In this issue of JAMA Pediatrics, Livingston et al1 address the important question of whether a therapy demonstrated to improve the care of adult patients with empyema, the addition of dornase alfa (DNase) to tissue plasminogen activator (tPA) intrapleural therapy, has similar benefits in children. The utility of DNase in adults requiring pleural drainage for empyema has been established in a prior randomized clinical trial by Rahman et al.2 In that study, adult patients who received a combination of intrapleural DNase and tPA had improved pleural effusion size compared with patients receiving DNase alone, tPA alone, and double placebo. Patients receiving the combination treatment also had a 6.7-day reduction in hospital stay (from randomization to discharge) and 77% fewer referrals for thoracic surgery within 3 months compared with patients receiving placebo. In this pediatric study,1 the authors use a pragmatic approach to determine whether the addition of intrapleural DNase to tPA therapy would provide clinically meaningful benefits for otherwise healthy children requiring pleural drainage for empyema when compared with the standard treatment of tPA alone. Chest tube placement with installation of tPA has previously been shown in a randomized clinical trial to be an efficacious primary drainage modality for children with empyema and less costly than primary video-assisted thoracoscopic surgery.3
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Kohler J, Kelly MM. Addition of Dornase to Intrapleural Fibrinolytic Therapy Is Not Superior to Fibrinolytic Therapy Alone for Otherwise Healthy Children Hospitalized With Empyema. JAMA Pediatr. 2020;174(4):323–324. doi:10.1001/jamapediatrics.2019.5910
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