Rational treatment of empyema in children

Thoracotomy versus Video-Assisted Thoracoscopy in Pediatric Empyema

Background

To compare the outcomes of video-assisted thoracoscopic surgery (VATS) in comparison to open thoracic surgery in pediatric patients suffering from empyema.

Methods

A prospective study was carried out in 80 patients referred to the Department of Pediatric Surgery between 2015 and 2018. The patients were randomly divided into thoracotomy and VATS groups (groups I and II, respectively). Forty patients were in the thoracotomy group (16 males [40%], 24 females [60%]; average age, 5.77±4.08 years) and 40 patients were in the VATS group (18 males [45%], 22 females [55%]; average age, 6.27±3.67 years). There were no significant differences in age (p=0.61) or sex (p=0.26). Routine preliminary workups for all patients were ordered, and the patients were followed up for 90 days at regular intervals.

Results

The average length of hospital stay (16.28±7.83 days vs. 15.83±9.44 days, p=0.04) and the duration of treatment needed for pain relief (10 days vs. 5 days, p=0.004) were longer in the thoracotomy group than in the VATS group. Thoracotomy patients had surgical wound infections in 27.3% of cases, whereas no cases of infection were reported in the VATS group (p=0.04).

Conclusion

Our results indicate that VATS was not only less invasive than thoracotomy, but also showed promising results, such as an earlier discharge from the hospital and fewer postoperative complications.

Tissue Plasminogen Activator as an Adjuvant Therapy for Pleural Empyema in Pediatric Patients

The authors retrospectively review the clinical course and outcome of 6 pediatric patients, ranging in age from 2 to 13 years, who were treated with TPA for complex empyema. Efficacy was assessed by evaluating pleural fluid drainage for 6 hours prior to and subsequent to each dose of TPA, as well as by resolution of fever and length of hospital stay. The average volume drained for 6 hours before infusion of TPA was 22.5 mL ± 18.4 mL, and the average volume 6 hours after TPA therapy was 141.7 mL ± 28.3 mL, P < .0001. After initiation of TPA therapy, 5 out of 6 patients became afebrile within 48 hours. The median length of stay after initiation of TPA therapy was 6 days, with a range from 4 days to 12 days. A discussion of other current therapies for empyema, along with a comparison of these therapies to TPA regarding the costs of therapies and risk-benefit ratios, is also included.

Outcome of Pediatric Empyema Thoracis Managed by Tube Thoracostomy

The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.

Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage

AIM

To evaluate epidemiology, pre-admission characteristics and management of paediatric parapneumonic effusions (PPEs) and empyema in a tertiary paediatric pulmonary centre between 1993 and 2010.

METHODS

Retrospective chart review study using paediatric and thoracic database searches, with particular emphasis on pre-admission characteristics, disease stage (simple or complex effusion or empyema), general management and surgical procedures.

RESULTS

One hundred children were eligible, exhibiting a significant increase in incidence from 0.5 to 2.6 per 100 000 across the study period. Baseline characteristics were similar across disease stages. Streptococcus pneumoniae was the most common pathogen. Surgical intervention beyond chest tube drainage (CTD) was required in 50%; this rate showed a particular increase in children aged 0-5 years (OR, 3.1), but was otherwise not influenced by baseline characteristics, disease stage or use of intrapleural fibrinolytics. Length of hospitalisation did not differ across disease stages or primary interventional procedures.

CONCLUSION

This study confirmed an increasing incidence of PPEs and empyema in a Scandinavian tertiary paediatric pulmonary centre. Young children exhibited higher treatment failure after CTD. Length of hospitalisation was similar across disease stages and was comparable to previous reports according to primary interventional procedure.

Intrapleural fibrinolytic therapy (IPFT) in loculated pleural effusions--analysis of predictors for failure of therapy and bleeding: a cohort study

OBJECTIVES

To assess risk factors associated with failure and bleeding in intrapleural fibrinolytic therapy (IPFT) for pleural effusions.

DESIGN

Retrospective case series.

SETTING

Two tertiary-care centres in North America.

PARTICIPANTS

We identified 237 cases that received IPFT for the treatment of pleural effusions. Data for 227 patients were compiled including demographics, investigations, radiological findings pretherapy and post-therapy and outcomes.

