Intrapleural Fibrinolytics Use in Children with Pleural Empyema: Safe and Effective

We assessed the number of children with pleural empyema in which video-assisted thoracoscopy (VATS) could be avoided in a center where standard therapy is drainage using a chest drain with/without intrapleural fibrinolytics.

We included all children referred for chest drainage of a pleural effusion to Radboud University Medical Center between January 2022 and April 2023. Children were referred in case of pneumonia with respiratory distress and suspected pleural effusion on the chest X-ray or an effusion size of >20 mm in the chest ultrasound, indicating the need for chest drainage or VATS. We analyzed symptoms, test results, and treatment.

Thirty-two children aged 0-16 years were referred for treatment of pleural effusion. Most children presented with fever, cough, and dyspnea (72%). Four children presented with abdominal pain (13%), which led to 2 appendectomies prior to referral. In 11 (33%) children, an invasive group A streptococcus was cultured from the pleural fluid. All patients were treated with antibiotics. One patient received VATS primarily. 27 (84%) patients received a chest drain, and 4 patients continued conservative treatment. 14 (52%) of the 27 children with a chest drain were treated with intrapleural fibrinolytics (alteplase or urokinase) because of persistent pleural effusion on ultrasound despite chest drainage. No side effects were observed. Two patients received VATS secondary to chest drainage without receiving prior intrapleural fibrinolytics.

Intrapleural fibrinolytic treatment appeared safe and could avoid VATS in children with poor drainage, and is therefore a useful minimal invasive treatment in children with pleural empyema.