Management Strategies for Paediatric Pleural Empyema: A Systematic Review

To examine and compare management strategies for paediatric pleural empyema with respect to efficacy, safety, length of hospital stays, complications and long-term outcomes.

Database searches across PubMed, Web of Science, Cochrane Library and ScienceDirect (January 2005-May 2025) were conducted following PRISMA guidelines. After exclusions, 22 studies (RCTs and observational) were included. Quality was assessed using the Newcastle-Ottawa Scale and Cochrane Risk of Bias tool. Because studies defined success inconsistently, effectiveness was also expressed as single-procedure success: resolution without a further drainage procedure. Other outcomes included reintervention, hospital stay, complications and mortality.

Included were 18 cohort studies and 4 RCTs (3667 patients; empyema stages 1-3). Evaluated approaches included video-assisted thoracic surgery (VATS), intrapleural fibrinolysis, chest tube drainage and thoracotomy. Study-reported success ranged from 90%-96% with VATS and 70%-95% with fibrinolysis; expressed as single-procedure success, these fell to 67%-100% and 63%-98%, respectively, against 47% for drainage alone. Chest tube duration was often shorter after VATS, although the drain serves a different purpose in each pathway and is not a measure of efficacy. Overall complication rates were low; bronchopleural fistula was reported by only three studies.

Both VATS and intrapleural fibrinolysis are safe and effective treatments for paediatric empyema. Both are superior to chest drainage alone. VATS more often achieves resolution with a single procedure, whereas fibrinolysis remains a viable, less-invasive first-line option. Simple parapneumonic effusion requires intravenous antibiotics and supportive care alone. Because allocation was not standardized, differences in reintervention should not be read causally.