To Study the Role of Intrapleural Streptokinase in The Treatment of Loculated Pleural Effusions - A Randomized Controlled Trial

Background: Loculated pleural effusions respond poorly to simple tube drainage, and surgical options are invasive and not widely available in resource-limited settings. Intrapleural fibrinolysis may be a practical alternative. We compared intrapleural streptokinase with saline irrigation in loculated pleural effusions. Material and Methods: In this randomised controlled trial at a tertiary care hospital in Mumbai, 50 adults with ultrasound-confirmed loculated pleural effusion were allocated by block randomisation to streptokinase (n = 25; 2.5 lakh IU in 100 mL saline per wash) or normal saline (n = 25) instilled through an intercostal drain or pigtail catheter, clamped for 2 hours, for 3 to 4 consecutive days. All patients received antitubercular therapy when indicated. Drain output, serial chest radiographs, post-wash ultrasonography, catheter duration, hospital stay, need for surgery and adverse reactions were recorded, with follow-up at 2 weeks, 2 months and 6 months. Success was defined as complete radiological resolution without surgery. Results: Tubercular effusion accounted for 86% of cases. Mean daily drain output was significantly higher with streptokinase on every wash day (day 1: 310.8 vs 202.0 mL, p < 0.001). Complete radiographic resolution on day 3 was 84% vs 44% (p = 0.003) and was sustained at 6 months. Complete dissolution of adhesions on ultrasonography was 60% vs 36% (p = 0.030). Catheter duration (14.4 vs 23.1 days) and hospital stay (16.5 vs 28.4 days) were shorter with streptokinase (both p < 0.001). Overall success was 84% vs 44% (p = 0.003). Surgery was needed in 1 (4%) vs 4 (16%) patients (p = 0.35, not significant). Fever with chills occurred in 16% of each group. Conclusion: Intrapleural streptokinase improved drainage, radiological resolution and hospital stay compared with saline in loculated pleural effusions, mostly of tubercular origin, with acceptable tolerability. It is an affordable option where thoracoscopic surgery is not readily available; larger, blinded multicentre trials are needed.

Keywords: Loculated Pleural Effusion, Streptokinase, Intrapleural Fibrinolysis, Tubercular Pleural Effusion, Randomised Controlled Trial.