Management of Empyema Thoracis inChildren: Tube Thoracostomy
VersusEarly DecorticationINTRODUCTION:Empyema thoracis is a common
surgical complicationof pneumonia. It is an important cause of
paediatrichospital admissions and paediatric morbidity.
Variousmodes of treatment are described for themanagement of this
condition. The propermanagement of empyema thoracis in
childrencontinues to be a source of debate. Thoracicempyema
continues to have a high mortality rate(10-16%)1.It occurs when
bacteria invade andpropagate in the normally sterile pleural space,
andprogresses in three phases. The exudative phase iscaused by
increased permeability of the inflamedpleura. The fibrinopurulent
phase is characterizedby accelerated fibrin deposition, giving rise
toloculations and pus formation. The organizationalphase begins one
week after infection and ischaracterized by multiloculated empyema
and pleuralpeel, with subsequent lung entrapment. Thepredominant
organisms involved are staphylococcus,streptococcus, and mycoplasma
species.Bacterial pneumonia is the most common cause ofthoracic
empyema in the paediatric age group.Pleural effusion during the
course of nonspecificbacterial pneumonia progresses to empyema
forseveral reasons including malnutrition,immunodeficiency,
irregular antibiotic treatment,delay in diagnosis of pneumonia,
contaminationduring thoracentesis, the tendency for
antibiotictreatment in the acute phase in paediatric clinics,and
disappearance of the signs and symptoms ofpneumoniaThere are many
treatment options but unfortunatelyresults with these treatment
regimens have beenhighly variable. As a result, the optimum
therapeuticstrategy for empyema has yet to be elucidated.Moreover,
the availability of non-operativealternatives frequently results in
delayed surgicalconsultation, and ultimately, increased
patientmorbidity and mortality.8,9,10 Determination of thestage of
the empyema has been reported to becrucial in choosing an
appropriate therapeutic option.Duration of symptoms has been
suggested as oneof the means of estimating the stage of
theempyema.9In complicated para-pneumonic effusion, both
serialthoracentesis and chest tube drainage can beadvocated as a
first-line therapy. There have beensome reports of the
effectiveness of this procedureafter early diagnosis.11,12 Tube
drainage isrecommended in children because of its
reliability,rather than multiple thoracentesis.13 Pleural lavagevia
the chest tube is useful for augmenting drainageand mechanical
clearance and various antimicrobialagents can be added to the
washing fluid.8,11 LeMenseet al14 have suggested that this
decreases the severityof pleural sepsis while instituting further
therapy.We have not used any agent for lavage purposesafter chest
tube placement.Because of the low reported success rate of
tubethoracostomy for loculated empyema, alternativeapproaches have
been developed. Intrapleuralfibrinolytic agents (IPFA) have been
used in thetreatment of thoracic empyema.15 Several reportshave
documented successful drainage of multiloculatedempyema using
streptokinase andurokinase.13,16 Temes17 used IPFA in all 26
patientssent for decortication. More than two-thirds of
patientswith traditional indication for decortication forempyema
thoracis were treated successfully. Wehave no experience of using
this mode of treatmentwhich appears feasible in early stages of the
disease.The presence of a thick rind with trapped lung
areindications for operation and decortication.8,11,14 Theinability
to evacuate fibrinous debris via chest tubeis also an indication
for decortication. Decorticationshould be performed as soon as
possible if drainageis not effective. It may be an initial
treatment insteadof wasting time by performing tube
thoracostomy.When the patient's status is suitable for surgery,
werecommend this approach because of the decreasein mortality and
morbidity, reduction of hospital stay,and discharge of the patient
without an open wound.Postoperative complications such as
atelectasis anddelayed expansion are mainly from
parenchymaldisease. The results of our study are comparable tothat
of Brohi et al18 but are somewhat different fromthat of Light et
al.105. Majid F, Zubair M. Management of empyema thoracis in
children: tube thoracostomy versus early decortication. Journal of
Surgery Pakistan (International). 2011
Management of Postpneumonic Empyemas in ChildrenParapneumonic
effusion is any pleural effusion secondaryto pneumonia (bacterial
or viral) or lung abscess.Approximately 0.6% of childhood cases of
pneumoniaare complicated by the formation of pleural empyema.The
incidence of empyema ranges from 4 to 6 per100,000 children (1). It
is recommended that a stepwiseapproach be taken with patients with
parapneumoniceffusions. The treatment options are observation,
therapeuticthoracentesis, tube thoracostomy, tube thoracostomywith
intrapleural fibrinolytics, thoracoscopy andthoracotomy with
decortication, and open drainageprocedures. Unfortunately, results
with these treatmentregimens have been highly variable (2, 3). The
aim ofthis study was to assess different treatment options in
themanagement of postpneumonic pediatric empyemas.DiscussionLow
socio-economic level, delay in diagnosis of pneumonia,unsuitable
antibiotic treatment, immunodeficiencyand malnutrition are
contributing factors to the developmentof empyema in patients with
pneumonia.Bacterial pneumonia is the most common cause ofpleural
effusions or empyema in the pediatric agegroup (2, 3). The
treatment of empyema in children stillremains controversial.
