 66.76

179:771-775

the Departments of Radiology (K.S.L., S.H.H., W.K.B., B.H.L.) and Internal Medicine (Y.H.K.), Soonchunhyang University Hospital, No. 23-20, Bongmyung-Dong, Chunan, 330100, Korea, and the Department of Radiology, Seoul National University Hospital, Seoul (J.G.I.). Received October 22, 1990; revision requested December 7; revision received January 7, 1991; accepted January 16. Address reprint requests to K.S.L. #{176}RSNA, 1991 1

Hoon

Kim,

MD

e Sun

Hee

Hwang,

MD

of Thoracic Multiloculated with Intracavitary Urokinase: Study’

consecutive

66.202,

#{149} Yong MD

Radiology

S

INCE

the

successful

treatment

of

thoracic empyemas with percutaneous catheter drainage by vanSonnenberg et al in 1984, percutaneous catheter drainage has been regarded as a primary

treatment

modality

for

thoracic empyemas, with cure rates of 80%-90% (1-4). Failure of percutaneous catheter drainage in the treatment of thoracic empyemas is due to multiloculation and the fibrinous and viscous nature of empyemic fluid (1-4). Active empyemas can be differentiated into three stages (4-6). Stage I empyemas are exudative, characterized by thin pleural fluid, with a low white blood cell count (pleural pH> 7.20, glucose > 40 mg/dL [2.2 mmol/ L]). Stage H empyemas are fibrinopurulent, characterized by thicker, more turbid fluid, with the appearance of fibrin on the pleural surfaces that begins to form a peel around the lung; stage II empyemas may be subcategorized into early stage II empyemas (no gross pus, pH of 7.00-7.20, glucose > 40 mg/dL [2.2 mmol/L]) and late stage II empyemas (gross pus, pH < 7.00, glucose < 40 mg/dL [2.2 mmol/L]) (5,6). Stage III empyemas are chronic, characterized by thickened pleural peel with infiltration of fibroblasts, entrapment of the lung, and restriction of lung motion. Multiloculation can develop during the fibrinopurulent stage (stage II) as fibrin is deposited on the pleural surface. Instillation of intrapleural streptokinase and streptodornase to accelerate drainage of loculated hemothorax and empyema has been reported since the 1950s (7-9). Vogelzang et al reported successful treatment of infected extravascular hematomas with transcatheter

tion tary

intracavitary

of urokinase instillation

streptodornase

instilla-

instead of intracaviof streptokinase and (10).

ton et al successfully who had loculated

Recently,

with transcatheter intracavitary urokinase (11), but, unlike our study protocol, they instilled urokinase via multiple catheters in three of five patients. In our clinical prospective study, we evaluated the potential role of intracavitary instillation of urokinase via a percutaneous drainage catheter for the lysis of the fibrin septa that are present in multiloculated thoracic empyemas. PATIENTS

AND

METHODS

We performed prospective intracavitary urokinase treatment in 10 consecutive patients with multiloculated pleural empyemas from January 1989 to June 1990. Patients were eight men and two women, ranging in age from 35 to 76 years (mean, 57 years). To be included, patients met the foblowing criteria: (a) The pleural empyemas were boculated; no fluid shifted during radiography in the decubitus position. (b) Multiboculation was demonstrated in the empyema cavity at computed tomography (CT). (c) The patients had received no treatment except diagnostic thoracentesis. (d) Clinical evidence showed that the pleural empyema had been present for at least 7 days, but not for more than 6 weeks (Wilcox has suggested that dense scar tissue begins to form in a pleural peel at the 6th week after the onset of acute illness [12]). Multiboculation of empyemas was defined on the basis of consecutive CT findings of more than two bocules that were separated and without communication. All patients met these criteria except one patient who was referred for intracavitary urokinase treatment after failure of previous treatment with conventional tube

thoracostomy.

patients, except one with tubercubus empyema, had postpneumonic empyemas that had been diagnosed clinicalby and radiologically. Most patients showed clinical symptoms of a septic condition. In addition, signs of a pneumonic All

process in lung in radiographs

Moul-

The nine

treated patients pleural effusions

tubercubous in one case

parenchyma or CT scans

active empyemas effusion) were (pH

of 7.0-7.2,

were of the

found chest.

(except one early stage II glucose

>40

771

Figure 1. Multiloculated empyema in a 40year-old woman. (a, b) CT scans show large, multiloculated empyema in superior portion of right major fissure and lateral posterior pleural space in lower level. Air in pleural

space

is due

(c) Lateral

to previous

.

-

thoracentesis.

radiograph

with percutaneous a large loculated

-

after

natural

catheter empyema

drainage

drainage in superior

shows por-

tiort of right major fissure and small amount of empyema in posterior pleural space (arrows). (d) Lateral radiograph after instillation of 200,000 IU of urokinase shows that

loculated empyema right major fissure scans kinase

after

in superior portion of is much smaller. (e, ft CT

instillation

show

empyema.

of 500,000

IU of uro-

nearly complete drainage of There is mild pleural thickening

in right major fissure (arrow nor pleural cavity (arrowheads

in e) and in f).

poste-

mg/dL [2.2 mmol/L]) and late stage II in eight cases (pH < 7.0, glucose < 40 mgI dL [2.2 mmol/L]). After needle aspiration of fluid to be analyzed for protein and glucose levels, cell count, Gram stain, and culture, an 8-F

drainage catheter with six side holes (Percuflex; Medi-tech/Boston Scientific, Watertown, Mass) was inserted. The level of pleural plasminogen in the aspirate was assessed by using the chromogenic method, with substrate 2251, to demonstrate the presence of substrate for action of urokinase. Fibrin degradation product

was also measured Weilco test of fibrinolytic fluid,

as well

as in the

In all patients, inserted

by using

the Thrombo-

to demonstrate the existence activity in the empyema

with

serum.

a single

8-F catheter

fluoroscopic

guidance

was into

the largest locule demonstrated at CT. After catheter insertion, pleural fluid was drained via the catheter, which was connected to water-seal suction (negative

pressure

of 20 cm H20),

but drainage

stopped in 1-2 days in most cases. Treatment with intracavitary urokinase began when little or no drainage appeared (