INTERVENTION

Fibrinolytic therapy in the form of tissue plasminogen activator (t-PA) or streptokinase.

PRIMARY AND SECONDARY OUTCOMES

Success of therapy is defined as the presence of both clinical and radiological improvement leading to resolution. Failure was defined as persistence (ie, ineffective treatment) or complications requiring intervention from IPFT. Incidence of bleeding post-IPFT, identifying factors related to failure of therapy and bleeding.

RESULTS

IPFT was used in 237 patients with pleural effusions; 163 with empyema/complicated parapneumonic effusions, 32 malignant effusions and 23 with haemothorax. Overall, resolution was achieved in 80% of our cases. Failure occurred in 46 (20%) cases. Multivariate analysis revealed that failure was associated with the presence of pleural thickening (>2 mm) on CT scan (p=0.0031, OR 3, 95% CI 1.46 to 6.57). Bleeding was not associated with any specific variable in our study (antiplatelet medications, p=0.08).

CONCLUSIONS

Pleural thickening on a CT scan was found to be associated with failure of IPFT.

Current evidence for the management of paediatric parapneumonic effusions

BACKGROUND

Parapneumonic effusions (PPE) and empyema, secondary to bacterial pneumonia, are relatively uncommon but their prevalence is increasing lately. Even if their prognosis is generally good, they may still cause significant morbidity. The traditional treatment of PPE has been intravenous antibiotics and, when necessary, chest tube drainage. Open thoracotomy with decortication has usually been applied in case of failure of the traditional approach. Lately, the use of fibrinolysis and/or video-assisted thoracoscopic surgery (VATS) are utilized in the management of PPE; however, there is still little consensus on the most effective primary treatment.

SCOPE

In this article our goal was to summarize, based on up-to-date evidence, all the management options for PPE available to physicians and weigh the benefits and risks of the most popular ones, in an effort to figure out which one is superior as a first-line approach in children.

FINDINGS

A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.

CONCLUSION

The main steps in treatment are diagnostic thoracocentesis and imaging, small percutaneous drainage, and considering fibrinolysis in complicated PPE. In case of failure, VATS should be the surgical method to be applied.

Review of video-assisted thoracoscopy in children

Open thoracotomy is the standard procedure for various thoracic diseases against which other procedures are compared. Currently Video Assisted Thoracoscopic Surgery (VATS) has gained widespread acceptance in the management of a variety of thoracic disorders. It decreases the morbidity and duration of hospital stay. A total of 133 children with various thoracic diseases who presented at a University Teaching Hospital in the Department of Pediatric Surgery, from June 2000 to December 2007, were included. Of the 133 patients,116 patients had empyema, all of whom were subjected to VATS, and an attempt at debridement/decortication and drainage was made. Other thoracic disorders treated included lung abscesses, lung biopsies, hydatid cysts, and so on. Patients with empyema were treated according to their stage of disease. Of the 116 patients who underwent thoracoscopy, 16 had to be converted to open surgery due to various reasons. The mean duration for removal of drain was three days and the average total duration of hospital stay was six days. Similarly the application of VATS was advantageous in other thoracic diseases.

Complications and treatment failures of video-assisted thoracoscopic debridement for pediatric empyema

PURPOSE

Video-assisted thoracoscopic debridement (VATD) is a well-established intervention to treat pediatric empyema. There is ongoing controversy at what stage in the treatment algorithm it should be utilized. To shed further light onto this debate, we reviewed our institutional experience looking for factors predicting treatment failure or complications of VATD.

METHODS

We retrospectively analyzed data on patients that had undergone VATD for empyema from 1995 to 2008. We used independent sample t tests and Chi-square tests (SPSS) for statistical analysis.

RESULTS

One hundred and fifty-two procedures in 151 patients [81 male (53.6%)] were identified. In 146 (96.7%) the etiology of the empyema was pulmonary, in 3 (1.98%) due to an infectious abdominal process and in 2 (1.3%) due to abdominal trauma. 118 patients (78.1%) were transferred from outside hospitals. 107 (70.1%) underwent VATD primarily, 44 (29.1%) following another procedure. The overall complication rate was 13.8%, most of which were minor. Treatment failures occurred in seven patients, resulting in three reoperations; two patients died. The average length of stay was 10.1 days, but was significantly longer if VATD followed another procedure or if a complication occurred. The risk for complications correlated with older age (6.2 vs. 8.8 years, p = 0.023) and lower hematocrit on admission (31.1 vs. 27.9%, p = 0.006).

