Intrapleural Fibrinolysis with tPA-Based Regimens

Standard Treatment Protocol

The American College of Chest Physicians recommends using tPA 10 mg combined with DNase 5 mg twice daily for 3 days for intrapleural fibrinolysis in pleural infection, as this combination is significantly more effective than either agent alone 1
The standard regimen of tPA 10 mg + DNase 5 mg administered twice daily for 3 days results in significant reduction in hospital length of stay, decreased likelihood of persistent fevers, increased radiographic improvement, and increased fluid drainage volume 1

The guideline recommends administering tPA/DNase through an existing chest tube after initial drainage has slowed, clamping the chest tube for 1 hour after instillation, and obtaining patient consent due to potential bleeding risk 1

The British Thoracic Society recommends against using streptokinase for pleural infection treatment due to its lack of beneficial effect, increased post-treatment complications, and higher risk/benefit ratio compared to other fibrinolytics 1, 2, 3
Urokinase has significant limitations, including no longer being available in North America, and has shown inferior efficacy compared to alteplase in direct comparison 3, 4, 5