Narrative review and creation of an institutional protocol for the use of fibrinolytics in parapneumonic effusion in children

Abstract

Objective: Pneumonia is the leading cause of morbidity and mortality in children under 5 years old, with an increasing incidence of parapneumonic pleural effusion. Pleural effusion is a common complication, sometimes requiring surgical intervention. A literature review was conducted on parapneumonic pleural effusion and its treatment in the pediatric population, and an institutional protocol for intrapleural fibrinolysis was developed.

Data sources: Articles from the past 15 years were reviewed in the databases PubMed-MEDLINE, LILACS, Cochrane, and Scielo using the terms pleural effusion, empyema, pneumonia, fibrinolytic, and children. A protocol for intrapleural fibrinolytic use in cases of parapneumonic pleural effusion was established.

Summary of findings: Fifteen studies were included in the review. Chest ultrasound was the imaging modality used for diagnosis and monitoring. Most studies evaluated and compared the use of pleural drainage combined with fibrinolytics and video-assisted thoracoscopic surgery (VATS). The most used fibrinolytics were tissue plasminogen activator and urokinase. Hospitalization duration and adverse effects were similar across groups. The therapeutic failure rate of chemical debridement ranged from 0 to 37.2%. VATS and drainage combined with fibrinolytics were safe and well-tolerated, offering advantages over simple pleural drainage.

Conclusions: Chemical debridement is cost-effective and less invasive, with complication rates and hospitalization times similar to VATS, making it preferable as a first-line treatment. The created protocol will standardize institutional practices and support evidence-based decision-making.

Keywords: Children; Empyema; Fibrinolytic agents; Pneumonia.

Figure 1

Patient management protocol.