Efficacy of standardizing fibrinolytic therapy for parapneumonic effusion

Implications of Using a Clinical Practice Guideline on Outcomes in Pediatric Empyema

INTRODUCTION

Various randomized control trials in the pediatric population have shown no therapeutic advantage of video-assisted thoracoscopic surgery over fibrinolytic therapy (tissue plasminogen activator [tPA]) for empyema management. However, literature detailing changes in practice management and protocol implementation is limited. In 2018, we instituted clinical practice guidelines (CPGs) for empyema management utilizing tissue plasminogen activatorinstillation via a small bore chest tube as initial therapy. Before standardization, surgeon preference drove management. Our aim was to determine differences in management and outcomes following institutional CPG implementation.

METHODS

A single-institution retrospective study (2002-2022) examined patients 0-18 y of age diagnosed with pneumonia and associated empyema (loculated pleural fluid on ultrasound or computed-tomographic scan). The comparison groups were pre- and post-CPG implementation groups. Comparative statistics were performed, and the significance level was set at P < 0.05.

RESULTS

Sixty-one patients met the inclusion criteria: 33 (54%) preimplementation and 28 (46%) postimplementation. The demographics and diagnostic imaging modalities were similar between groups. There were no significant differences in time to initiate antibiotics, antibiotic duration, intensive care unit length of stay (LOS), or total hospital LOS. The utilization of video-assisted thoracoscopic surgery as initial intervention significantly decreased from 66% to 10% after protocol implementation (P < 0.01); the failure rates of initial therapy choice were similar (12% versus 10%, P = 0.87). Marked reduction in total patients undergoing operative intervention at any point during the course of therapy was observed, 76% preimplementation versus 21% postimplementation (P < 0.01).

CONCLUSIONS

In children treated for empyema, the overall incidence of operative intervention significantly decreased following CPG implementation. The changes in antibiotic usage, intensive care unit/total LOS, and initial therapy failure rates did not differ. In our experience, the implementation of a CPG was instrumental in adherence to national guidelines.

Imaging of Acute Complications of Community-Acquired Pneumonia in the Paediatric Population-From Chest Radiography to MRI

The most common acute infection and leading cause of death in children worldwide is pneumonia. Clinical and laboratory tests essentially diagnose community-acquired pneumonia (CAP). CAP can be caused by bacteria, viruses, or atypical microorganisms. Imaging is usually reserved for children who do not respond to treatment, need hospitalisation, or have hospital-acquired pneumonia. This review discusses the imaging findings for acute CAP complications and the diagnostic role of each imaging modality. Pleural effusion, empyema, necrotizing pneumonia, abscess, pneumatocele, pleural fistulas, and paediatric acute respiratory distress syndrome (PARDS) are acute CAP complications. When evaluating complicated CAP patients, chest radiography, lung ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) can be used, with each having their own pros and cons. Imaging is usually not needed for CAP diagnosis, but it is essential for complicated cases and follow-ups. Lung ultrasound can supplement chest radiography (CR), which starts the diagnostic algorithm. Contrast-enhanced computed tomography (CECT) is used for complex cases. Advances in MRI protocols make it a viable alternative for diagnosing CAP and its complications.