Empyema thoracis in children: a 26-year review of the Montreal Children's Hospital experience

A Global Bibliometric Analysis of the Top 100 Most Cited Articles on Early Thoracotomy and Decortication in Pleural Empyema

Most pleural empyema cases are linked to pneumonia, a substantial fraction of patients present with empyema without any association to pneumonia. The occurrence of empyema caused by tuberculosis (TB) is increasing in regions where TB is prevalent. In May 2024, a bibliometric analysis was conducted involving the screening of 7,620 articles sourced from Google Scholar. Google Scholar was selected for its comprehensive nature, encompassing articles indexed in prominent databases like Web of Science, Scopus, and PubMed. This allowed access to significant studies that might be overlooked if they were not indexed by these databases. Articles were selected based on their citation count and specific inclusion criteria, focusing on early thoracotomy and decortication in pleural empyema. Two authors (VB and MK) independently conducted a thorough screening and data collection. The hundred top articles published from 1945 to 2015, garnered a total of 16,928 citations. These articles were written by 93 distinct first authors from 22 countries and 83 institutions, and were featured in 35 journals. The primary categories of literature included those describing the disease characteristics, features, causes, and types of pleural empyema, as well as various treatment modalities and management strategies, each constituting 37% of the literature. Additionally, pediatric empyema was a focus in 11% of the articles. The present analysis highlights publication trends, identifies gaps in the literature, and suggests areas for future research, serving as a valuable resource for guiding upcoming studies on early thoracotomy and decortication in pleural empyema.

Empyema necessitans in a pediatric patient: A case study

INTRODUCTION AND IMPORTANCE

Empyema necessitans is a rare and severe complication of pleural effusion characterized by the extension of purulent material from the pleural cavity into the surrounding soft tissues, resulting in the formation of a subcutaneous abscess.

CASE PRESENTATION

A one-year-old boy presented with symptoms that were in line with empyema necessitans, and Escherichia coli was shown to be the causative organism. A successful outcome required early detection, rapid diagnosis, and proper management, which included targeted antibiotic medication and drainage of the pleural collection. When a young patient exhibits a growing chest wall swelling, empyema necessitans should be considered in the differential diagnosis.

CLINICAL DISCUSSION

The best care for individuals with empyema necessitans requires a multidisciplinary approach comprising pediatricians, thoracic surgeons, infectious disease experts, and interventional radiologists. Escherichia coli infection requires a comprehensive approach involving antibiotic therapy and surgical intervention if necessary.

CONCLUSION

Empyema necessitans in pediatric patients, caused by Escherichia coli, is an infrequent disease that requires more investigation to enhance our understanding of the associated risk factors, optimal treatment modalities, and potential long-term consequences.

Empyema necessitans in an infant due to pseudomonas aeruginosa at a referral hospital in mogadishu, somalia: A case report

Empyema necessitans (EN) is a rare complication of bacterial pneumonia, especially in children. It can be caused by many infectious agents, but Mycobacterium tuberculosis is the most common cause of EN. We report a 3-month-old girl who had EN on the 90th day of life, multidrug-resistant P. aeruginosa was isolated from her pleural fluid culture. We could not find another published report about EN caused by Pseudomonas aeruginosa (P. aeruginosa) in an infant. The case highlights that children presenting with fever and chest wall mass should be immediately imaged by chest computed tomography as there might be an urgent need for intervention.

Pediatric empyema thoracis: What has changed over a decade?

OBJECTIVES

The purposes of this paper are to study clinicobacteriological profile, treatment modalities and outcome of pediatric empyema thoracis and to identify changes over a decade.

DESIGN

This is a retrospective study.

SETTING

Department of Pediatrics of a tertiary care hospital in North India.

PATIENTS

We enrolled 205 patients (1 month-12 years) of empyema thoracis admitted over 5 years (2007-11) and compared the profile with that of a previous study from our institute (1989-98).

RESULTS

Pleural fluid cultures were positive in 40% (n = 82) cases from whom 87 isolates were obtained. Staphylococcus aureus was the most common isolate (66.7%). Methicillin-sensitive S. aureus accounted for 56%, Methicillin-resistant S. aureus (MRSA) 10% and gram-negative organisms 18.3% of isolates. Intercostal drainage tube (ICDT) was inserted in 97.5%, intrapleural streptokinase was administered in 33.6%, and decortication performed in 27.8% cases. Duration of hospital stay was 17.2 (±6.3) days, duration of antibiotic (intravenous and oral) administration was 23.8 (±7.2) days and mortality rate was 4%. In the index study (compared with a previous study), higher proportion of cases received parenteral antibiotics (51.7% vs. 23.4%) and ICDT insertion (20.5% vs. 7%) before referral and had disseminated disease (20.5% vs. 14%) and septic shock (11.2% vs. 1.6%), less culture positivity (40% vs. 48%), more MRSA (10.3% vs. 2.5%) and gram-negative organisms (18.4% vs. 11.6%), increased use of intrapleural streptokinase and surgical interventions (27.8% vs. 19.7%), shorter hospital stay (17 vs. 25 days) and higher mortality (3.9% vs. 1.6%).

CONCLUSIONS

Over a decade, an increase in the incidence of empyema caused by MRSA has been noticed, with increased use of intrapleural streptokinase and higher number of surgical interventions.

Trends in Hospital Treatment of Empyema in Children in the United States

OBJECTIVE

To evaluate trends in procedures used to treat children hospitalized in the US with empyema during a period that included the release of guidelines endorsing chest tube placement as an acceptable first-line alternative to video-assisted thoracoscopic surgery.

