Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia

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 Additional unpublished data were obtained by contacting individual study authors.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.

Is open thoracotomy still a good treatment option for the management of empyema in children?

BACKGROUND

The incidence of pediatric postpneumonic empyema increases, and there is little consensus on its management. Open thoracotomy has been linked with high morbidity and prolonged hospitalization. Our aim was to review the outcome after open thoracotomy and to provide a set of data for comparison with other treatment modalities.

METHODS

Forty-four children (median age, 8 years, 2 months to 16 years) undergoing surgery for postpneumonic empyema between 1993 and 2002 in our unit were studied.

RESULTS

The median time from onset of symptoms to admission in a pediatric unit was 8 days (range, 2 to 63 days), the median time from pediatric admission to surgical referral was 3 days (range, 0 to 19 days), and the median time from surgical admission to thoracotomy was 1 day (range, 0 to 2 days). Eight children had a chest drain before surgical admission. Six patients, who were referred late (19 to 69 days), had lung abscesses. A limited muscle sparing thoracotomy (44 patients), formal decortication (36 patients), lung debridement (5 patients), and lobectomy (1 patient) were performed. After thoracotomy, median time to apyrexia was 1 day (range, 0 to 27 days) and drain removal was 3 days (range, 1 to 16 days). A pathogen was isolated in 21 patients. There were no deaths. Four children with abscesses remained septic and had lobectomies (2 patients) and debridements (2 patients). The median postoperative hospital stay was 5 to 53 days. One child had postpneumonic empyema develop and had decortication 3 months postoperatively. At follow-up, all children were doing well and had satisfactory radiographs. The Kaplan-Meier 5-year and 10-year survival rate, freedom from any reoperation, and freedom from hospital readmission were 100%, 87%, and 98%, respectively.

CONCLUSIONS

Open thoracotomy remains an excellent option for management of stage II-III empyema in children. When open thoracotomy is performed in a timely manner there is low morbidity and it provides rapid resolution of symptoms with a short hospital stay. However, delayed referrals may result in advanced pulmonary sepsis and a protracted clinical course. The late results are encouraging. Use of thoracoscopy or fibrinolysis should be considered on the basis of their own merit, not on the assumption of probable adverse outcomes after thoracotomy.

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.

Real-time chest ultrasonography: a comprehensive review for the pulmonologist

This review discusses real-time pulmonary ultrasonography (US) for the practicing pulmonologist. US supplements chest radiography and chest CT scanning. Major advantages include bedside availability, absence of radiation, and guided aspiration of fluid-filled areas and solid tumors. Pulmonary vessels and vascular supply of consolidations may be visualized without contrast. US may help to diagnose conditions such as pneumothorax, hemothorax, pleural or pericardial effusion, pneumonia, and pulmonary embolism in the critically ill patient who is in need of bedside diagnostic testing. The technique of US, which is cost-effective compared to CT scanning and MRI, may be learned relatively easily by the pulmonologist.

Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage

BACKGROUND

Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided.

OBJECTIVES

A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients.

STUDY DESIGN

One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment.

RESULTS

No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (plus minus SD) duration of a temperature > or = 39 degreesC, 6.2 +/- 2.4 vs 6.5 +/- 1.8 days, respectively; mean duration of a temperature > or = 38 degreesC, 9 +/- 3.9 vs 8.2 +/- 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 +/- 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 +/- 13.2 vs 30.2 +/- 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 +/- 7.6 vs 24.2 +/- 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation.

CONCLUSION

The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.

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.

[Value of thoracoscopy in purulent pleuresies in children younger than four years]

Video-assisted thoracoscopic surgery is widely performed in adults but there are few publications concerning the paediatric population. The objective is to effect optimal adhesiolysis of post-pneumonic loculated empyema with lower morbidity.

PATIENTS AND METHODS

Over a 4-year period we used thoracoscopic debridement in five children younger than 4 years of age with loculated thoracic empyema. All patients failed initial treatment, including antibiotics and chest tube drainage. Early sonographic evaluation of the empyema organization guided the most appropriate moment for the intervention. The average duration of tube drainage after thoracoscopy was 4 days (range: 1 to 7 days).

RESULTS

All patients made an uneventful postoperative recovery. At a follow-up visit 1 month after discharge, the children were clinically asymptomatic; however, some degree of pleural thickening was still visible on chest X-rays.

CONCLUSION

In skilled hands, thoracoscopy is a safe procedure for post-pneumonic empyema in young children, providing a rapid clinical and radiological recovery with a good cosmetic result.

