Tissue plasminogen activator for the treatment of parapneumonic effusions in pediatric patients.

Intrapleural fibrinolysis has been investigated for the treatment of pleural effusion for several decades. Fibrinolytics have the ability to break up fibrin and loculations that characterize complicated pleural effusions, facilitating drainage. Older fibrinolytics such as urokinase and streptokinase have been replaced by tissue plasminogen activator (tPA) for this indication due to product availability and a more favorable safety profile. The literature supports tPA as a treatment approach for this indication in adult patients, and the use of tPA has become a standard management approach in this population. Over the past decade, data on the efficacy of intrapleural fibrinolytic therapy in children have also been generated, which now support the use of fibrinolysis as a treatment alternative to more invasive therapeutic options such as surgical intervention. In this review, we discuss the pathophysiology, diagnosis, and treatment of parapneumonic effusion and empyema, with a focus on intrapleural fibrinolysis, specifically tissue plasminogen activator, in the pediatric population. Recent articles provide sufficient evidence to support the use of this drug in pediatric patients for the management of pleural effusions; however, due to study heterogeneity, questions remain that may be addressed in future studies.