STUDY DESIGN

We used National Inpatient Samples to describe empyema-related discharges of children ages 0-17 years during 2008-2014. We evaluated trends using inverse variance weighted linear regression and characterized treatment failure using multivariable logistic regression to identify factors associated with having more than 1 procedure.

RESULTS

Empyema-related discharges declined from 3 in 100 000 children to 2 in 100 000 during 2008-2014 (P = .04, linear trend). There was no significant change in the proportion of discharges having 1 procedure (66.1% to 64.1%) or in the proportion having 2 or more procedures (22.1% to 21.6%). The proportion coded for video-assisted thoracoscopic surgery as the only procedure declined (41.4% to 36.2%; P = .03), and the proportions coded for 1 chest tube (14.6% to 20.9%; P = .04) and 2 chest tube procedures (0.9% to 3.5%; P < .01) both increased. The median length of stay for empyema-related discharges remained unchanged (9.3 days to 9.8 days; P = .053). Having more than 1 procedure was associated with continuous mechanical ventilation (adjusted OR, 2.7; 95% CI, 1.8-4.1) but not with age, sex, payer, chronic conditions, transfer admission, hospital size, or census region.

CONCLUSIONS

The use of video-assisted thoracoscopic surgery to treat children in the US hospitalized with empyema seems to be decreasing without associated increases in length of stay or need for additional drainage procedures.

Complicated community acquired pneumonia in childhood: Different types, clinical course, and outcome

The incidence of pediatric community acquired complicated pneumonia (PCACP) is increasing. Questions addressed: Are different types of PCACP one disease? How do different treatment protocols affect the outcome?

METHODS

Retrospective analysis of medical records of PCACP hospitalizations in the three major hospitals in Jerusalem in the years 2001-2010 for demographics, clinical presentation, management, and outcome.

RESULTS

Of the 144 children (51% aged 1-4 years), 91% of Jewish origin; 40% had para-pneumonic effusion (PPE), 40% empyema (EMP), and 20% necrotizing pneumonia (NP). Bacterial origin was identified in 42% (empyema 79%, P = 0.009), most common S. pneumoniae (32%), group A streptococcus (9%). Patients with EMP, compared to PPE and NP, were less likely to receive prior antibiotic treatment (35% vs. 57% and 59%, respectively, P = 0.04). Mean hospitalization was longer in patients with NP followed by EMP and PPE (16.4 ± 10.6, 15.2 ± 7.9, and 12.7 ± 4.7 days, respectively), use of fibrinolysis was not associated with the outcome. All children had recovered to discharge regardless of antibiotic therapy or fibrinolysis.

ANSWER

NP is a more severe disease with prolonged morbidity and hospitalization in spite of prior antibiotic treatment. All types had favorable outcome regardless of treatment-protocol. Complicated pneumonia has an ethnic predominance. Pediatr Pulmonol. 2017;52:247-254. © 2016 Wiley Periodicals, Inc.

Management of Parapneumonic Empyema in Children

Empyema is a serious complication of bacterial pneumonia in children. Between July 1992 and July 1998, 53 children aged 7 months to 12 years (mean age, 5.5 years) were treated for empyema complicating pneumonia. After diagnostic thoracentesis, closed tube drainage was carried out with appropriate antibiotic therapy and other treatment strategies such as pleural lavage, intrapleural enzymatic debridement, decortication, or pulmonary resection, according to the effectiveness of drainage and clinical status. There was one death from toxic shock. It was concluded that early decortication in the chronic stage of the disease is a safe and effective treatment modality.

Thoracoscopy in the management of pediatric empyemas

INTRODUCTION

Thoracoscopy is increasingly being used in the treatment of empyema. This study assesses feasibility, efficacy and safety in children.

MATERIAL AND METHODS

Clinical files of patients who underwent primary thoracoscopy for empyema between 2006 and 2014 were reviewed. Demographic, clinical and surgical data were analyzed and a comparison between the period before (period1) and after (period2) the learning curve was performed.

RESULTS

Ninety-one patients (53 males, 58%) were submitted to thoracoscopy at a median age of 4 years. There were 19 conversions to thoracotomy with a steady decrease of conversion rate until 2009 (period1) and no conversions thereafter (period2). There was no difference in any of the analyzed parameters between patients submitted to thoracoscopy alone and those requiring conversion in period1. Six cases (6.6%) needed redo-operation (five in period2) and thoracotomy was the elected approach in four. Necrotizing pneumonia was present in 60% of the reoperated cases; in other words, in period2 3 out of 9 cases with necrotizing pneumonia required reintervention (p=0.07). Thoracotomy was avoided in sixty-eight (75%) patients (62% in period1 versus 92% in period2, p=0.001).

DISCUSSION AND CONCLUSIONS

Thoracoscopic approach for empyema is feasible and safe avoiding a significant number of thoracotomies after a short learning curve. An increase of reintervention rate should be expected, but throracoscopy alone is effective in the great majority of the cases. Necrotizing pneumonia may be associated with a higher risk of reintervention, as it is a contra-indication to thoracoscopy and probably surgery.

Empyema necessitans complicating pleural effusion associated with proteus species infection: a diagnostic dilemma

Background. Empyema necessitans, a rare complication of pleural effusion, could result in significant morbidity and mortality in children. It is characterized by the dissection of pus through the soft tissues and the skin of the chest wall. Mycobacterium tuberculosis and Actinomyces israelii are common causes but Gram negative bacilli could be a rare cause. However, there were challenges in differentiating between Mycobacterium tuberculosis and nontuberculous empyema in a resource poor setting like ours. We report a child with pleural effusion and empyema necessitans secondary to Proteus spp. infection. Methods. We describe a 12-year-old child with empyema necessitans complicating pleural effusion and highlight management challenges. Results. This case was treated with quinolones, antituberculous drugs, chest tube drainage, and nutritional rehabilitation. Conclusion. Empyema necessitatis is a rare condition that can be caused by Gram negative bacterial pathogens like Proteus species.

Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial

BACKGROUND AND OBJECTIVE

Parapneumonic empyema (PPE) is a frequent complication of acute bacterial pneumonia in children. There is limited evidence regarding the optimal treatment of this condition. The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood.

METHODS

This prospective, randomized, multicenter clinical trial enrolled patients aged <15 years and hospitalized with septated PPE. Study patients were randomized to receive urokinase or thoracoscopy. The main outcome variable was the length of hospital stay after treatment. The secondary outcomes were total length of hospital stay, number of days with the chest drain, number of days with fever, and treatment failures. The trial was approved by the ethics committees of all the participating hospitals.

RESULTS

A total of 103 patients were randomized to treatment and analyzed; 53 were treated with thoracoscopy and 50 with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay (10 vs 9 days), median hospital stay (14 vs 13 days), or days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of children in the thoracoscopy group versus 10% in the urokinase group (P = .47).

CONCLUSIONS

Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children.

Treatment trends and outcomes in US hospital stays of children with empyema

BACKGROUND

Recently published practice guidelines continue to reflect uncertainty about the comparative effectiveness of various treatments for empyema in children. We describe treatment trends and outcomes in pediatric empyema using the most current nationally representative data.

METHODS

Using survey methods and Kids' Inpatient Databases from 1997 to 2009, we evaluated hospital stays in children 0-18 years of age. We used 2009 data to compare transfer-out rates and lengths of stay across various types of treatment, after adjusting for patient and hospital factors.

RESULTS

From 1997 to 2009, empyema discharges steadily increased from 3.1 to 6.0 per 100,000 children (P < 0.001 for trend) and also were increasingly likely (P < 0.01) to be coded for: (1) at least 1 pleural drainage procedure (76.4-83.2%), (2) multiple drainage procedures (36.0-41.6%) and (3) home health care (8.7-15.0%). By 2009, video-assisted thoracoscopic surgery was more commonly coded than chest tube drainage and was associated with a lower transfer-out rate (0.6% vs. 10.1%, adjusted P < 0.001) but no reduction in mean length of stay [11.2 vs. 13.4 days, adjusted incidence rate ratio 0.95 (95% confidence interval: 0.88-1.04)] for children neither admitted nor discharged by transfer.

CONCLUSIONS

US hospital stays for empyema in children not only continued to increase through 2009 but were also characterized by more intense procedural management. Outcomes results in this population-based study are consistent with practice guidelines and recommendations that recently endorsed chest tube drainage as an acceptable first treatment option for most children with empyema.

Acute scoliosis in a 3-year-old boy

The case describes the presentation of a fit and well 3-year-old boy to the emergency department of a district general hospital after he developed an acute scoliosis overnight. There was no history of trauma, his observations were normal and he had non-specific symptoms of lethargy and reduced appetite, but no fevers or respiratory distress. Bloods showed raised inflammatory markers and he was referred to orthopaedics as a septic disc as there was some spinal tenderness. An urgent MRI was considered initially but on further examination there was some reduced air entry on the left lung base which a chest radiograph confirmed as a left-sided pneumonia. A diagnosis of pneumonia and secondary functional scoliosis was made. The child was admitted under paediatrics and made a full recovery on antibiotics. At 8 weeks follow-up there was resolution of scoliosis clinically and radiologically.

The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America

Evidenced-based guidelines for management of infants and children with community-acquired pneumonia (CAP) were prepared by an expert panel comprising clinicians and investigators representing community pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, pulmonology, and surgery. These guidelines are intended for use by primary care and subspecialty providers responsible for the management of otherwise healthy infants and children with CAP in both outpatient and inpatient settings. Site-of-care management, diagnosis, antimicrobial and adjunctive surgical therapy, and prevention are discussed. Areas that warrant future investigations are also highlighted.

[Treatment of loculated parapneumonic empyema. Video assisted thoracoscopy or fibrinolytics?]

OBJECTIVE

There is no consensus regarding the ideal treatment of loculated parapneumonic empyema (PPE). The aim of this study is to compare the effectiveness of drainage plus urokinase (DF) with video-assisted thoracoscopy (VATS).

MATERIAL AND METHODS

Retrospective review. Patients admitted with a PPE between January 2001 and July 2008. Loculated empyema was diagnosed by chest ultrasound and patients were treated with DF or VATS depending on the attending surgeon. Compared variables were: post-operative stay, total hospital stay, days of tube thoracostomy, post-operative fever and treatment failure.

RESULTS

One hundred and twenty one patients were admitted with the diagnosis of PPE. Seventeen patients were excluded from analysis because of simple parapneumonic effusions. Of the 104 patients included in the study, 47 were treated with urokinase and 57 with videothoracoscopy. No statistically significant differences (P>.05) were found between the median values in the DF and VATS groups for hospital stay (median 12 vs 12 days) or post-operative stay (median 9 vs 9 days). There were differences in duration of tube thoracostomy (median DF group 5 days, VATS, 4 days, P<.05) and in the post-operative fever (median 3 vs 2 days, p<0,05).Twenty two per cent of children needed a second procedure (14 patients of DF and 9 of VATS group, P=.09).

