“Parapneumonic effusions evolve through a spectrum of three stages. The initial exudative stage (stage 1; analogous to simple parapneumonic effusion) is characterised by an increased outpouring of fluid into the pleural space mediated by capillary permeability. If left
untreated, persistent inflammation with the associated rise in fluid plasminogen activator inhibitor causes a decrease in fluid fibrinolytic concentrations. During this second stage (stage 2; fibrinopurulent stage), as the effusion becomes infected, septations and adhesions
induced by fibrin deposition divide the space into pockets or locules. With the proliferation of fibroblasts and the formation of a pleural peel, lung expansion becomes restricted and can result in a non-expandable lung. It is important to initiate all medical treatment before this
final so-called organising stage (stage 3) ensues.”

“This consensus statement on the use of intrapleural fibrinolytic and DNase therapy for the management of empyema is intended to offer guidance in decision making. One of the strengths of this Position Paper is that it represents the opinions and perspectives of
experts in pulmonary and thoracic surgery from 20 institutions across five countries. We anticipate considerable progress in the field of empyema in the near future and, therefore, there is likely to be a need to reassess our practice periodically, building on the suggestions and recommendations presented in this Position Paper.”

Chaddha U,et al Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. Lancet Respir Med. 2021 Sep;9(9):1050-1064.