Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living
Clara Fernandez Elviro1, Bryn Longcroft-Harris2, Emily Allin3
1Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, BC, Canada; Department Woman-Mother-Child, Service of Paediatrics, Paediatric Pulmonology and Cystic Fibrosis Unit, University Hospital of Lausanne and Faculty of Biology and Medicine, University of Lausanne, Switzerland.
Insights
Chest tube alone for childhood empyema leads to longer hospital stays. Adding fibrinolytics to chest tubes, thoracotomy, or VATS shortens stays, with fibrinolytics offering cost benefits.
Area of Science:
- Pediatric Pulmonology
- Thoracic Surgery
- Evidence-Based Medicine
Background:
- Optimal treatment for pediatric community-acquired pneumonia with empyema is not well-defined.
- Clinical outcomes and hospital length of stay (LOS) may vary by treatment modality.
Purpose of the Study:
- To compare the effectiveness of different treatment modalities for pediatric parapneumonic effusion or empyema.
- To evaluate the impact of treatment on hospital length of stay (LOS) and other clinical outcomes.
Main Methods:
- A living systematic review of randomized controlled trials (RCTs) was performed.
- Searched multiple databases including Cochrane, Embase, LILACS, MEDLINE, and Web of Science.
- Network meta-analysis included 11 RCTs (590 patients) comparing antibiotics alone, chest tube with/without fibrinolytics, VATS, and thoracotomy.
Main Results:
- Chest tube with fibrinolytics, thoracotomy, and VATS were associated with significantly shorter LOS compared to chest tube alone.
- No significant LOS differences were found between chest tube with fibrinolytics, thoracotomy, and VATS.
- Fibrinolytics demonstrated cost advantages over VATS; morbidity and mortality were low across all treatments.
Conclusions:
- Chest tube alone is linked to longer hospital stays in pediatric empyema cases.
- Chest tube with fibrinolytics offers a cost-effective option with similar LOS and outcomes to VATS and thoracotomy.
Background:
The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.
Research Question:
In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used?
Study Design And Methods:
A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome.
Results:
Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality.
Interpretation:
The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.
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