Intrapleural streptokinase is effective and safe for children with multi-loculated empyema regardless of the time from disease onset

Comparison of Six versus Three Doses of Intrapleural Fibrinolytic Therapy in Children with Empyema: A Randomized Controlled Trial

OBJECTIVES

To compare six doses of intrapleural streptokinase (SK) vs. the conventional three doses in children with empyema.

METHODS

In this randomized controlled trial, children with empyema received intrapleural streptokinase, either twice daily for 3 d (total 6 doses); or once daily for 3 d (total 3 doses). The outcomes assessed were treatment failure, volume of fluid drained, duration of fever, duration of respiratory distress, length of hospitalization, need for surgical decortication, adverse events and cost.

RESULTS

Thirty-six children were enrolled. Cumulative pleural pus drainage was significantly higher with six doses [median (IQR) 367 (266, 850) vs. 195 (142, 422) ml, p 0.02]. The mean (SD) durations of fever and respiratory distress, after completing intrapleural therapy were also shorter; 2.3 (0.8) vs. 5.7 (1.6) d, p 0.04; and 2.2 (0.9) vs. 6.3 (1.9) d, p 0.03 respectively. However, there were no statistically significant differences in the length of hospitalization after completing therapy [median (IQR) 9 (6, 17) vs. 12 (4, 16) d], total duration of intercostal drainage [median (IQR) 13 (11, 21) vs. 12 (7, 19) d], treatment failure rate [4/16 (25%) vs. 7/16 (43.7%)], or need for surgical decortication [2/16 (16.2%) vs. 1/16 (6.2%)]. There were no significant adverse effects necessitating cessation or modification of therapy in either group. The cost of therapy was identical in both groups.

CONCLUSIONS

Six doses of intrapleural streptokinase appear superior to the conventional three doses in children with empyema, with comparable safety and cost.

Six Versus Three Doses of Intrapleural Streptokinase in Childhood Empyema: A Randomized Controlled Trial

OBJECTIVE

To compare the efficacy and safety of administering six doses of intrapleural streptokinase (SK) versus the conventional three doses, in children with empyema.

STUDY DESIGN

In this open label, placebo-controlled, randomized trial, we enrolled 53 children with empyema, who received three doses of intrapleural SK. Thereafter, those without clinical improvement (n = 34) and those showing clinical improvement but having persistent pleural fluid width > 10 mm on chest ultrasonography (n = 13), were randomized to receive three additional doses of SK, or three doses of placebo (normal saline). The remaining 6 children improved clinically and radiologically, hence were not randomized. The outcomes recorded were cumulative volume of pleural fluid drained, total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, proportion of children with treatment failure requiring surgery, and adverse events. Spirometry, 6-min walk test, chest X-ray and ultrasonography were done 3 months following discharge. We analyzed by intention-to-treat.

RESULTS

The baseline characteristics of children who received six versus three doses SK were comparable. There was no statistically significant difference in the cumulative volume of fluid drained; median (IQR): 810.0 (330.0, 1630.0) [95% CI: 505, 1463] mL versus 530.0 (255.2, 1325.0) [95% CI: 325, 1131] mL, p 0.46. There were no significant inter-group differences in the total duration of intercostal drainage, time taken for clinical improvement, duration of hospitalization, treatment failure, surgical decortication and adverse events.

CONCLUSION

In children with empyema, intrapleural therapy with six doses of SK is not superior to three doses, although it is safe.

Empyema in children

Empyema is the infection of the fluid in the pleural space due to different causes. The most common cause of empyema in children is parapneumonic effusion. Although its frequency has decreased significantly with the use of antibiotics, it is still a significant cause of morbidity and mortality worldwide. The main aim in the treatment of empyema is to drain the pleural cavity to provide reexpansion of the compressed lung, to treat the parenchymal infection with appropriate antibiotic therapy, and to prevent complications that may develop in the acute and chronic periods. Treatment options for this disease vary depending on the stage of the disease. Treatment success in childhood empyema detected at an early stage is high. The diagnosis and treatment of empyema in children differs from adults. Due to rapid tissue regeneration in childhood, healing can occur without the need for aggressive treatment options.

Debate 1: Is the Management of Childhood Empyema Primarily Medical, or Surgical?

This review aims to discuss the role of medical and surgical therapy in the management of pediatric empyema. There is considerable debate on the optimal treatment for the same. Early intervention is crucial as it allows rapid recovery of these patients. Antibiotics and adequate pleural drainage form the two pillars in the management of empyema. Chest tube drainage alone has significant failure rates due to its inability to clear loculated effusion. The two main modalities which target these loculations to augment drainage are video-assisted thoracoscopic surgery (VATS) and intrapleural fibrinolytic therapy. The latest evidence shows that both these interventions are equally effective. Children who present late are usually not candidates for intrapleural fibrinolytic therapy or VATS; for them, decortication remains the only option.