CONCLUSIONS

According to our experience, the results of DF and VATS for the treatment of loculated parapneumonic empyema are similar. Although there are no statistical differences, there seems to be a higher rate of failure, with the need of more procedures in the DF group. This difference does not affect the average total hospital stay.

Evaluation of a pediatric protocol of intrapleural urokinase for pleural empyema: a prospective study

BACKGROUND

Intrapleural urokinase has been shown to be effective in the treatment of pleural effusions in children. However, optimal dosing in children is debated. The aim of this study was to prospectively evaluate a specific pediatric protocol of intrapleural urokinase.

METHODS

All children admitted to a single institution over a 6-year period with a diagnosis of pleural empyema were managed with chest tube and fibrinolytics. Clinical data were collected prospectively. Urokinase (56,000 IU in 56 mL saline/m(2) body surface) was administered twice daily, and was continued until resolution of the effusion. Further operative treatment was considered if urokinase treatment was unsuccessful after >/=3 days. Results are shown as median values (interquartile range).

RESULTS

Forty-one consecutive children aged 4.4 (3.2-6.9) years were included in the study, and received 420,000 (280,000-750,000) IU of urokinase over 7 (4-8) days. Suction through the chest drain was applied for 8 (6-10) days, and IV antibiotics were discontinued after 12 (10-15) days from the start of intrapleural fibrinolytics. Four children (9.8%) required 5 additional operative procedures (3 thoracoscopic debridements and 2 minithoracotomic debridements). Patients were discharged after 13 (11-16) days from the beginning of intrapleural urokinase. No major side effects attributable to urokinase were observed.

CONCLUSION

Intrapleural instillation of urokinase according to a specific pediatric protocol results in a high success rate when applied as a primary treatment in children with pleural empyema. Administration of a size-adjusted dose of urokinase proved to be safe and could optimize drug utilization.

Clinical profile of pleural empyema and associated factors with prolonged hospitalization in paediatric tertiary centre in Angola, Luanda

SUMMARY

In a case series of 152 children aged from 2 to 132 months will pleural emphema from a paediatric tertiary hospital in Luanda, Angola between September 2004 and March 2005, the authors found a high prevalence of anaemia and malnutrition. The most prevalent bacteria in pleural fluid were: D pneumoniae, Haemophyllus and S aureus. The median for hospital stay was 25 days. The lethality was 7.8% and was not statistically associated with malnutrition, although this variable was associated, in multivariate analysis, with prolonged hospitalization time.

Balloon-assisted single-port thoracoscopic debridement in children with thoracic empyema

PURPOSE

In this study, we evaluated the results of a balloon-aided single-port thoracoscopic debridement of late-stage thoracic empyema in children.

PATIENTS AND METHODS

We retrospectively reviewed age, gender, duration of prehospital illness, physical findings, surgical interventions, and the morbidity in 12 children with late-stage parapneumonic empyema. The diagnosis of pleural effusion was confirmed by a thoracocentesis before thoracoscopy. A balloon connected to a 12 F feeding tube was inserted into the thoracic cavity and inflated with air before the enterance of the thoracoscope. By this maneuver, a cavity was formed just under the enterance point. Thereafter, a routine debridement and chest irrigation was performed by thoracoscopy. Only one port was inserted in all but 1 patient, and the telescope was used as a dissecting tool. A thorax tube was inserted through the port site at the end of the procedure and left for the drainage.

RESULTS

The main symptoms of the patients were dyspnea, cough, and fever. The empyema was located on the right hemithorax in 5 patients and on the left side in 7 patients. A second port was necessary to enhance the dissection in 1 case. The chest tube was removed within 3-30 days (median, 11 days) after the surgical approach. No complication directly related to the procedure was seen. The only problems postoperatively were a self-limited and spontaneously resolved bronchopleural fistula in 4 patients, and we had to perform an additional thoracoscopy to resolve the remaining intrapleural adhesions in 1 child.

CONCLUSIONS

Thoracoscopic debridement in patients with late-stage thoracic empyema may be very beneficial, and this treatment method may provide any further thoracotomy. A balloon inflated in the thoracic cavity may achieve a wider field of vision for thorascopic surgery, and single-port thoracoscopy is sufficient and safe for the dissection.

Incidence and outcome of scoliosis in children with pleural infection

AIMS

To ascertain the incidence and outcome of secondary scoliosis associated with parapneumonic effusions/empyema.

METHODS

Retrospective review of case notes of children with pleural effusions over a 3-year period. Review of digitalized erect chest radiographs by two observers with serial measurements of Cobb angles. Scoliosis defined as lateral curvature of the spine > or = 10 degrees.

RESULTS

Of 122 children (median age 4.3 years), 103 (84%) required chest drains of whom 83/103 (81%) received urokinase; 5 (4%) required surgical decortication. On admission, 56 (46%) had a scoliosis, 68 (62%) on the 2nd radiograph, and 68 (59%) at discharge; overall 87 (71%) had a scoliosis at some stage. In all cases, there was a single thoracic curve with the direction towards the side of the effusion. There was no association between scoliosis and size or type of effusion, nor inflammatory markers. There was a statistically significant but small effect from duration of illness prior to admission. At follow-up, 6 (5%) had a mild residual scoliosis but all subsequently resolved. Intraobserver variability for measurement of Cobb angles was +/-4.6 degrees and interobserver variability was +/-5.8 degrees.

CONCLUSIONS

Scoliosis was common but always resolved so therapy is unnecessary; follow up is recommended to exclude coincidental idiopathic scoliosis.

Minimal access thoracic surgery in the pediatric population

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

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.

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.