CONCLUSIONS

VATD provided effective treatment for pediatric empyema. Complications were mostly minor, occurring more frequently in older patients and those with a lower admission hematocrit. Early VATD decreased the length of hospitalization.

Costs of treating children with complicated pneumonia: a comparison of primary video-assisted thoracoscopic surgery and chest tube placement

OBJECTIVES

To describe charges associated with primary video-assisted thoracoscopic surgery (VATS) and primary chest tube placement in a multicenter cohort of children with empyema and to determine whether pleural fluid drainage by primary VATS was associated with cost-savings compared with primary chest tube placement.

STUDY DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Administrative database containing inpatient resource utilization data from 27 tertiary care children's hospitals. Patients between 12 months and 18 years of age diagnosed with complicated pneumonia were eligible if they were discharged between 2001 and 2005 and underwent early (within 2 days of index hospitalization) pleural fluid drainage.

MAIN EXPOSURE

Method of pleural fluid drainage, categorized as VATS or chest tube placement.

RESULTS

Pleural drainage in the 764 patients was performed by VATS (n = 50) or chest tube placement (n = 714). There were 521 (54%) males. Median hospital charges were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiologic imaging charges were $5,884 (IQR, $3,142-$11,357) and $2,875 (IQR, $1,703-$4,950), respectively. Adjusting for propensity score matching, patients undergoing primary VATS did not have higher charges than patients undergoing primary chest tube placement.

CONCLUSIONS

In this multicenter study, we found that the charges incurred in caring for children with empyema were substantial. However, primary VATS was not associated with higher total or pharmacy charges than primary chest tube placement, suggesting that the additional costs of performing VATS are offset by reductions in length of stay (LOS) and requirement for additional procedures.

Toracoscopia em crianças com derrame pleural parapneumônico complicado na fase fibrinopurulenta: estudo multi-institucional

OBJETIVO: Determinar a eficácia da toracoscopia em crianças com derrame pleural parapneumônico complicado (DPPC) na fase fibrinopurulenta. MÉTODOS: Estudo retrospectivo de 99 crianças submetidas à toracoscopia para tratamento de DPPC na fase fibrinopurulenta entre novembro de 1995 e julho de 2005. A média de idade foi de 2,6 anos (variação, 0,4-12 anos) e 60% eram do sexo masculino. A toracoscopia foi realizada em três hospitais diferentes utilizando-se o mesmo algoritmo de tratamento. RESULTADOS: A toracoscopia foi eficaz em 87 crianças (88%) e 12 (12%) necessitaram de outro procedimento cirúrgico: nova toracoscopia (n = 6) ou toracotomia/pleurostomia (n = 6). O tempo médio de drenagem torácica foi de 3 dias nas crianças em que a toracoscopia foi efetiva e de 10 dias naquelas que precisaram de outro procedimento (p < 0,001). A infecção pleural de todas as crianças foi debelada após o tratamento. As complicações da toracoscopia foram fuga aérea (30%) e sangramento pelo dreno torácico (12%), enfisema subcutâneo na inserção do trocarte (2%) e infecção da ferida operatória (2%). Nenhuma criança necessitou de reoperação devido às complicações. CONCLUSÕES: A efetividade da toracoscopia em crianças com DPPC na fase fibrinopurulenta foi de 88%. O procedimento mostrou-se seguro, com baixa taxa de complicações graves, devendo ser considerado como primeira opção em crianças com DPPC na fase fibrinopurulenta.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study

BACKGROUND/PURPOSE

A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.

METHOD

A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.

RESULTS

114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.

CONCLUSION

Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Thoracic empyema, application of video-assisted thoracic surgery and its current management

PURPOSE OF REVIEW

Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention.

RECENT FINDINGS

We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy.

SUMMARY

We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.

Pleurésies purulentes communautaires de l'enfant. Où en sommes-nous?