Contrast-Enhanced Ultrasound of the Pleural Cavity: A Method to Locate Pleural Catheters and Identify Fibrous Septa

We aimed to explore the value of contrast-enhanced ultrasound (CEUS) of the pleural cavity in locating catheters and identifying fibrous septa and to compare CEUS with multiple existing methods. We included 304 participants whose pleural effusion could not continue to be drained and compared the catheter-localization capabilities of empirical diagnosis, B-mode ultrasound with normal saline and CEUS, with computed tomography as the reference standard. CEUS performed the best (accuracy, 100%; sensitivity, 100%; specificity, 100%), followed by B-mode ultrasound with normal saline (accuracy, 77.78%; sensitivity, 62.5%; specificity, 100%), and finally empirical diagnosis (accuracy, 54.17%; sensitivity, 66.67%; specificity, 33.33%). The capabilities of CEUS and computed tomography to identify fibrous septa were evaluated, with B-mode ultrasound as the reference, and CEUS (accuracy, 100%; sensitivity, 100%; specificity, 100%) was superior to computed tomography (accuracy, 82.41%; sensitivity, 26.09%; specificity, 97.65%). Overall, CEUS can accurately locate catheters and identify fibrous septa, with performance superior to existing methods.

Loculations and Associated Risk Factors of Childhood Pleural Tuberculosis

Background: Pleural loculation in childhood pleural tuberculosis (TB) remains a problem in practice, it is usually associated with failure drainage. Therefore, to improve the management of childhood pleural TB, a retrospective study was conducted to identify the risk factors associated with loculated effusion in childhood pleural TB. Methods: Between January 2006 and December 2019, consecutive children (≤15 years old) with tuberculous pleural effusion (definite and possible) were included for further analysis. The demographic, clinical, laboratory, and radiographic features were collected from the medical records. Univariate and multivariate logistic regressions were used to explore the factors associated with the presence of pleural loculation in children with pleural TB. Results: A total of 154 children with pleural TB (definite, 123 cases; possible, 31 cases) were included in our study and then were classified as loculated effusion (n = 27) and non-loculated effusion (n = 127) groups by chest X-ray or ultrasonography. Multivariate analysis revealed that male gender (age-adjusted OR = 3.903, 95% CI: 1.201, 12.683), empyema (age-adjusted OR = 4.499, 95% CI: 1.597, 12.673), peripheral monocytes ≤0.46 × 10⁹/L (age-adjusted OR = 4.122, 95% CI: 1.518, 11.193) were associated with the presence of loculated effusion in children with pleural TB. Conclusion: In conclusion, several characteristics, such as male gender, empyema, and peripheral monocyte count have been identified as risk factors for pleural loculation in children with pleural TB. Our findings may be helpful to improve the management of pleural loculation in childhood pleural TB.

Pleural empyema in children - benefits of primary thoracoscopic treatment

Introduction

Pleural empyema is the condition of the pleural cavity when initially sterile pleural effusion has become infected. In the majority of cases, it is of parapneumonic origin. Parapneumonic effusions and pleural empyemata usually continuously progress in severity. The American Thoracic Society divides them into three stages: exudative, fibrinopurulent and organizing. The therapy depends on the stage.

Aim

To assess whether thoracoscopy should be considered better than conservative treatment and to assess the feasibility of the thoracoscopic approach to the 3^rd phase of pleural empyema.

Material and methods

The clinical course of 115 patients treated from 1996 to 2017 was analyzed. 45 patients operated on thoracoscopically after the failure of conventional treatment were compared with 70 patients treated by primary thoracoscopic drainage and decortication.

Results

The results of the study demonstrated that patients treated primarily by thoracoscopy had a shortened length of hospital stay (16.6 vs. 19.3 days), reduced drainage time (7.9 vs. 9.8 days), and shorter time of general therapy (31.8 vs. 38.0 days). They required fibrinolysis less frequently (12.8 vs. 26.7% of patients) and had reduced risk of reoperation (10 vs. 15.6% of cases). Operation time in the 3^rd stage was only 15 min longer. The difference in length of hospital stay was only 0.8 days in favor of less severe cases.

Conclusions

The thoracoscopic approach is safely feasible in the 3^rd stage of pleural empyema and should be considered as the preferred approach. Furthermore, the post-operative stay and general course of the disease are milder whenever surgery would not be delayed by prolonged conservative treatment attempts.