Treatment of complicated pleural effusion with intracavitary urokinase in children

Intrapleural administration of fibrinolytic agents such as urokinase (UK) has been advocated as an alternative method to manage complicated pleural effusion (CPE). Despite the increasing number of empyemas successfully treated with UK in adults, the experience in children is limited to a few cases. We report the results of image-guided catheter drainage (IGCD) with intracavitary instillation of UK in six children with CPE. Urokinase (25,000-100, 000 IU) was diluted in 20 mL of normal saline and instilled into the pleural cavity via a percutaneously placed drainage catheter. After 4 hr, the clamped catheter was released and connected to water-seal suction at a negative pressure of 20 cm H(2)O. UK instillation was repeated daily until no further drainage occurred. During IGCD, repeated radiographic and ultrasound imaging determined the location and amount of any remaining pleural fluid. Mean duration of hospital stay before initiating UK therapy was 4.3 days. Mean duration of catheter drainage before initiating UK therapy was 3.5 days, and the mean total drainage was 86 mL. All patients had an increase in chest tube drainage within 24 hr after the first instillation of UK. The mean net total drainage after UK instillation was 281 mL, most of the drainage being occurring in the first 2 days of treatment. Mean hospital stay following UK treatment was 5.8 days, and the average total duration of hospital stay was 13.8 days. No complications and no adverse events occurred during treatment with UK. Complete resolution of the consequences of the pleural effusion was observed in all patients at follow-up. Our results suggest that IGCD with adjunctive UK therapy is a reliable, simple, and safe approach to treat CPE, and it can reduce the risks associated with thoracotomy and decortication.

[Pleurisy: diagnostic and therapeutic management]

Diagnosis of pleural effusion is difficult in children. The etiologies are numerous; however, infectious agents are more frequent. Thoracocentesis proves to be the first-line diagnostic tool. Light's criteria are the best for distinguishing whether the effusion is a transudate or an exudate. If the patient has an exudative pleural effusion, other tests are indicated to determine the etiology and in some cases the treatment: macroscopic appearance, cytology and differential white cell count (level of glucose, lactate dehydrogenase, adenosine deaminase, pH, bacterial cultures). Others investigations--biopsy of pleura by thoracoscopy or video-assisted thoracoscopy, bronchofibroscopy, CT scan--are sometimes useful. Intrapleural instillation of urokinase appears to be useful and safe. Evaluation is necessary for video-assisted thoracoscopy used early.

Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients

OBJECTIVE

To describe the efficacy of percutaneous pigtail catheters in evacuating pleural air or fluid in pediatric patients.

DESIGN

A case series of children with percutaneous pigtail catheters placed in the pediatric ICU between January 1996 and August 1997.

SETTING

Urban pediatric teaching hospital in Seattle, WA.

METHODS

A retrospective chart review.

RESULTS

Ninety-one children required 133 chest catheters. Most patients were infants with congenital heart disease (80%). One hundred thirteen of the catheters (85%) were placed for pleural effusion, with 20 tubes (15%) placed for pneumothorax. Efficacy of drainage of pleural fluid was significantly greater in serous (96%) and chylous (100%) effusions compared with empyema (0%) or hemothorax (81%). Evacuation of pneumothorax was achieved by a pigtail catheter in 75% of patients. Resolution of pleural air or pneumothorax was significantly greater in patients < 10 kg compared with larger children. Complications due to placement of the pigtail catheters included hemothorax (n=3, 2%), pneumothorax (n=3, 2%), and hepatic perforation (n= 1, 1%). There were also complications arising from the use of the catheters, including failure to drain, dislodgment, kinking, loss of liquid ventilation fluid, empyema, and disconnection in 27 of 133 catheters (20%). Significantly more complications during catheter use occurred in patients <5 kg than in larger children.

CONCLUSIONS

Percutaneous pigtail catheters are highly effective in drainage of pleural serous and chylous effusions, somewhat less efficacious in drainage of hemothorax or pneumothorax, and least efficacious in drainage of empyema. Infants and smaller children had higher rates of resolution of pleural air and fluid from placement of a pigtail catheter than larger children. Complications from catheter placement were uncommon (5%) but serious, whereas complications associated with continued use of the catheters were more common (20%) but less grave. Strict attention to anatomic landmarks and close monitoring may reduce the number of complications.

Pediatric chest lesions

Pediatric chest lesions are usually either symptomatic or strikingly visible. The most common lesions, as well as the lesions that require prompt surgical treatment, are reviewed in this article. Careful imaging studies and diagnostic tests such as bronchoscopy can usually characterize these lesions and enable a safe, directed surgical approach. Although many chest lesions can be managed without surgery, primary care providers can expedite treatment of these problems by early referral to pediatric surgeons or pediatric thoracic surgeons.