Community-acquired pleural infection is a life-threatening complication of pneumonia in children. It seems to be more prevalent actually. This pathology is associated with an high morbidity and frequently requires prolonged hospitalization and invasives procedures. However, there is no consensus on its management in pediatrics, especially because of the lack of trials. To improve the quality of the future studies and to compare the series, a child-adapted classification is required. To date, in attempt of evidence, chest drainage or thoracocentesis-thoracoscopy are questionable. For treatment, high regimens of synergic and intravenously-delivered antibiotics seem to be the better choice.

Echo-guided management of complicated parapneumonic effusion in children

The optimal management of parapneumonic effusion and empyema in children remains controversial; currently there is insufficient evidence to give clear guidance on therapy. The aims of this study were to delineate the biochemical characteristics and to examine the effect of different therapeutic strategies on ultrasound staging of parapneumonic effusion. The ultrasonic appearances were classified according to the deposition of fibrin or formation of fibrin septations. A total of 81 patients were enrolled in the present study. Chest ultrasound was performed and results were stratified into anechoic fluid (stage 1, n = 23), with floating fibrin strands (stage 2, n = 30), and with septated fibrin (stage 3, n = 28). The mean days of fever elapsed before detection of these stages appeared to be higher at advanced stages (7.3 +/- 2.1 vs. 8.5 +/- 2.7 vs. 9.7 +/- 4.2, respectively; P = 0.03). Univariate analysis revealed that WBC, platelet count in hemogram and pH, glucose, protein, LDH in pleural effusion were significantly associated with the stages of parapneumonic effusion. Multivariate logistic analysis revealed that pH (less than 7.27) in pleural fluid was the only significant factor for the formation of fibrin with/without fibrin septations. The rate of successful tube drainage decreased as the advancement of stages of parapneumonic effusion, especially in patients using chest tube for drainage initially (P = 0.001). Total duration of fever and hospital stay was significantly shorter for those children who had initial video-assisted thoracic surgery (VATS) compared to those who had initial chest tube drainage (P < 0.001). Chest sonography can well discriminate the progressive stages of bacterial parapneumonic effusion. In children with a progressive parapneumonic effusion with fibrin formation, early aggressive tube drainage may avoid a subsequent surgical intervention. In children with a fibrin septated parapneumonic effusion, an initial VATS is recommended to shorten the duration of fever and hospital stay.

Paediatric thoracic tumours presenting as empyema

Ultrasonography (US) is considered to be adequate for the preoperative evaluation of childhood empyema. This study was aimed to improve awareness that paediatric intra-thoracic tumours can mimic childhood post-pneumonic empyema and highlights the value of computed tomogram (CT) scan with intravenous (IV) contrast in preoperative evaluation of childhood empyema. The data were analysed on eight children (four boys and four girls) presented at the median age of 6.2 years (1.8-15 years) for the management of empyema and later confirmed to have intra-thoracic tumours. Intra-thoracic tumours in 8 (5.3%) children out of 150 cases of post-pneumonic empyema were managed during the study period. All eight had clinical features, increased white cell count, raised inflammatory markers and biochemical parameters suggestive of childhood empyema. Chest X-ray showed localised opacity in 3/8 while in other five suggested significant pleural collection with mediastinal shift. Additional investigations in referring hospital were suggestive of empyema in four children; US in three, CT scan without IV contrast in one. Referring hospital carried out non-diagnostic thoracocentesis in four children with blood stained pleural tap in two. In four children corroborative evidence suggestive of infection within pleural cavity and acute respiratory distress led to an emergency mini-thoracotomy resulting in significant intra-operative bleeding in two children. Histology on biopsy of the infected material showed primitive neuroectodermal tumour (PNET) in one, pleuropulmonary blastoma in one, metastatic malignant melanoma in one and cytology of pleural fluid diagnosed lymphoma in one. Pre-operative CT scan with IV contrast in four children correctly identified underlying intra-thoracic tumour (two benign teratoma, two PNET). In two cases CT with IV contrast was performed because chest X-ray suggested mediastinal loculated empyema while in other two high clinical index of suspicion prompted preoperative evaluation with CT scan with IV contrast. We advocate caution and increased awareness before considering therapeutic options in childhood empyema and recommend preoperative CT scan with IV contrast in some selected and unusual cases.

Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors

PURPOSE

The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision.

METHODS

From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization.

RESULTS

The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia.

CONCLUSION

The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.

