What is the best treatment for empyema?
Date First Published:
February 1, 2008
Last Updated:
February 1, 2008
Report by:
O Kerek, T Hilliard, J Henderson, Specialist Registrar in Paediatrics (Bristol Royal Hospital for Children and University of Bristol, UK)
Three-Part Question:
In [children with an empyema] should [video assisted thoracoscopy (VATs) or percutaneous chest drain with fibrinolytic therapy] be used [to resolve symptoms]?
Clinical Scenario:
A 7-year-old child with a history of cough and fever for 1 week, has bronchial breathing over her left lower zone on auscultation. A diagnosis of lobar pneumonia is made, confirmed on plain chest x ray, and she is treated with appropriate intravenous antibiotics. However, she continues to have a spiking fever and develops signs of a left sided pleural effusion. Repeat chest x ray shows a "white out" of the left chest with no mediastinal shift. She is referred to the regional thoracic centre for consideration of thoracotomy and drainage of a left sided parapneumonic effusion. Should she be referred to the surgeons and if so, what should they do?
Search Strategy:
Searched Medline and Pubmed, 1966 to present
Search Details:
(search words: empyema; parapneumonic; pneumonia; pleural effusion; thoractomy; VATS; chest-drain; fibrinolytic), restricted to children.
Cochrane: no relevant results
Cochrane: no relevant results
Outcome:
Fifty relevant papers were found, of which the majority were review articles. Two RCTs were identified that looked at the outcomes of chest drain plus fibrinolysis.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Kurt BA, Winterhalter KM, Connors RH, et al. 2006, USA | 18 patients under 18 with large parapneumonic effusions Each randomly assigned VATS (10) or thoracostomy tube drainage (8) with option of adding reteplase if there was not sufficient drainage within 24 h (7) |
PRCT (level 1b) | Hospital stay | VATS significantly shorter 5.8 compared with 13.2) | No ethical consent obtained. Chest drain removed when <1 ml/kg per day of fluid drained. Primary outcomes (hospital stay and number of days of chest drain) are dependent on the nature of the treatment Small number in study defended by authors as statistically and clinically significant |
| Number of days of chest drain | VATS 2.80 (significant), thoracostomy 9.63. | ||||
| Narcotic use (days) | VATS 2.20 (significant), thoracostomy 7.63 | ||||
| Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Sonnappa S, Cohen G, Owens CM, et al. 2006, USA | 60 patients under 16 with radiographic evidence of empyema (CXR and US) and persistent fever or >24 h of parenteral antibiotics or respiratory distress caused by collection. Randomised to VATS (30) or chest drain and urokinase (30) | PRCT (level 1b) | Number of days in hospital after procedure | No significant difference (both 6 days) | Cost analysis performed, urokinase US$9127 significantly lower than VATS US$11 379. Protocol biased in favour of VATS as urokinase is administered over 3 days. Although chest drain in situ days were slightly less in VATS arm, no clinical difference was noted as the patients spent the same number of days in hospital |
| Total number of hospital days | No significant difference (VATS 8, chest drain 7) 1 day less in VATS arm, borderline significance | ||||
| Failure rate | Both arms had 5 failures | ||||
| CXR at 6 months | No difference found |
Author Commentary:
The incidence of parapneumonic effusion complicating pneumonia in children has increased in the last decade (Eastham). Three stages of disease are recognised:(Balfour-Lynn).
Stage 1: "exudative" – fluid accumulates within the pleural space but is free flowing, and no loculations are present.
Stage 2: "fibropurulent" – the fluid becomes loculated due to the presence of fibrin.
Stage 3: "organisational" – there are multiple loculations and a thick pleural peel entraps the underlying lung.
Following chest radiography, ultrasonography is able to estimate the size of the effusion, detect loculations and determine its echogenicity.2 Routine chest CT is usually not required but may be helpful in defining lung consolidation, abscesses and necrosis (Ampofo).
