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Non-Operative Management of Pediatric Empyema
Nadeen Alturki1, Jieun Lee1, Efua H Bolouvi1
1Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA.
Background:
Primary fibrinolysis is the standard treatment for pediatric empyema at our institution. A prior randomized trial demonstrated no clinical benefit of video-assisted thoracoscopic surgery (VATS) compared with fibrinolysis. After garnering more experience, subsequent protocol refinement reduced progression to VATS to 4.5%. This study aims to report outcomes following further maturation of our protocol.
Methods:
A retrospective review was performed of patients ≤18 years treated for empyema between March 1, 2019 and July 1, 2025. The protocol includes placement of a ≤12Fr thoracostomy tube and administration of three daily doses of tissue plasminogen activator (tPA), 4 mg in 40 mL normal saline. Patients with immunocompromised status, alternative indications for thoracostomy, or contraindications to VATS at presentation were excluded. The primary outcome was progression to VATS. Secondary outcomes included examining potential factors associated with repeat fibrinolysis.
Results:
70 patients met inclusion criteria. Median age was 4.6 years [IQR 2.1-7.4]. Median chest tube duration was 5 days [IQR 4-7]. Median number of tPA doses was 3 [IQR 3-3]. Median length of stay (LOS) was 8 days [IQR 5-11]. All patients were treated with intrapleural fibrinolysis. No patients subsequently required VATS. Fifteen patients (21%) underwent repeat fibrinolysis. On multivariable analysis, persistent oxygen requirement after one course of tPA (OR 5.819, 95% CI 1.230-27.521; p=0.026) was independently predictive of repeat therapy. There were no 30-day readmissions.
Conclusion:
With a standardized protocol emphasizing primary and repeat intrapleural fibrinolysis, operative intervention was not required for pediatric empyema.
Insights
Pediatric empyema treatment using intrapleural fibrinolysis (tissue plasminogen activator) proved highly effective, with no patients requiring surgery. Repeat fibrinolysis was sometimes necessary but avoided operative intervention in all cases.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Pulmonary Medicine
Background:
- Intrapleural fibrinolysis is a standard treatment for pediatric empyema.
- Previous studies showed no benefit of video-assisted thoracoscopic surgery (VATS) over fibrinolysis.
- Protocol refinement has decreased VATS progression rates.
Purpose of the Study:
- To report outcomes of a refined pediatric empyema treatment protocol.
- To evaluate the efficacy of standardized intrapleural fibrinolysis.
- To identify factors associated with repeat fibrinolysis.
Main Methods:
- Retrospective review of pediatric patients treated for empyema (March 2019 - July 2025).
- Protocol involved thoracostomy tube placement and tissue plasminogen activator (tPA) administration.
- Exclusion criteria included immunocompromised status and contraindications to VATS.
Main Results:
- 70 pediatric patients were included; none required VATS.
- Median chest tube duration was 5 days; median length of stay was 8 days.
- Persistent oxygen requirement predicted the need for repeat fibrinolysis (OR 5.819).
Conclusions:
- A standardized protocol using primary and repeat intrapleural fibrinolysis effectively treated pediatric empyema without surgery.
- This approach minimizes the need for operative intervention.
- No 30-day readmissions were reported.
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