Intrapleural enzyme therapy for parapneumonic effusion or thoracic empyema in adults

Intrapleural enzyme therapy is a combination of:

• recombinant human DNase (dornase alfa) – reduces intrapleural pus viscosity
• a fibrinolytic (alteplase).

Intrapleural enzyme therapy significantly reduces length of hospital stay and the need for surgical interventionRahman, 2011. Neither drug is currently registered by the Australian Therapeutic Goods Administration (TGA) for this indication. Seek advice from a respiratory physician on whether intrapleural enzyme therapy is indicated for parapneumonic effusion or thoracic empyema (see also Definitions and management of parapneumonic effusion and thoracic empyema).

Administration of intrapleural enzyme therapy is a highly specialised area and should only be undertaken by a clinician with relevant expertise and experience. Therapy is only effective when both drugs (dornase alfa with alteplase) are used. Various dosages are used in practice; evolving evidence suggests that low doses may be efficacious and usually up to 6 doses are usedPopowicz, 2017Popowicz, 2022Rahman, 2011. The dosage and duration of therapy should be guided by the respiratory physician involved.