What is the best treatment for empyema?

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Aug 3, 2007 - Tom Hilliard, Paediatric Respiratory Consultant, Bristol Royal Hospital for ... 6 Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW.
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ADC Online First, published on August 3, 2007 as 10.1136/adc.2007.127373

What is the best treatment for empyema? 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? Structured clinical question In children with an empyema [patient] should Video Assisted Thoracoscopy (VATs) [intervention] or percutaneous chest drain with fibrinolytic therapy [intervention] be used to resolve symptoms [outcome]? Search strategy Secondary sources: Cochrane: no relevant results. Primary sources: searched Medline and Pubmed, 1966 to present. (Search words: empyema; parapneumonic; pneumonia; pleural effusion; thoractomy; VATS; chest-drain; fibrinolytic, restricted to children.) 50 relevant papers were found, of which the majority were review articles. Two RCTs and one review article were identified that looked at the outcomes of chest drain plus fibrinolysis. Commentary The incidence of parapneumonic effusion complicating pneumonia in children has increased in the last decade.1 Three stages of disease are recognised:2 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.3 The choice of therapy lies between conservative management (i.e. continuation of IV antibiotics alone) which may lead to resolution of the empyema in 60–80% of cases, but often requires prolonged hospitalisation 2, 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.4 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.5 No papers reporting direct comparisons of the outcomes of open thoracotomy versus VATS were found. Two prospective randomised controlled 1 Copyright Article author (or their employer) 2007. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence.

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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.6 Intrapleural reteplase was only given if there was incomplete resolution of the effusion on CXR within 24 hours. VATS was associated with a shorter length of 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.7 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.2 Clinical Bottom Line There is no evidence to support a better clinical outcome from VATS compared to a chest drain with intrapleural fibrinolytic in children with empyema. Most children will do well with this therapy alone.

Authors Orlena Kerek (Respiratory Registrar, Bristol Royal Hospital for Children) [[email protected] 07914864114 Fax 0117 3428990] Tom Hilliard, Paediatric Respiratory Consultant, Bristol Royal Hospital for Children John Henderson, Reader in Paediatric Respiratory Medicine, University of Bristol

REFERENCES

1 Eastham KM, Freeman R, Kearns AM et al. Clinical features, aetiology and outcome of empyema in children in the north east of England. Thorax 2004;59:522525. 2 Balfour-Lynn IM, Abrahamson E, Cohen G et al. BTS guidelines for the management of pleural infection in children. Thorax 2005;60 Suppl 1:i1-21. 3.

Ampofo K, Byington C. Management of Parapneumonic Empyema. The Pediatric Infectious Disease Journal May 2007; 26; 5; 445-446. 4 Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child 2003;88:915-917. 5 Thomson AH, Hull J, Kumar MR, Wallis C, Balfour Lynn, I. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57:343-347. 2

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6 Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006;118:e547-e553. 7 Sonnappa S, Cohen G, Owens CM et al. Comparison of urokinase and videoassisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006;174:221-227.

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Citation, country

Study group

Beth et al USA Sept 2006

18 patients under 18 with large parapneumonic effusions. Each randomly assigned VATS (10) or thoracostomy tube drainage (8) with the option of adding reteplase if there was not sufficient drainage within 24 hours(7).

Sonnappa et al UK May 2006

60 patients under 16 with radiographic evidence of empyema (CXR and US) and persistent fever or >24hours of parenteral antibiotics or respiratory distress caused by collection. Randomised to VATS (30) or chest drain and urokinase (30).

Study type (level of evidence) Prospective randomised control trial (level 1b)

Outcome

Key results

Comments

Hospital stay

VATS significantly shorter (5.8 compared with 13.2) VATS 2.80 (significant) Thoracostomy 9.63 VATS 2.20 (significant) Thoracostomy 7.63ß

Prospective randomised control trial (level 1b)

No of days in hospital after procedure Total no of hospital days Chest drain in situ days Failure rate CXR at 6 months

No ethical consent obtained. Chest drain removed when