Pediatric pleural empyema - decision making beyond imaging - a retrospective cohort study

In children and infants, thoracic empyema most often develops as a complication of parapneumonic pleural effusions progressing to purulent collections. With an estimated incidence of approximately 0.6% among pediatric pneumonia cases, empyema remains associated with significant morbidity. This study aimed to characterize pediatric parapneumonic empyema by analyzing clinical, biochemical, and radiological parameters and their relationship with treatment decisions and outcomes.

We conducted a retrospective, single-center study including children diagnosed with parapneumonic pleural empyema and treated in the Pulmonology Department of the "Grigore Alexandrescu" Emergency Hospital for Children between January 2021 and December 2024. Only patients managed surgically-either by chest-tube drainage or video-assisted thoracic surgery (VATS)-were included. Fibrinolytic therapy was not used due to limited institutional experience, with VATS preferred in complicated cases. Patients were stratified according to initial intervention. Clinical, laboratory, and imaging data were extracted from medical records.

A total of 33 patients were included, with a median age of 4 [3-8] years. The median time to initial intervention was 2 [1-5] days. Fourteen patients (42.4%) underwent primary VATS after a median of 4.5 [2-6.3] days, while 19 received initial chest-tube drainage after 1 [0-3] days, with a mean drainage duration of 21.2 ± 11.5 days. Median hospital stay for the cohort was 27 [21-38.5] days. Loculations and septations were significant predictors of hospitalization length. Drainage duration was significantly shorter in the primary VATS group compared with the chest-tube group (9.5 [7.8-12.5] vs. 19 [11-30] days; p = 0.011). Dyspnea strongly predicted selection of VATS as initial treatment (OR 18.0, 95% CI 1.86-174.21; p = 0.013). Imaging findings on thoracic ultrasound did not significantly influence the choice of initial intervention. Computed tomography, performed in 45.5% of cases, identified complications such as bronchopleural fistula, empyema necessitans, and pyopneumothorax, and was associated with prolonged hospitalization.

Chest-tube drainage was the most frequent initial treatment, with escalation decisions driven primarily by clinical presentation rather than imaging or biochemical markers. Thoracic ultrasound was valuable for assessing effusion complexity but had limited prognostic utility. The lack of fibrinolytic therapy resulted in a high rate of VATS, highlighting the need for standardized, symptom-driven management algorithms integrating clinical, laboratory, and imaging data.