الفهرس 
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Abstract
Despite the improvement in the management options of pleural effusion; intrapleural adhesions remain a significant problem in many patients with pleural disease. The most common causes are parapneumonic effusion, malignancy, tuberculosis and clotted haemothorax.
In our study we found that the shorter the duration of illness, the higher the success rate of intrapleural adhesiolysis.
We noticed in our study that the more the frequency of thoracentesis, the higher the incidence of adhesions and the higher the failure of adhesiolysis.
The lower the pH of the pleural fluid (<7.2) the higher the incidence of adhesions.
from our results we detected that one ampoule of streptokinase (6 doses) or less was successful in most cases (88%).
Chest x-ray gave us a rough idea about the improvement or failure after adhesiolysis.
While chest ultrasonography plays a central role in management of pleural effusion especially with adhesions from the start for detection of adhesions as well as for assessment after adhesiolysis. The presence of complex septated effusion suggested higher rate of failure (86%), while the presence of mobile septa suggest higher success rate (100%).
This concludes the more comlex the septations of the effusion , the more high the failure rate.
So, the use of intrapleural fibrinolytics is a safe easy and cost effective option specially in patients who are not candidates for surgery.
Intrapleural purified streptokinase may be used as an adjunct to initial chest tube drainage when there is residual collection of pleural fluid. Summary and conclusion Streptokinase enhances the drainage of fluid, which is loculated or too viscous to be drained by tube thoracostomy alone.
The study concludes the safety, cost effectiveness and efficacy of intrapleural streptokinase. However, each patient should be evaluated individually with consideration of stage, etiology of effusion and condition of the patient.
It is noticed that the earlier the presentation, the more likely the chance for successful drainage without surgical intervention.
However, still the optimum time for the introduction of intrapleural streptokinase in the medical management of loculated pleural effusion is controversial.
Regarding the evaluation with chest ultrasonography, it is noticed that identification of fluid loculations and pleural thickening may give a clue for the need of intrapleural fibrinolytics, and daily follow up of the patient with chest ultrasonography represent a sufficient method for follow up without the hazardous of irradiation.
Recommendation
At the end of our study, we recommend further trials to be done in this aspect (preferably a multicenter controlled trials) to clarify the role of this technique in the management of adhesive pleural effusion.
As we found encouraging results, we suggest another fibrinolytic agents with a larger number of patients to be studied in this aspect to found the optimal intrapleural fibrinolysis protocol.