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Postpneumonic empyema in childhood: selecting appropriate therapy
S J Hoff1, W W Neblett, R M Heller
1Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN.
Insights
A new scoring system helps classify pediatric postpneumonic empyema severity. This aids in selecting treatments like antibiotics or decortication, leading to faster recovery and improved outcomes for children.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Infectious Diseases
Background:
- Postpneumonic empyema in children often requires complex management.
- Current treatment strategies vary, necessitating a refined approach to optimize outcomes.
Purpose of the Study:
- To review treatment outcomes for pediatric postpneumonic empyema.
- To develop a severity scoring system for early classification and treatment selection.
- To evaluate the efficacy and safety of decortication.
Main Methods:
- Retrospective review of 51 children treated for empyema over 11 years.
- Analysis of treatment modalities: antibiotics alone, tube thoracostomy, and decortication.
- Development of a scoring system based on clinical and radiographic factors.
Main Results:
- A severity scoring system identified predictors of severe pleural disease, including low pleural fluid pH/glucose, scoliosis, pleural peel/parenchymal entrapment, and specific pathogens.
- Mild cases responded well to antibiotics alone with shorter hospital stays.
- Decortication in moderate to severe cases led to earlier improvement and discharge compared to tube thoracostomy, with no associated morbidity or mortality.
- Pulmonary function tests and chest radiographs normalized promptly after decortication.
Conclusions:
- A pleural disease severity scoring system is useful for guiding treatment selection in pediatric postpneumonic empyema.
- Early decortication is a safe and effective option for severe cases, improving patient recovery.
- Optimized treatment selection based on disease severity can reduce hospitalization duration and improve long-term outcomes.
Abstract:
In order to identify appropriate treatment options for postpneumonic empyema, we reviewed the medical records and, when possible, obtained long-term follow-up chest radiographs and pulmonary function tests on children treated for empyema during the past 11 years. Fifty-one patients were treated in various ways, with antibiotics alone (N = 10), or in combination with tube thoracostomy (N = 23) or decortication (N = 18). Despite administration of appropriate antibiotics and establishment of pleural drainage, many children required prolonged hospitalization and eventual decortication. Based on this review, a scoring system was developed allowing early classification by severity of pleural disease. Factors found to be predictors of severe pleural disease include (1) low pleural fluid pH or (2) glucose; (3) presence of moderate or severe scoliosis or (4) pleural peel or parenchymal entrapment by chest radiography; and (5) infection due to anaerobes, gram-negative organisms, or mycoplasma. Complete opacification of a hemithorax on chest radiography and a pleural peel to thoracic ratio greater than 40% were also associated with severe pleural disease. In patients with mild disease (N = 7), response to antibiotics alone, rapid resolution of fever, and shorter hospital stays were observed. In patients with more severe infections (moderate = 22, severe = 22), decortication accomplished earlier defervescence, radiographic improvement, and hospital discharge than simple tube thoracostomy. No deaths or morbidity were associated with decortication, which could often be accomplished through a minithoracotomy. Follow-up chest radiographs and pulmonary fuction tests showed a prompt return to normal after decortication. This experience indicates utility of a pleural disease severity scoring system in selection of treatment options for children with postpneumonic empyema.(ABSTRACT TRUNCATED AT 250 WORDS)