The evaluation and cluster analysis of parapneumonic effusion in childhood

We studied 80 children with parapneumonic effusion (PPE) with respect to the clinical manifestations and treatment alternatives as well as prospective follow-up for 1 year. Out of the 80 patients, 59 per cent were male. The mean age of the patients was 4.0 +/- 3.1 years. Mild effusion was successfully treated by antibiotic alone in 33 per cent of the patients. Tube thoracostomy (TT) was utilized in 63 per cent of the patients. In this group, 11 healed completely, 13 patients required surgical treatment, and 25 required fibrinolytic therapy (FT). FT was successful in 18, and no complication due to FT was observed. Six patients who received FT required surgical therapy later in the course of treatment. Cluster analysis revealed a group of patients with rapid progression and a short history of symptoms (4-6 days) that showed significantly higher rate of complicated prognosis (p<0.05). Successful FT prevented surgical operation in 22 per cent of the patients who were candidates for surgical treatment. The follow-up for one year revealed sequelae on chest X-ray in 28 per cent of the patients most of whom had an operation for necrotizing pneumonia. Pulmonary function tests performed over seven years of age were abnormal in 57 per cent of the patients.

Scoring system for empyema thoracis and help in management

OBJECTIVE

To evaluate the implications of a newly defined severity scoring of empyema in children for the prediction of surgical management and to compare the length of hospitalization as an outcome measure of patients treated using medical therapy, salvage video-assisted thoracoscopic surgery (VATS) vs early elective VATS.

METHODS

A retrospective chart review of parapneumonic empyema of patients below 18 years of age admitted to a tertiary children's hospital in northern Taiwan from April 1993 to December 2002 was performed. Patients were categorized into a medical group who received antibiotic therapy, needle aspirations with/without tube thoracostomy; a salvage VATS group when the patients required surgery for the relief of persistent fever > 38 degrees C, chest pains or dyspneic respirations despite initial medical therapy; an early VATS group when the patients received elective surgery early after admission. The demographic data, clinical features, laboratory findings, and duration of hospitalization were compared using a severity score of empyema (SSE).

RESULTS

Streptococcus pneumoniae was the most common infecting organism, followed by Staphylococcus aureus, Pseudomonas aeruginosa. No organisms were recovered in 39% of patients. A pleural pH < 7.1 increases the odds of requiring surgical intervention by 6 times among this cohort. Children who required decortication of empyema had a higher severity score (mean 4.8 vs 3.0, p < 0.005). The duration of hospitalization for patients having early VATS showed a shortening stay (mean 18 vs 28 days) as compared to salvage VATS.

CONCLUSION

A pleural pH < 7.1 and a newly designed clinical severity score of empyema 4 are two predictors of surgical intervention for fibrinopurulent empyema in the present study. Early elective VATS may be adopted not later than 7 days after failure of appropriate antibiotic therapy and adequate drainage of empyema to decrease the length of stay and minimize morbidity.

Diagnosis of parapneumonic pleural effusion by polymerase chain reaction in children

PURPOSE

Most pleural effusions are associated with bacterial pneumonia, and the identification of the pathogen will assist the therapeutic decision. A specific method that is not affected by previous antibiotic therapy is sought to detect the main causative agents of pneumonia in infants and children (Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus). The aim of the present study was to compare the polymerase chain reaction (PCR) technique with standard culture methods in identifying bacterial infections in infants' and children's pleural effusion.

METHODS

Samples obtained from pediatric patients (n = 37) with a diagnosis of pneumonia associated to pleural effusion, submitted to thoracentesis, were analyzed by PCR with specific primers.

RESULTS

The PCR technique identified the presence of bacterial infection in a larger proportion (95.2%) than the standard culture method (33.3%) on complicated pleural effusion samples. The microorganism detection on uncomplicated pleural effusion samples was positive only by the PCR method (31.3%). The frequencies of microorganisms identified on complicated pleural effusion were 57.1% of all patients for methicillin-resistant Staphylococcus; 52.4%, S pneumoniae; 28.6%, S aureus; and 23.8%, H influenzae. The previous use of antibiotics interferes with standard culture method, but it did not interfere with the PCR results.

CONCLUSIONS

The molecular diagnosis by PCR method could improve the etiologic diagnosis and might help to guide the treatment of parapneumonic effusion in children.

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.

Empyema Management: Twelve Years' Experience Since the Introduction of Video-Assisted Thoracoscopic Surgery

We reviewed empyema management at our center since video-assisted thoracoscopic surgery (VATS) was introduced. Between 1991 and 2003, 58 patients (34 male, 24 female) ages 1 day to 17 years (median, 6 years) were identified. The median interval from the onset of symptoms to presentation was 7 days; 31% of patients received inpatient care at another hospital, and 24% were from northern communities, including the Arctic. Symptoms included fever (100%), cough (66%), shortness of breath (46%), chest pain (38%), and abdominal pain (17%). Most patients (96%) had pneumonia. The most common organisms were Streptococcus pneumoniae (22%), group A streptococcus (8%), and Mycobacterium tuberculosis (3%). No organisms were identified in 31% of patients. One empyema was trauma-related and one was due to complications of esophageal stricturoplasty. All patients received intravenous antibiotics (median, 17 days). Three patients had thoracentesis, 17 had chest tubes, 3 had thoracentesis and chest tubes, 26 had VATS, 6 had thoracotomy, and 3 had minithoracotomy. Median operative times were 86 minutes for VATS, 90 minutes for thoracotomy, and 75 minutes for minithoracotomy. Median total length of stay (LOS) was 15 days for VATS, 20.5 days for thoracotomy, and 21 days for minithoracotomy. The median preoperative LOS was longer for thoracotomy (10 days) than for VATS (5 days) or minithoracotomy (1 day). The median postoperative LOS was 14 days for VATS, 9.5 days for thoracotomy, and 8 days for minithoracotomy. Our experience shows that VATS is a safe and effective approach to managing children with empyema. The shorter preoperative LOS for VATS is likely due to earlier surgical referral and intervention using less invasive surgical procedures.

