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Pediatric Empyema Treatment & Management

  • Author: Peter H Michelson, MD; Chief Editor: Michael R Bye, MD  more...
 
Updated: Dec 03, 2014
 

Medical Care

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.
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Surgical Care

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.
  • Marhuenda et al conducted a prospective, randomized, multicenter clinical trial comparing the efficacy of drainage plus urokinase therapy with that of video-assisted thoracoscopic surgery in the treatment of pediatric parapneumonic empyema.[12] The study included a total of 103 patients (age, younger than 15 years); 53 patients were randomly assigned to receive treatment with thoracoscopy, and 50 were assigned to treatment with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between the thoracoscopy group and the urokinase group in the median postoperative stay (10 vs 9 days), the median hospital stay (14 vs 13 days), or the number of days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of the children in the thoracoscopy group and in 10% in the urokinase group. The investigators concluded that drainage plus therapy withurokinaseisaseffective as video-assisted thoracoscopic surgery as first-line treatment of septated parapneumonic empyema in children.[12]
  • Proesmans et al reported on the use of a standardized medical treatment of parapneumonic empyema as a first-step nonsurgical approach in a tertiary care center.[13] The purpose of the study was to evaluate the need for surgery and to collect data on disease course, outcome, and microbiology. The study cohort consisted of 132 children treated for parapneuonic empyema between 2006 and 2013. Of the 132 children, 20% required surgical intervention. Median duration of in-hospital fever was 5 days. The duration of fever correlated with pleural LDH levels and pleural glucose levels and was inversely correlated with pleural pH. On the basis of pleural polymerase chain reaction results, 85% of the cases were caused by Streptococcus pneumoniae (40% were of serotype 1). After introduction of a standardized primary medical approach (chest drainage with or without fibrinolysis), the need for surgical rescue interventions remained at 20%overall.[13]
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Consultations

See the list below:

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

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.
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Contributor Information and Disclosures
Author

Peter H Michelson, MD Associate Professor of Pediatrics, Division of Pulmonary and Sleep Medicine, Duke University School of Medicine

Peter H Michelson, MD is a member of the following medical societies: International Society for Heart and Lung Transplantation, American Academy of Pediatrics, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Charles Callahan, DO Professor, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Scanlin, MD Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, Rutgers Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Pediatric Research, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research

Disclosure: Nothing to disclose.

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Radiographic imaging of a parapneumonic effusion may be useful in assessing the stage of the effusion and the type of drainage needed. In Figure A, the left heart border is obscured, and more than 50% of the left hemithorax is filled with an effusion, as evidenced by a fluid meniscus. In Figure B, the effusion is demonstrated to be fluid because it layers out on a decubitus film. In Figure C, the lateral radiograph again demonstrates the fluid meniscus and filling of the posterior sulcus. These findings suggest tube thoracostomy placement may be sufficient to drain this pleural process.
Most parapneumonic effusions treated with the appropriate antimicrobials of sufficient duration resolve without the development of complications or sequelae. The series of radiographs represent a patient treated with thoracentesis alone. Figure A illustrates the patient at presentation. Note the amount of fluid present. In Figure B, the radiograph demonstrates progression of the pleural fluid accumulation with further airspace disease and scoliosis noted. Despite the radiographic evidence of disease progression, the patient was clinically improving. Figure C illustrates the radiograph at follow-up, 6 months following completion of therapy. Resolution of the parapneumonic effusion with no evidence of pleural thickening or fibrosis occurred.
 
 
 
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