Current treatment of pediatric empyema

Pneumonia with complicated parapneumonic effusion and empyema is increasing in incidence and continues to be a source of morbidity in children seen in our institution. Current diagnostic modalities include chest radiographs and CT scanning with ultrasound being helpful in some situations. Exact management of empyema remains controversial. Although open thoracotomy drainage is well accepted in children, video-assisted thoracoscopic surgery (VATS) drainage has become more prevalent in the current era. Over the last 4 years, we have treated 58 children with intrapleural placement of pigtail catheters and administration fibrinolytics consisting of tissue plasminogen activator (tPA). Successful drainage and resolution of 54 of the 58 effusions was achieved with percutaneous methods alone. There was no mortality or 30-day recurrence. Mean hospital stay was 9.1 days (range 5 to 21) and mean chest catheter removal was 6 days post placement (range 1.5 to 20). Of the four patients that failed percutaneous tube therapy, 3 underwent video assisted thoracic surgery (VATS), and one had open thoracotomy with decortication. Based on our experience, tPA administered through a small bore chest tube for drainage of complicated parapneumonic effusions has become our standard practice. We reserve VATS for treatment failures and open thoracotomy and decortication for patients with VATS failure.

[Clinical phase I trial of concurrent chemo-radiotherapy with S-1 for T2NO glottic carcinoma]

We conducted a phase I study to determine a recommended dose (RD) of S-1 for chemo-radiotherapy consisting of S-1+ radiotherapy for T 2 N 0 larynx cancer. The method of administration used to assess the RD was irradiation with 2 Gy/day for 5 days a week until a total dose of 60 Gy, and concomitant administration of S-1 once a day for 2 weeks beginning on the day therapy was started followed by 2 weeks off the drug and 2 weeks on the drug with the dose escalating from S-1 60 mg/body/day (level 1) to 80 mg/body/day (level 2), and then to 100 mg/body/day (level 3). 18 patients were enrolled. 4 patients developed an adverse event of grade 3 radiation dermatitis which became a dose-limiting toxicity (DLT) at level 3. We then concluded that 100 mg/body/day was the maximum tolerated dose (MTD) of S-1 and decided that the RD of S-1 was 80 mg/body/day.

Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema

BACKGROUND

Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema.

AIM

To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema.

METHODS

Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs.

RESULTS

Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001).

CONCLUSIONS

There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.

Pharmacotherapy in complicated parapneumonic pleural effusions and thoracic empyema

Parapneumonic pleural effusions (PPE) and pleural empyema (PE) present a frequently diagnostic and therapeutic challenge in clinical practice. Although pleural diseases have received increased attention during the past decade, there are still many unanswered questions concerning the diagnosis and treatment of PPE and PE. A lack of controlled studies concerning the management of PPE and PE was noted in recent guidelines. The use of fibrinolytics intrapleurally appears to enhance intercostals tube drainage, reducing the requirement for subsequent surgical mechanical debridement. Recently, there has been interest in other intrapleural agents including combination drugs consisting of streptokinase and streptodornase-alpha, Dnase. Factors to be considered in evaluating whether or not intrapleural instillation of fibrinolytics is effective include an assessment of clinical responses. This review discusses the use of fibrinolytic agents as a novel therapeutic options for treating the various stages of parapneumonic effusions and empyemas.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis

OBJECTIVE

The optimal treatment of children with empyema remains controversial. The purpose of this review was to compare reported results of nonoperative and primary operative therapy for the treatment of pediatric empyema.

METHODS

A systematic comprehensive review of the scientific literature was conducted with the PubMed (National Library of Medicine) database for the period from 1981 to 2004. This reproducible search identified all publications dealing with treatment of empyema in the pediatric population (<18 years of age). A meta-analysis was performed with studies with adequate data summaries for > or =1 of the outcomes of interest for both treatment groups.

RESULTS

Sixty-seven studies were reviewed. Data were aggregated from reports of children initially treated nonoperatively (3418 cases from 54 studies) and of children treated with a primary operative approach (363 cases from 25 studies). The populations were similar in age. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs 3.3%), reintervention rate (2.5% vs 23.5%), length of stay (10.8 vs 20.0 days), duration of tube thoracostomy (4.4 vs 10.6 days), and duration of antibiotic therapy (12.8 vs 21.3 days), compared with patients who underwent nonoperative therapy. In 8 studies for which meta-analysis was possible, patients who received primary operative therapy were found to have a pooled relative risk of failure of 0.09, compared with those who did not. Meta-analysis could not be performed for any of the other outcome measures investigated in this review. Similar complication rates were observed for the 2 groups (5% vs 5.6%).