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.

Evaluation of chronic infectious interstitial pulmonary disease in children by low-dose CT-guided transthoracic lung biopsy

BACKGROUND

Children with chronic infectious interstitial lung disease often have to undergo open lung biopsy to establish a final diagnosis. Open lung biopsy is an invasive procedure with major potential complications. Transthoracic lung biopsy (TLB) guided by computed tomography (CT) is a less-invasive well-established procedure in adults.

OBJECTIVE

Detailing the role of low-dose CT-guided TLB in the enhanced diagnosis of chronic lung diseases related to infection in children.

MATERIALS AND METHODS

A group of 11 children (age 8 months to 16 years) underwent CT-guided TLB with a 20-gauge biopsy device. All investigations were done under general anaesthesia on a multidetector CT scanner (SOMATOM Volume Zoom, Siemens, Erlangen, Germany) using a low-dose protocol (single slices, 120 kV, 20 mAs). Specimens were processed by histopathological, bacteriological, and virological techniques.

RESULTS

All biopsies were performed without major complications; one child developed a small pneumothorax that resolved spontaneously. A diagnosis could be obtained in 10 of the 11 patients. Biopsy specimens revealed chronic interstitial alveolitis in ten patients. In five patients Chlamydia pneumoniae PCR was positive, in three Mycoplasma pneumoniae PCR was positive, and in two Cytomegalovirus PCR was positive. The average effective dose was 0.83 mSv.

CONCLUSION

Low-dose CT-guided TLB can be a helpful tool in investigating chronic infectious inflammatory processes in children with minimal radiation exposure. It should be considered prior to any open surgical procedure performed for biopsy alone. In our patient group no significant complication occurred. A disadvantage of the method is that it does not allow smaller airways and vessels to be assessed.

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.

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.

Treatment of Complicated Parapneumonic Pleural Effusion With Intrapleural Streptokinase in Children

OBJECTIVE

To evaluate the role of intrapleural streptokinase in the management of complicated parapneumonic effusions in children.

DESIGN

Prospective comparative study.

SETTING

Cheng Kung University Hospital, a tertiary medical center in Tainan, Taiwan.

PATIENTS AND METHODS

We enrolled as our prospective study group 20 consecutive children with complicated parapneumonic effusions who received intrapleural streptokinase treatment between August 2000 and July 2002. We also retrospectively analyzed a comparison group of 22 consecutive children with complicated parapneumonic effusions who received chest tube drainage without streptokinase treatment from January 1992 to July 2000. We then compared the clinical manifestations and outcome of these two patient groups. The patient population (21 boys and 21 girls) ranged in age from 9 to 130 months (mean age, 41.5 +/- 26.3 months [mean +/- SD]). The characters of pleural effusion showed no difference between the two groups. Nineteen patients had positive findings for Streptococcus pneumoniae, 2 patients had positive findings for Staphylococcus aureus, 2 patients had positive findings for Pseudomonas aeruginosa, and 19 patients had undetermined pathogens. All patients were treated with appropriate antibiotics.

RESULTS

More pleural fluid was drained from the streptokinase group than from the comparison group during streptokinase treatment (816 +/- 481 mL vs 279 +/- 238 mL, p < 0.01). The duration of fever after chest tube insertion was also significantly lower in the study group (5.3 +/- 3.1 days vs 7.9 +/- 4.6 days, p < 0.05). Only two patients in the streptokinase group required surgical intervention compared with nine patients in the comparison group (p < 0.05). No major side effects were noticed after streptokinase instillation.

CONCLUSION

Intrapleural fibrinolytic treatment with streptokinase is safe and effective, and it can obviate the need for surgery in most cases. The combination treatment should be attempted early on, when complicated parapneumonic effusion is first diagnosed.

Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia

AIMS

To study the clinical and microbial profile of childhood empyema in South Asia and to identify the changes over the past three decades.

METHODS

A total of 265 children (aged 1 month to 12 years) with empyema admitted to the Advanced Pediatric Center, PGIMER, Chandigarh, India in 1989-98, were reviewed retrospectively.

RESULTS AND CONCLUSIONS

One third of children were under 5. Culture positivity had decreased significantly (48% v 75%) over the years. Staphylococcus aureus continues to be the commonest (77%) aetiological agent; clustering was seen during hot and humid months (46%). Culture positive Streptococcus pneumoniae cases also decreased (9% v 27%); all were seen during the winter and spring season. Gram negative rods grew in more patients (11% v 7%). Community acquired methicillin resistant S aureus (MRSA) was isolated in three patients. Most children (93%) were treated with parenteral cloxacillin and an aminoglycoside. Tube drainage (TD) was used in 92% of fibropurulent cases, and was successful in 79%. Of 48 patients with failed TD, 12 needed decortication; limited thoracotomy was sufficient in the remaining 36. Surgery was mainly required by children with persistent pleural sepsis after 10 days of TD. Delaying surgery until 14 days had a significantly higher potential of requiring decortication. Early change to oral antibiotics (after 1-2 weeks of parenteral therapy) reduced the hospital stay significantly (17+7 v 23+7 days) without compromising long term outcome. Twenty two patients presenting late in the chronic stage underwent decortication at admission.

