University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• Is there a population of children with pleural empyema that would benefit from surgical decortication?

Clinical Bottom Lines

1. In children with high-grade ultrasounds, operative interventions (open decortication or video-assisted thorascopic surgery) reduced the length of stay in hospital by 50%.
   
2. In children with low-grade ultrasounds, operative interventions did not decrease the length of hospitalization vs. non-operative group.
   
3. In children with low-grade ultrasounds who did not receive an operative procedure, non-operative drainage did not decrease length of hospitalization vs. antibiotics alone.
   

Summary of Key Evidence

1. Retrospective study of 46 patients admitted to two university children's hospitals examining patient age, length of hospitalization, treatment strategies, and reassessment of chest ultrasounds.
   
2. Ultrasounds graded using two grade system: Low-grade - anechoic fluid, no evidence of fibrinous organization; High-grade - evidence of fibrinous organization (i.e. fronds, septations, loculations, or thickening of visceral pleural surface).
   
3. Patients were excluded if either full chart or ultrasound were unavailable.
   
4. Patients were divided as having low- or high-grade ultrasounds. Patients were also divided based on whether they underwent operative procedure (VATS or open thoracotomy and decortication) vs non-operative procedure (i.e. antibiotics alone or antibiotics with non-operative drainage [tube thoracotomy]).
   
5. The length of stay (LOS) for those with high-grade ultrasounds and non-operative treatment was longer than those with high-grade ultrasounds and operative treatment (16.4 days vs. 8.6 days, p<0.0001) and longer than those with low-grade ultrasounds and non-operative treatment (16.4 days vs. 9.8 days, p<0.005). The LOS for those with low-grade ultrasounds was similar whether treatment was operative or non-operative.
   
6. For those who received non-operative interventions, those with high-grade ultrasounds had a shorter LOS (11.4 days vs. 19.9 days, p<0.005) if they received antibiotics alone as opposed to non-operative drainage. The LOS for those with low-grade ultrasounds was similar regardless of the non-operative intervention.
   
7. Limitations: a) Retrospective study, small sample population; b) LOS was the only outcome measured -- could have included other morbidity scales, comfort/pain, medical costs, complications, etc.; c) Do not control for preassessment morbidity, days of antibiotics, days of fever etc.
   

Additional Comments

• 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.
  

Citation

1. 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.
   
2. Shankar KR, Kenny SE, Okoye BO, et al. Evolving experience in the management of empyema thoracis. Acta Paediatr 2000; 89:417-420.
   
3. Shankar S, Gulati M, Kang M, et al. Image-guided percutaneous drainage of thoracic empyema: Can sonography predict the outcome? Eur Radiol 2000; 10:495-499.
   
4. Gocmen A, Kiper N, Toppare M, et al. Conservative treatment of empyema in children. Respiration 1993; 60:182-185.
   
5. Alkrinawi S, Chernick V. Pleural fluid in hospitalized pediatric patients. Clin Pediatr 1996; 35: 5-9.
   
6. Hardie W, Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas in children. Clin Infect Dis 1996; 22: 1057-1063.
   
7. Grewal H, Jackson RJ, Wagner CW, Smith SD. Early video-assisted thoracic surgery in the management of empyema. Pediatrics 1999; 103 (e63): 1-5.
   

CAT Author: Martin L. Bocks, MD

CAT Appraisers: John G. Frohna, MD, MPH

Date appraised: February 25, 2002