However, the treatment objectivesoutlined by MAYO (5) are 1) to
save life, 2) to eliminatethe empyema, 3) to re-expand the trapped
lung,4) to restore mobility to the chest wall and diaphragm,5) to
return the respiratory function to normal, 6) toeliminate
complications or chronicity, and 7) to reducethe duration of
hospital stay.The reported rate of identifying an infectious
organismfrom pleural fluid varies markedly, from 8% to 76%.However,
in present day practice, pleural fluid culture isoften negative due
to use of antibiotics before obtaininga pleural fluid sample (6).
In our study, pleural fluid cultureswere positive in 49.55% of the
patients. As in manyother studies (1, 3, 6, 7) the most frequently
identifiedmicro-organism in our study was
Staphylococcusaureus.Chest tube thoracostomy is considered to be
theappropriate treatment modality for stage II thoracicempyema
(especially for non-multiloculated cases). TheBritish Thoracic
Society recommends that all patientswith significant pleural
infection should be treated withantibiotics and drainage of the
pleural fluid (6). In manystudies the rate of success of chest tube
thoracostomywas reported as being between 61% and 100% (8-12).Chest
tube thoracostomy rate of success was 89.9% inour study. Although
chest tube thoracostomy is a treatmentwith a high rate of success,
the hospital stay islong. This period is reported to be
approximately 8-14days (range 3-35 days) in the literature (8-10,
12, 13).Likewise in the present study, the duration of hospitalstay
in group I was 11.46 3.79 days (range 6-22 days).The hospital stay
and chest tube removal time in group Iwas a little longer than in
group II, however there was nostatistically significant difference
between the twogroups (P = 0.040, P = 0 .019 respectively).We
applied fibrinolytic treatment with chest tube thoracostomyto
patients in whom multiloculation wasfound by US and CT.
Intrapleural fibrinolytic drugs maylyse the fibrinous strands in
loculated empyemas.Several reports have documented successful
drainage ofmultiloculated empyema using streptokinase and
urokinase(11, 14-17). However, MASKELL and associates (18)reported
that (multi-centre, randomised, double-blindstudy) there was no
benefit from streptokinase in termsof mortality, rate of surgery,
radiographic outcomes, orduration of the hospital stay. Moreover
BALCI et al. (7)have concluded that fibrinolytic treatment is not
an alternativeto surgery, especially in loculated empyemas
inchildren. We have performed tube thoracostomy withintrapleural
fibrinolytic treatment on 22 patients. Nine(40.9%) of them were
successful and 13 (59.1%), onwhom treatment was unsuccessful,
underwent decortication.Both BALCI et al. (7) and MASKELL and
associates(18) agreed that fibrinolytic treatment does notreduce
hospital stay or the need for surgery.Video-assisted thoracoscopic
surgery (VATS)achieves debridement of fibrinous pyogenic
material,breakdown of loculations, and drainage of pus from
thepleural cavity under direct vision. Many authors havereported
that VATS can be performed safely and effectivelyin children with
stage II empyema. In addition,VATS was associated with a lower
mortality rate, loweropen surgery rate, shorter hospital stay, and
chest tubedrainage, compared with non-operative treatment (1, 2,11,
18, 19). Unfortunately we do not have any experiencewith
VATS.Decortication has to be performed on patients
whereconservative treatment is radiologically and clinicallyproven
to be insufficient. We applied decortication on 19of our patients
(9 of group I and 10 of group II patients)who did not show clinical
recovery and who had thickpleural peel with trapped lung and
multiple loculationsat control CT. The chest tube removal time was
5.00 2.43 days and hospital stay was 6.32 2.54 days ingroup III.
Both OZCELIK and associates (3) and POTHULAet al. (20) have
reported that decortication decreaseschest tube drainage and
hospital stay. In addition, decorticationhas low morbidity and
mortality rates (3, 7, 20).
Dapus3. OZCELIK C., LK R., ONAT S., OZCELIK Z., INCI I., SATICI
O.Management of postpneumonic empyemas in children. Eur
JCardiothorac Surg, 2004, 25 : 1072-1078.7. BALCI A. E., EREN S.,
LK R., EREN M. N. Management of multiloculatedempyema thoracis in
children : thoracotomy versusfibrinolytic treatment. Eur J
Cardiothorac Surg, 2002, 22 : 595-598.A. Kosar, M.D.Sureyyapasa
Chest Disease and Chest Surgery Training and
ResearchHospitalDepartment of Thoracic SurgeryAtaturk cad. Murat
Apt. 46/1634734 Erenkoy, Istanbul, TurkeyTel. : + 90 216 386 35
90Fax : + 90 216 459 68 59E-mail : [email protected]
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Sheldon Pediatrics 2004;113;1735journal of the American Academy of
Pediatrics
St. Peter SD, Tsao K, Harrison C, et al. Thoracoscopic
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