Management of thoracic empyema in childhood: does the pleural thickening matter?

AIMS

To determine the clinical course and long term outcome of empyema treated without decortication.

METHODS

Fourteen consecutive admissions to one hospital were studied; radiological resolution and lung function were subsequently followed. The children were aged 2-14 years. All were treated with intravenous antibiotics and chest drain only.

RESULTS

All patients had extensive pleural thickening evident on chest x ray examination at the time of discharge, which resolved entirely over a period of 2-16 months. Lung function was measured in 13 children, and showed no evidence of restrictive or obstructive deficit: mean (SD) values as per cent predicted for height were: forced expiratory volume in one second (FEV1) 107.5 (9.6), forced vital capacity (FVC) 95.5 (8.8), total lung capacity (TLC) 98.6 (20.7). Individual children all had values in the normal range (80-120 per cent predicted).

CONCLUSION

Results suggest that decortication is not necessary in children to prevent long term problems with pleural thickening, and should be undertaken on the basis of the clinical picture (failure of fever resolution), rather than radiological appearance.

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.

A new sterilization technique with balloon-tube thoracostomy for thoracic empyema

OBJECTIVE

Failure or prolongation of treatment for refractory thoracic empyema by the current chest-tube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed.

METHODS

Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30-60 minutes, followed by an antibiotic solution for more than 20 hours.

RESULTS

Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2-13 days. Neither recurrence nor treatment-related major complications were observed.

CONCLUSIONS

This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.

Intrapleural fibrinolysis for parapneumonic effusion and empyema in children

PURPOSE

To assess the safety and efficacy of urokinase and alteplase for intrapleural fibrinolysis in children with parapneumonic pleural fluid collections.

MATERIALS AND METHODS

A retrospective review was performed of 71 children with parapneumonic pleural fluid accumulations who were treated with thoracostomy tube placement and intrapleural instillation of either urokinase or alteplase. The procedures were performed with urokinase between September 2, 1995, and March 27, 1998, and with alteplase between March 30, 1998, and January 2, 2002. The medical records and daily chest radiographs were reviewed by a pediatric radiologist to ascertain demographic information, signs and symptoms, laboratory results, thoracostomy tube output, treatment details, and radiographic pleural thickness and lung opacification. Multiple variables were compared for the alteplase and urokinase groups by using univariate and multivariate statistics. We defined primary treatment success as resolution of signs and symptoms at the time of discharge, without surgical intervention.

RESULTS

Primary treatment success was 98% for alteplase and 100% for urokinase, with no major complications. Greater pleural fluid drainage occurred with alteplase than urokinase during the 1st (P =.001) and 2nd (P =.002) days of fibrinolytic therapy, and for the duration of thoracostomy drainage (P <.001). Multivariate models showed greater total drainage with alteplase (P <.001), greater patient age (P <.001), larger tube size (P =.002), and greater volume of drainage during the 24 hours prior to fibrinolysis (P <.001).

CONCLUSION

Intrapleural fibrinolysis with urokinase or alteplase facilitates thoracostomy tube drainage of parapneumonic pleural fluid. With the dosing regimen used in this study, alteplase produces greater thoracostomy tube output than does urokinase.

Randomised trial of intrapleural urokinase in the treatment of childhood empyema

BACKGROUND

The role of intrapleural fibrinolytic agents in the treatment of childhood empyema has not been established. A randomised double blind placebo controlled trial of intrapleural urokinase was performed in children with parapneumonic empyema.

METHODS

Sixty children (median age 3.3 years) were recruited from 10 centres and randomised to receive either intrapleural urokinase 40 000 units in 40 ml or saline 12 hourly for 3 days. The primary outcome measure was length of hospital stay after entry to the trial.

RESULTS

Treatment with urokinase resulted in a significantly shorter hospital stay (7.4 v 9.5 days; ratio of geometric means 1.28, CI 1.16 to 1.41 p=0.027). A post hoc analysis showed that the use of small percutaneous drains was also associated with shorter hospital stay. Children treated with a combination of urokinase and a small drain had the shortest stay (6.0 days, CI 4.6 to 7.8).

CONCLUSION

Intrapleural urokinase is effective in treating empyema in children and significantly shortens hospital stay.

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.

Management of parapneumonic collections in infants and children

BACKGROUND/PURPOSE

Video-assisted thoracoscopic surgery (VATS) has a recognized role in treatment of empyema thoracis. The purpose of this report is to show the value of initial VATS as the primary treatment of parapneumonic collections.

METHODS

A retrospective review was done of 139 children who required surgical consultation for parapneumonic collections between January 1992 and July 1998. Management options were (M1) thoracentesis, chest tube drainage, or fibrinolytic therapy and delayed thoracotomy for unresolved collections; (M2) thoracentesis, chest tube drainage, fibrinolytic therapy with delayed VATS if the child remained ill; or (M3) primary VATS. Comparative data included age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, number of procedures performed per patient, duration of chest tube drainage, complications, and length of stay. Kruskal-Wallis 1-way analysis was used, with significance at P less than .05.

RESULTS

A total of 60 children were treated by M1, 38 by M2, and 41 by M3. Age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, and complication rates were comparable. The median length of stay was 12 days for M1, 11 days for M2, and 7 days for M3, with M3 significantly shorter at P<.001. The number of procedures was a median of 2 in M1, 2 in M2, and 1 in M3, with M3 significantly fewer at P<.001. Duration of chest tube drainage was a median 5 days for M1 and 3 days for M2 and M3, with M1 significantly longer at P<.001. There were 9 thoracotomies in the M1 group, 3 in the M2 group, and none in the M3 group. One child in M3 required a second VATS.

