Medical management of pleural infection: Why not saline intrapleural lavage?

[...]MIST-1 trial comparing streptokinase to placebo with the aim to reduce mortality (primary outcome), hospital stay, and surgical referral (secondary outcomes) showed no difference between the two groups. The following MIST-2 trial showed significant effect in improving chest X-ray (primary outcome), although failed to enroll the predicted number of patients, reducing the surgical referral and the length of hospital stay with the combination of r-TPA to DNAse. The recent Cochrane meta-analysis comparing intrapleural fibrinolytic therapy to placebo concluded that fibrinolytics were associated with a reduction of surgical intervention and overall treatment failure but with no evidence of change in mortality. [...]the mechanical process of irrigation increases pleural fluid drainage by reducing stasis and organization of the intrapleural contents. [...]saline irrigation resulted in a 32.3% reduction in computed tomography-assessed pleural collection volume, compared to 15.3% receiving standard care (p = 0.03) and referral to surgery (p = 0.03), with no difference in mortality rates.