CONCLUSIONS

These aggregate results suggest that primary operative therapy is associated with a lower in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy, compared with nonoperative treatment. The meta-analysis demonstrates a significantly reduced relative risk of failure among patients treated operatively.

Outcome of parapneumonic empyema

OBJECTIVE

Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome.

METHODS

Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases.

RESULTS

0.8% (C.I. 0.6-1.0) of total pediatric admission had empyema, who were more likely to be females (P< 0.05), under-weight (P< 0.05) compared to children admitted for other reasons. Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases.

CONCLUSION

Chest tube drainage is a safe, efficacious primary method of empyema management.

Medical management of parapneumonic pleural disease

Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.

Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema

BACKGROUND

The current treatments of pediatric empyemas include tube thoracostomy with or without the instillation of fibrinolytics, video-assisted thoracoscopic surgery (VATS), and open thoracotomy with decortication. Whereas success has been reported for all of these techniques, VATS has been suggested as the best method because of decreased length of stay.

METHODS

A chart review of children who presented with parapneumonic effusions from February 2000 to June 2002 was conducted. The patients were divided into 4 groups depending on the treatment received: group I, chest tube alone (n = 18); group II, chest tube and fibrinolytics (n = 24); group III, chest tube, fibrinolytic, and surgery (n = 5); and group IV, surgery alone (n = 6). Preadmission, in-hospital, and outcome variables for the groups were recorded and compared using the Kruskall-Wallis test, with a P value less than .05 considered significant. All the patients who received fibrinolytics (group II and III) were grouped into subjects who received immediate transpleural fibrinolytics versus those who received fibrinolytics 48 hours after chest tube insertion. Length of stay (LOS), need for surgery, and hospital costs were compared between the early and late fibrinolytic groups using the Wilcoxon rank-sum test, with a P value less than .05 considered significant.

RESULTS

Comparison of duration of symptoms, duration of preadmit antibiotics, initial white blood cell count, total lymphocyte count, and antibiotics showed no significance among the 4 groups. When comparing outcome variables, the "nonsurgery groups" (groups I and II) had shorter LOS, intensive care unit stay, and hospital charges when compared with the "surgery groups" (groups III and IV). The timing of fibrinolytic instillation (immediate versus later) did not significantly affect in the LOS, hospital charges, or the tendency to need surgery eventually in the patients who received intrapleural fibrinolytics (group II and III combined). LOS was predicted by preadmit duration of symptoms (P = .025) and overall duration of fever (P < .01). The level of pleural glucose seemed to be predictive of need for surgery (P = .015). Overall, 11 of 54 children (20.2%) eventually needed surgery.

CONCLUSIONS

Tube drainage with intrapleural instillation of fibrinolytics can be performed successfully in a large number of children with empyemas. Ultrasound characterization of the fluid and, perhaps, glucose levels may guide surgical versus nonsurgical therapy. In centers in which percutaneous drainage and tissue plasminogen activator are available, this option may be a safe and less costly alternative to surgery.

The changing face of pleural empyemas in children: epidemiology and management

OBJECTIVE

Empyema remains a significant cause of morbidity in children. This study evaluates the changes that have affected the outcome in children with pleural empyema, including the emergence of resistant organisms, the introduction of the pneumococcal conjugate vaccine, and earlier treatment with video-assisted thoracoscopy (VATS).

METHODS

A retrospective chart review was performed on all patients who were discharged with a diagnosis of empyema and community-acquired pneumonia over a 10-year period (1993-2002) at Texas Children's Hospital in Houston, Texas. Data collected included demographic information, clinical presentation, radiographic studies, laboratory data including culture results, and hospital course.