CONCLUSIONS

Primary VATS has significantly decreased the number of procedures, duration of chest tube drainage and length of stay for children with parapneumonic effusions. Primary VATS appears to be of value in management of bacterial pneumonia with effusion.

Decorticação pleural precoce no tratamento do empiema pleural complicado na criança

Os autores avaliam dez casos de empiema pleural tratados inicialmente pela drenagem pleural fechada e que tiveram evolução desfavorável e arrastada. Pacientes que evoluíram com septação do empiema, persistência de fístula broncopleural de alto débito ou de falta de expansão pulmonar após a drenagem pulmonar foram submetidos a estudo pela tomografia computadorizada e encaminhados para a decorticação pleural precoce como alternativa para o tratamento. Todos os pacientes tratados desta forma tiveram uma rápida melhora clínica, evoluindo com boa expansão pulmonar, recebendo alta hospitalar num prazo máximo de dez dias após a cirurgia. Concluem os autores que tal procedimento é seguro devendo ser considerado para o tratamento do empiema pleural de má evolução.

Early video-assisted thoracic surgery in the management of empyema

OBJECTIVE

The appropriate timing, as well as the type of intervention, for the treatment of empyema in children is controversial. The advent of video-assisted thoracic surgery (VATS) has changed the way we treat these children. Therefore, we reviewed our experience with the early use of VATS in the treatment of empyema and formulated a treatment algorithm.

METHODS

We retrospectively reviewed medical records of all patients undergoing VATS for empyema at Arkansas Children's Hospital from December 1994 to February 1997. All patients were treated by the pediatric surgical service and had the diagnosis of empyema confirmed at surgery. Results are reported as means, unless otherwise noted.

RESULTS

Twenty-five children with empyema were treated with VATS during the review period. Their age was 48.3 months, and the duration of symptoms was 7.4 days. All the patients had parapneumonic empyemas and had received preoperative antibiotics for 10.1 days. Preoperative imaging included chest radiography in 25 (100%), ultrasonography in 20 (80%), and computed tomography in 10 (40%). All patients with documented loculated parapneumonic fluid collections underwent VATS within a mean of 2 days of hospitalization. Chest tubes were removed in 3.2 days, resulting in a postoperative length of stay of 4.9 days. Total length of stay was 7.3 days. One patient required conversion to minithoracotomy and required a transfusion. There were no other complications or deaths. Follow-up was available for 22 (88%) children, and there was resolution of symptoms in all children with no recurrences.

CONCLUSIONS

Earlier intervention with VATS in the treatment of empyema in children is safe and may reduce hospital charges by shortening hospital stay. A treatment algorithm based on early use of VATS is also described.

Early definitive intervention by thoracoscopy in pediatric empyema

PURPOSE

Nineteen children had early thoracoscopic intervention for empyema between 1992 and 1997 at the LeBonheur Children's Medical Center. The authors have evaluated the results of this treatment.

METHODS

Thoracoscopic intervention was performed at the fibrinopurulent state of empyema. An irrigating laparoendoscope was inserted, loculi were disrupted, debris was evacuated, and a chest tube was passed through the port site.

RESULTS

The patients were aged between 11 months and 16 years (mean, 6.5 years). The etiology of the empyema was parapneumonic in 17, and there was one case each of perforated appendicitis and mediastinal histoplasmosis. They underwent thoracoscopy at a mean of 4.6 days after hospital admission (range, 1 to 12 days). Chest tubes were removed at 1 to 5 days (mean, 2.9 days) after operation, and resolution of fever occurred at 1 to 9 days (mean, 3.8 days) postoperatively. Patients were discharged home between 4 and 10 days (mean, 6.1 days) postoperatively, and the mean hospital stay was 10.3 days (range, 5 to 21). There were no complications. The surgical technique was simple and well tolerated, requiring few disposable items, and the mean operating time was 77 minutes.

CONCLUSIONS

Thoracoscopy eliminated the morbidity of thoracotomy and the discomfort and expense of prolonged chest tube drainage. Thoracoscopy may be used as early first-line therapy in a majority of pediatric patients with fibrinopurulent empyema.

Timing of video-assisted thoracoscopic debridement for pediatric empyema

BACKGROUND

Video-assisted thoracoscopic debridement (VATD) is a new method of managing pediatric empyema. The purpose of this retrospective study was to determine the relation between the timing of VATD and its success in avoiding the need for open decortication.

STUDY DESIGN

Twenty-one children aged 3 to 16 years (mean, 8 years) with symptomatic, loculated, parapneumonic empyema were treated with VATD at two tertiary pediatric centers between 1994 and 1997. The preoperative duration of symptoms, hospitalization, and previous need for thoracostomy drainage were compared between patients having VATD only and those who subsequently required a thoracotomy and decortication. Statistical analysis used the Wald chi-square test or Fisher's exact test with p < 0.05 considered significant.

RESULTS

Video-assisted thoracoscopic debridement was successful in 15 patients (group 1) and unsuccessful in six patients (group 2), who required a thoracotomy and decortication. Group 1 had a shorter mean duration of preoperative symptoms (13 versus 27 days; p=0.03), a shorter median duration of preoperative hospitalization (6 versus 18 days; p=0.04), and a lower incidence of previous thoracostomy drainage (4/15 versus 5/6; p=0.05).

CONCLUSIONS

The technique of VATD is most likely to be successful when used within one week of diagnosis of a loculated parapneumonic empyema. A prospective trial comparing VATD with intrapleural fibrinolytic agents for the initial treatment of pediatric empyema is needed.