Pediatric Empyema Treatment & Management

Treatment of parapneumonic effusions should address control of the infection and often involves drainage of the pleural fluid and reexpansion of the affected lung tissue.

• Appropriate antibiotic selection should be based on the Gram stain and culture of the pleural fluid; however, because a large number of patients may have already received antibiotics at the time of thoracentesis, an empiric selection of the most appropriate antibiotics is necessary.

  • Base the choice on the most common pathogens that cause pneumonia within the patient's age range and geographic location.
  • When the organism is identified, change the antibiotics to most specifically cover for the pathogen.
  • Patients with empyema should receive a longer course of therapy analogous to necrotizing pneumonia, but the response to therapy determines the duration of treatment. The patient receives 10-14 days of intravenous antibiotics and receives treatment until he or she is afebrile, off supplemental oxygen, and appropriately responds to therapy.
  • Continuation of oral antibiotics may be recommended for 1-3 weeks after discharge but is not required for less complicated infections.
• The most controversial area in the management of parapneumonic effusions is the identification of patients who would benefit from pleural drainage and the selection of the appropriate drainage intervention.

  • No clinical studies have effectively contrasted antibiotic treatment without drainage to currently available drainage techniques. However, long-term follow-up studies show no differences in pulmonary function or exercise capacity between the groups. The therapeutic discussion rests on available clinical, radiologic, and laboratory evidence; host factors; and individualization to make the appropriate decision.
  • The pulmonologist, intensivist, interventional radiologist, or surgeon can perform simple tube thoracostomy with an underwater seal.
  • Diagnostic thoracentesis and chest tube drainage are effective therapies in more than 50% of patients. Prompt drainage of a free-flowing effusion prevents the development of loculations and a fibrous peel.
  • Remove the tube when the lung re-expands and drainage ceases. If the fluid is not free flowing, undertake further radiologic imaging to better define the pleural space disorder.
• Clinical resolution is not hastened by chest physical therapy used as an adjunct to standard treatment in children hospitalized with acute pneumonia.^[6]
• In addition to the benefit of CT and ultrasonographic imaging to characterize loculated pleural effusions, the radiologist has become significantly involved in the treatment of complicated parapneumonic effusions (CPE).

  • The ability of the interventional radiologist to assist in the placement of small-bore catheters, specifically localized to loculated pleural fluid collections, has helped to facilitate drainage. Furthermore, with smaller diameter tubes, patients have tolerated tube placement better, with less associated morbidity.
  • In addition, radiologists can lyse adhesions directly using imaging during the tube placement.
  • Finally, interventional radiologists, using fibrinolytics, have further improved the care of the complicated empyema by improved management of loculations and amelioration of fibrous peel formation and fibrin deposition.
• Numerous studies have documented the effectiveness of intrapleural fibrinolytics to treat obstructed thoracostomy tubes, increase drainage in multiloculated effusions, and to lyse adhesions; however, initial studies report on the use of urokinase, the fibrinolytic most commonly described prior to 1998, evolving to the use of tissue plasminogen activator (tPA), which has become the most frequently used treatment. Increased use of tPA has shown it to be well tolerated, effective, and less costly than surgery.^{[7, 8]} Randomized trials of chest tube drainage with fibrinolytics versus simple drainage and surgical therapy need to be undertaken to fully assess the relative clinical value of fibrinolytic therapy in the more complicated patient.

Controversy continues regarding the surgical treatment of CPE.

• For the uncomplicated free-flowing parapneumonic effusion, surgical intervention is rarely needed; however, the multiloculated persistently symptomatic effusion, for which initial therapy may have been delayed, is likely to require more than conservative management.
• The surgical literature supports the use of thoracotomy to remove the pleural peel and lyse the adhesions, if the patient does not respond promptly to treatment. Length of stay and long-term morbidity are reduced by this more aggressive approach, but this must be contrasted with the increased cost and short-term morbidity associated with thoracotomy and decortication. This treatment regimen is very effective, with a reported 95% success rate for patients with fibrinopurulent effusions. Because no prospective comparative studies have contrasted the current techniques, decortication is likely to remain a treatment of choice for advanced empyema.
• Video-assisted thoracoscopic surgery (VATS) has proven to be an effective and less-invasive replacement for the limited decortication procedure.^{[9, 10]} Thoracoscopic debridement closely imitates open thoracotomy and drainage. Mechanical removal of purulent material and the breakdown of adhesions can be easily accomplished via this route. VATS results in more rapid relief of symptoms, earlier hospital discharge, and significantly less discomfort and morbidity.
• Despite the benefits, a small percentage of patients still progress to require thoracotomy. As with fibrinolytic therapy, those patients in which this therapy has been most effective are those slightly less affected in whom earlier and potentially more aggressive treatment has been initiated.
• The definitive approach is thoracotomy drainage with mechanical release of the pleural peel and lysis of adhesions. Studies of decortication and debridement report 95% effectiveness for empyemas in the fibrinopurulent stage. These outcomes are determined by selected clinical outcomes, such as resolution of symptoms; however, these studies are subject to selection bias and do not account for the morbidity associated with the procedure, as well as increased costs associated with an operative procedure and the associated anesthesia risk. Furthermore, most children heal well in the long run, even without immediate surgical intervention.
• A meta-analysis reviewed the differences between primary operative treatment with nonoperative management and revealed striking reductions in length of stay, duration of tube thoracostomy, and duration of antibiotics.^[11] However, these data are susceptible to critics who point out the same concerns regarding selection biases that have been listed above. An additional review of surgical options demonstrated that early VATS resulted in shortening hospitalization times, but other outcomes such as duration of symptoms or antibiotic use were less dramatic between surgical treatments. In conclusion, early intervention of any sort is likely to improve outcomes, but early VATS is the surgical approach now most preferred in managing children with empyema.
• Alternative procedures, such as rib resection and open drainage or pleural obliteration, are rarely needed in the pediatric population.
• To most effectively determine the optimal therapeutic intervention, a carefully designed, multicentered, randomized, clinical trial would help to develop evidence-based standards for the treatment of complicated parapneumonic effusion in children.

• Consultants may include pediatric surgeons (thoracic or general), interventional radiologists, intensivists, and pulmonologists.

Patients should perform as much activity as can be tolerated.

• Encourage the facilitation of deep breathing and airway clearance.
• Use analgesics on an individual basis to facilitate airway clearance.