RESULTS

A total of 230 charts were available for review. The mean age of the patients was 4.0 +/- 3.6 years. Of the pleural fluid cultures performed, 32% (69 of 219) were positive. An additional 27 patients had a cause identified by blood culture. The first penicillin-nonsusceptible Streptococcus pneumoniae was identified in 1995, and the first methicillin-resistant Staphylococcus aureus was identified in 1998. After the universal use of the pneumococcal conjugate vaccine, 3 major changes have occurred (1999-2000 vs 2001-2002): 1) the number of patients admitted with empyema (per 10 000 admissions) has decreased from 23 to 12.6; 2) the prevalence of S pneumoniae has decreased from 66% (29 of 44) to 27% (4 of 15); and 3) S aureus has become the most common pathogen isolated (18% vs 60%), with 78% of those being methicillin resistant. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization (11.49 +/- 6.56 days vs 15.18 +/- 8.62 days).

CONCLUSIONS

The microbiologic cause of empyema has changed with an increasing incidence of S aureus, particularly methicillin-resistant S aureus. The use of VATS for initial therapy of empyema results in decreased duration of fever and length of hospitalization.

Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions

OBJECTIVE

The management of parapneumonic effusions in children is controversial. The objective of this study was to evaluate the effectiveness and safety of intrapleural tissue plasminogen activator (tPA) in children who require tube thoracostomy for drainage of a complicated parapneumonic effusion.

METHODS

An observational cohort study was used to compare children who were treated with intrapleural tPA (either early or late administration) with children who were treated with thoracostomy tube drainage alone.

RESULTS

Over a 6-year period, 12 children received early tPA (within 24 hours of diagnosis), 18 children received late tPA (>24 hours after diagnosis), and 23 children received thoracostomy tube drainage alone for the management of a complicated parapneumonic effusion. Total pleural fluid drainage was highest for the late tPA group (691 mL vs 360 mL in the control group); however, the rate of pleural fluid drainage was highest for the early tPA group (7 mL/h vs 3 mL/h in the control group). The duration of chest tube placement was 84 hours for the early tPA group, 209 hours for the late tPA group, and 130 hours for the control group. There was a significant difference in duration of chest tube placement between the early and late tPA groups. No child who was treated with tPA developed local or systemic bleeding.

CONCLUSIONS

Early administration of intrapleural tPA seems to be a safe and potentially effective treatment in children with complicated parapneumonic effusions. Randomized controlled trial evidence is needed to confirm this finding.

Does VATS provide optimal treatment of empyema in children? A systematic review

PURPOSE

The surgical literature is replete with studies describing methods of treatment for pediatric empyema. The purpose of this report was to perform an evidence-based review of the literature to determine the most effective and appropriate treatment for empyema in infants and children.

METHODS

The MEDLINE database was searched for English- and Spanish-language articles published from 1987 through 2002 on the treatment of thoracic empyema in children. Additional unpublished data were obtained by contacting individual study authors. There were no multiinstitutional prospective studies; all were retrospective, institutional series. A true meta-analysis could not be performed because of inherent institutional bias and variability in outcome measures among studies. A Kruskal-Wallis nonparametric test was used to compare methods detailed in the individual studies.

RESULTS

Forty-four retrospective studies with a total of 1,369 patients were available for analysis. Four treatment strategies were compared: chest tube drainage alone (16 studies, 611 patients), chest tube drainage with fibrinolytic instillation (10 studies, 83 patients), thoracotomy (13 studies, 226 patients), and video-assisted thoracoscopic decortication (VATS; 22 studies, 449 patients). Outcome measures common to the majority of studies included length of stay, fever duration, l of antibiotic therapy duration, and duration of chest tube drainage. Patients undergoing early VATS or thoracotomy had shorter length of stay (P =.003). There was a trend for shorter duration of postoperative fever compared with chest tube alone or with fibrinolytic therapy, but this did not reach statistical significance (P =.055). There was no statistical difference in chest tube duration between methods. There was no trend correlating antibiotic use with treatment methods, length of hospital stay, duration of fever, or length of chest tube requirement.

CONCLUSIONS

Early VATS or thoracotomy leads to shorter hospitalization. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. A carefully designed, multiinstitutional, randomized study would lead to the development of evidence-based standards that may optimize the treatment of thoracic empyema in children.

Management of parapneumonic effusion and empyema

AIMS

To gather data on the clinical presentation of parapneumonic effusion and empyema and to examine the effect of different management strategies on short term outcomes.

METHODS

Retrospective case note review of 48 children admitted to a tertiary unit between January 1998 and March 2001. Effusions were classified into three stages dependent on ultrasound findings.

