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Evolution of practice in the management of parapneumonic effusion and empyema in children
D Griffith1, M Boal1, T Rogers1
1Department of Surgery, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS28BJ, UK.
Insights
Management of pediatric parapneumonic effusion and empyema evolved with increased use of fibrinolysis and video-assisted thoracoscopic surgery (VATS), reducing the need for thoracotomy.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Pediatric Critical Care
Background:
- Parapneumonic effusion and empyema are significant causes of respiratory morbidity in children.
- Optimal management strategies continue to evolve, balancing conservative and surgical interventions.
Purpose of the Study:
- To evaluate the changes in management of pediatric parapneumonic effusion and empyema over a decade.
- To assess the impact of interventions like fibrinolysis and video-assisted thoracoscopic surgery (VATS) on patient outcomes.
Main Methods:
- Retrospective review of pediatric cases with parapneumonic effusion and empyema from December 2006 to December 2015.
- Analysis of demographic data, investigations, length of stay, and morbidity.
- Comparison of intervention rates and outcomes between different management approaches.
Main Results:
- 115 children underwent 159 interventions.
- Intercostal drainage (ICD) with urokinase fibrinolysis was successful in 54 children.
- A decrease in thoracotomy rates (26%) was observed with increased utilization of fibrinolysis and VATS.
Conclusions:
- Intercostal drainage and intrapleural fibrinolytics are effective initial treatments for parapneumonic effusion.
- A subset of patients requires further surgical intervention, with VATS being a preferred option over thoracotomy.
- While ultrasound identified severe disease, it did not reliably predict fibrinolytic therapy failure.
Aim:
To assess the evolution in management of children with parapneumonic effusion and empyema in a tertiary referral centre.
Method:
We conducted a retrospective case note review of paediatric patients with parapneumonic effusion, pleural effusion and pleural empyema between December 2006 and December 2015. Digital database searches were performed to identify demographic data, referring hospital, radiological and microbiological investigations. Length of stay and morbidity were analysed.
Results:
One hundred fifteen patients had 159 interventions over the study period. Fifty-four children were successfully treated with intercostal drainage (ICD) and urokinase fibrinolysis alone. There were 19 primary video assisted thoracoscopic surgeries (VATS) and 12 VATS after initial intercostal drains. Thirty-three children required a thoracotomy, a reduction of 26% from the previous era (p=0.009). The median length of stay was 9days (range 2-54).
Conclusion:
Parapneumonic effusion can be successfully treated with intercostal drainage and intrapleural fibrinolytics, but a proportion requires further surgical intervention. In our hospital, increased utilisation of fibrinolysis and VATS occurred with a corresponding decrease in the need for thoracotomy. Patients needing thoracotomy all had severe disease on ultrasound, but ultrasound did not reliably predict failure of fibrinolytic therapy.
Level Of Evidence:
III.
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