Intrapleural Enzyme Therapy Outperforms Saline Lavage in Pleural Infection: SCOPE Trial
Spain: A study published in the European Respiratory Journal reports that saline lavage alone may prolong pleural drainage in patients with pleural Infection compared with intrapleural enzyme therapy (IET). The findings also indicate that adding saline lavage to IET does not provide a meaningful clinical advantage over enzyme therapy alone.
Pleural infection, including complicated parapneumonic effusion and Empyema, often requires chest tube drainage along with antibiotic therapy. Intrapleural enzyme therapy—commonly involving fibrinolytics and DNase—is frequently used to enhance fluid drainage by breaking down fibrinous septations and reducing fluid viscosity. However, the clinical value of saline lavage, either as a standalone treatment or combined with enzyme therapy, has remained unclear.
To investigate this, researchers led by José M. Porcel from the Pleural Medicine and Clinical Ultrasound Unit at Arnau de Vilanova University Hospital in Lleida, Spain, conducted the SCOPE trial, a randomized superiority study. The trial aimed to determine whether saline lavage alone or in combination with enzyme therapy was superior to standard IET in adults with pleural infection.
The two-center prospective study included 89 patients with pleural infection, with a median age of 62 years; 73% were men. Participants were randomly assigned to one of three treatment groups: saline lavage alone (30 patients), saline lavage combined with IET (30 patients), or IET alone (29 patients). The enzyme therapy regimen consisted of once-daily intrapleural administration of 100,000 units of urokinase and 10 mg of DNase.
All patients also received broad-spectrum empiric antibiotics—most commonly amoxicillin-clavulanate—initially given intravenously and later switched to oral therapy once fever resolved. Antibiotic treatment lasted at least two weeks and could be extended depending on clinical response.
The primary outcome was the duration of pleural drainage, measured from randomization until chest tube removal. Secondary outcomes included radiographic reduction of pleural effusion on days two and five, length of hospital stay, and mortality or adverse events within 90 days.
Key Findings:
- Saline lavage alone was associated with a longer pleural drainage duration compared with enzyme-based treatment.
- The median drainage duration was 4 days in the saline-only group versus 3 days in both the intrapleural enzyme therapy (IET) alone and saline-plus-IET groups.
- No significant difference in drainage duration was observed between the two IET-containing regimens.
- Early radiographic improvement was similar across all treatment groups.
- By day 2, all groups showed a median reduction of about 30% in pleural effusion size.
- By day 5, patients receiving enzyme therapy demonstrated greater pleural fluid resolution, with a median residual effusion of zero.
- Serious adverse events were uncommon during the study.
- One patient in the combination therapy group developed hemothorax requiring video-assisted thoracoscopic surgery.
- Three-month mortality rates and the length of hospital stay were comparable across all treatment groups.
The researchers concluded that intrapleural enzyme therapy remains the preferred treatment approach for pleural infection. The findings do not support the routine use of saline lavage unless fibrinolytic therapy is contraindicated.
Reference:
DOI: https://doi.org/10.1183/13993003.01715-2025
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