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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 words: empyema; parapneumonic; pneumonia; pleural effusion; thoractomy; VATS; chest-drain; fibrinolytic), restricted to children.
Cochrane: no relevant results

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Kurt 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
Sonnappa 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

Comment(s)

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).

Editor Comment

CXR, chest x ray; US, ultrasound; VAT, video assisted thoracoscopy.

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: 522–5.
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. Pediatr Infect Dis J 2007; 26(5): 445–6.
4. Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child 2003; 88: 915–17.
5. Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002; 57: 343–7.
6. Kurt BA, Winterhalter KM, Connors RH, et al. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006; 118: e547–53.
7. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006; 174: 221–7.