RESULTS

The stage of effusion was not associated with duration of previous symptoms or length of previous admission. An interventional procedure was performed on median day 2 of admission in 46 children: eight (17%) had an intercostal drain alone, 14 (29%) had an intercostal drain followed by intrapleural fibrinolytic therapy, and 24 (50%) had a thoracotomy. Three children who had an initial intercostal drain alone returned to theatre for thoracotomy, and two children who had intrapleural fibrinolysis returned for thoracotomy. Median length of stay (interquartile range) for each initial procedure was 15 days (6-20) for intercostal drain alone, 8 days (6-12) for fibrinolytic therapy, and 6.5 days (5-9) for thoracotomy. Stay for intercostal drain alone was significantly longer than for thoracotomy.

CONCLUSION

Early surgical management of empyema is associated with a favourable outcome.

Alteplase in the treatment of complicated parapneumonic effusion: a case report

The treatment of complex parapneumonic effusions in children remains controversial, with some advocating less invasive, strictly medical management and others supporting a more aggressive approach of thoracotomy with or without decortication. Recent advances, including video-assisted thoracoscopic surgery and intrapleural fibrinolytic therapy, offer new options for effective treatment. We report the first case of successful resolution of a complex parapneumonic effusion in a 16-month-old girl with the use of tissue plasminogen activator (alteplase), infused via a catheter in the pleural space.

Use of urokinase in childhood pleural empyema

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.

Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema

OBJECTIVE

To describe the use of intrapleural instillation of fibrinolytic agents as adjunctive therapy for children with complicated pleural effusions and empyema.

DESIGN

Retrospective chart review.

SETTING

Tertiary care children's hospital in an academic medical center.

PATIENTS

Nineteen consecutive patients (median age, 36 months; range, 9 months to 13 yrs) with complicated pleural effusion or empyema by clinical, radiographic, and laboratory criteria who failed to have adequate drainage of the fluid collection by tube thoracostomy.

INTERVENTIONS

Patients who remained symptomatic with fever or respiratory distress and who had pleural fluid that could not be drained by tube thoracostomy were treated by intrapleural instillation of either urokinase (13 patients) or streptokinase (six patients) 8-72 hrs after chest tube insertion.

MEASUREMENTS AND MAIN RESULTS

Fibrinolytic therapy increased the volume of chest tube drainage in 15 (79%) of 19 patients. Fourteen of the 19 patients were successfully managed without referral for surgical drainage. No significant adverse events or side effects were noted.

CONCLUSION

Intrapleural instillation of fibrinolytic agents appears to be an effective and less invasive alternative to surgical drainage for children who have complicated pleural effusions or empyemas that do not drain adequately with tube thoracostomy alone.

Current issues in the diagnosis and management of pediatric empyema

Empyema is a rare but recognized complication of bacterial pneumonia in children. The incidence of empyema may be rising as vaccination practices and antibiotic prescribing practices promote the emergence of more virulent and resistant organisms. Diagnostic methods vary widely, from thoracentesis to plain radiographs to detailed computed tomography scans. Treatment practices also vary, with some practitioners preferring medical treatment, others employing chest tube drainage or fibrinolytic therapy, and still others aggressively pursuing surgical options. Further study is needed to define the ideal management of empyema. The authors review the current literature and propose an updated management algorithm that incorporates accepted practices as well as emerging trends in diagnosis and management of empyema.

Empyema: development of a critical pathway

Over the past 20 years at the authors' institution, the management of empyema has evolved. The authors recently have developed a critical pathway in an effort to facilitate diagnosis, guide therapy, and reduce cost. Currently, the average length of stay using this pathway is 4 to 5 days with decreased cost compared to the historic length of stay and a national children's hospital database. The authors review steps to develop a critical pathway as well as discuss their pathway for empyema management.

Radiological perspectives in empyema

Empyema is a common cause for hospital admission in children. For years, clinicians have relied on chest X-rays to aid diagnosis and monitor treatment. New imaging techniques, particularly ultrasound, have helped in planning the management of children with empyema. Other cross-sectional radiological investigations are useful in a small proportion of children with complicated disease. The mainstays of imaging in the vast majority of children with empyema are chest radiography and ultrasound.