The choice of therapy lies between conservative management (ie, continuation of IV antibiotics alone) which may lead to resolution of the empyema in 60–80% of cases but often requires prolonged hospitalisation (Balfour-Lynn). chest drain insertion (with or without the use of a fibrinolytic agent), and more invasive surgical treatment. Open thoracotomy with debridement of pyogenic material is increasingly only performed following failure of other therapy but is associated with a rapid recovery (Hilliard). Recently, VATS has been proposed as being a less invasive surgical technique and suitable as a primary procedure.
Previous RCT evidence supports the use of a chest drain with fibrinolytic therapy compared to a chest drain alone (Thomson). No papers reporting direct comparisons of the outcomes of open thoracotomy versus VATS were found. Two prospective randomised controlled trials of a chest drain compared with VATS for the treatment of empyema in children have now been published.
Kurt et al compared VATS to chest drain alone in 18 children. Intrapleural reteplase was only given if there was incomplete resolution of the effusion on chest x ray within 24 h. VATS was associated with a shorter length of hospital stay and fewer days of tube drainage; however, the mean length of stay in the chest drain group was 13 days, which is much longer than what would be now expected in this group.5 Sonnappa et al compared VATS to chest drain and 3 days of intrapleural urokinase in a larger study of 60 patients. There were no differences in clinical outcomes but the estimated overall cost of VATS was 20% greater than that for chest drain and fibrinolysis. In addition, the option to perform VATS depends on the availability of the appropriate equipment and suitably trained surgeons (Balfour-Lynn).
Stage 1: "exudative" – fluid accumulates within the pleural space but is free flowing, and no loculations are present.
Stage 2: "fibropurulent" – the fluid becomes loculated due to the presence of fibrin.
Stage 3: "organisational" – there are multiple loculations and a thick pleural peel entraps the underlying lung.
Following chest radiography, ultrasonography is able to estimate the size of the effusion, detect loculations and determine its echogenicity.2 Routine chest CT is usually not required but may be helpful in defining lung consolidation, abscesses and necrosis (Ampofo).
The choice of therapy lies between conservative management (ie, continuation of IV antibiotics alone) which may lead to resolution of the empyema in 60–80% of cases but often requires prolonged hospitalisation (Balfour-Lynn). chest drain insertion (with or without the use of a fibrinolytic agent), and more invasive surgical treatment. Open thoracotomy with debridement of pyogenic material is increasingly only performed following failure of other therapy but is associated with a rapid recovery (Hilliard). Recently, VATS has been proposed as being a less invasive surgical technique and suitable as a primary procedure.
Previous RCT evidence supports the use of a chest drain with fibrinolytic therapy compared to a chest drain alone (Thomson). No papers reporting direct comparisons of the outcomes of open thoracotomy versus VATS were found. Two prospective randomised controlled trials of a chest drain compared with VATS for the treatment of empyema in children have now been published.
Kurt et al compared VATS to chest drain alone in 18 children. Intrapleural reteplase was only given if there was incomplete resolution of the effusion on chest x ray within 24 h. VATS was associated with a shorter length of hospital stay and fewer days of tube drainage; however, the mean length of stay in the chest drain group was 13 days, which is much longer than what would be now expected in this group.5 Sonnappa et al compared VATS to chest drain and 3 days of intrapleural urokinase in a larger study of 60 patients. There were no differences in clinical outcomes but the estimated overall cost of VATS was 20% greater than that for chest drain and fibrinolysis. In addition, the option to perform VATS depends on the availability of the appropriate equipment and suitably trained surgeons (Balfour-Lynn).
References:
- Eastham KM, Freeman R, Kearns AM, et al.. Clinical features, aetiology and outcome of empyema in children in the north east of England.
- Balfour-Lynn IM, Abrahamson E, Cohen G, et al.. BTS guidelines for the management of pleural infection in children.
- Ampofo K, Byington C.. Management of parapneumonic empyema.
- Hilliard TN, Henderson AJ, Langton Hewer SC.. Management of parapneumonic effusion and empyema.
- Thomson AH, Hull J, Kumar MR, et al.. Randomised trial of intrapleural urokinase in the treatment of childhood empyema.
- Kurt BA, Winterhalter KM, Connors RH, et al.. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage.
- Sonnappa S, Cohen G, Owens CM, et al.. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema.