- Prospective, RCT's on children with empyema are severely lacking in
the published literature.
- There is great debate between disciplines (infectious disease, pulmonary,
surgery) as to the proper treatment of children with empyema. No one
has good prospective data.
- Parapneumonic pleural effusions are common in children with pneumonia
-- present in 34-40% of cases. Empyema in children with pneumonia is
rare -- present in only 1-2% of cases.6
- Incidence of pleural empyema in children is rising in U.S. and worldwide.
Cause is unknown, but thought to be related to increased drug resistance
and improper empiric therapy or compliance. Other theories include increased
incidence of gram negative and anaerobic infections in children.
- Early use of empiric antibiotic therapy has resulted in a significant
decrease in the ability to isolate organism (30-56% compared to ~70-75%
10 years ago).6 Unfortunately, studies have also shown that fluid analysis
in children is not reliable for differentiating transudate vs. exudate.5
Because of this most studies still conclude that an antibiotic-naïve
patient with pleural effusion should be tapped by thoracentesis to determine
bacterial etiology; not so in a patient who has been on antibiotics.
- Drainage by needle thoracentesis or closed-tube thoracotomy was historically
ineffective in preventing a patient from going on to decortication.
However, more recent literature supports use of these therapeutic modalities
especially during the early exudative phase. A more conservative approach
has been shown to be effective in many studies. 3,4
- There are many surgical studies that show decortication to be safe
and effective for treating empyema. In general, both VATS and open decortication
have been shown to safe and effective in children. 2,7 However, literature
is still lacking on which children may be at higher risk for complications
with delayed decortication or VATS, or what the indications for surgery
should be. Most of these studies do conclude that clinical condition
(presence of sepsis or pulmonary deterioration) should be the basis
for criteria, not radiographic appearance.
Ramnath RR, Heller RM, Ben-Ami T, et al. Implications of early sonographic
evaluation of parapneumonic effusions in children with pneumonia. Pediatrics
1998; 101: 68-71.
Shankar KR, Kenny SE, Okoye BO, et al. Evolving experience in the management
of empyema thoracis. Acta Paediatr 2000; 89:417-420.
Shankar S, Gulati M, Kang M, et al. Image-guided percutaneous drainage
of thoracic empyema: Can sonography predict the outcome? Eur Radiol
Gocmen A, Kiper N, Toppare M, et al. Conservative treatment of empyema
in children. Respiration 1993; 60:182-185.
Alkrinawi S, Chernick V. Pleural fluid in hospitalized pediatric patients.
Clin Pediatr 1996; 35: 5-9.
Hardie W, Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas
in children. Clin Infect Dis 1996; 22: 1057-1063.
Grewal H, Jackson RJ, Wagner CW, Smith SD. Early video-assisted thoracic
surgery in the management of empyema. Pediatrics 1999; 103 (e63):