Approach Considerations
Noninflammatory pleural effusions (such as transudates) are managed by treating the underlying cause and by supportive care of any functional disturbances. Treatment of tuberculous pleural effusion (TPE) is similar to that of pulmonary tuberculosis.
Treatment goals in empyema include sterilization of pleural fluid, reexpansion of the lung, and restoration of normal lung function. Prospective studies in pediatric empyema are lacking. Hence, the management of empyema in children remains controversial; given the limited evidence, no consensus has been reached on the role of medical versus surgical management. [20]
Parapneumonic effusion usually progresses through different stages over time, including exudative, fibrinopurulent, and organizational stages. [20] Therefore, different management strategies may be appropriate at different stages.
Currently available treatment options for pediatric parapneumonic effusion and empyema include antibiotics alone or in combination with thoracocentesis, chest tube drainage with or without instillation of fibrinolytic agents, and surgery (video-assisted thoracoscopic surgery or open thoracotomy with decortication). In practice, the care that a child with empyema receives depends on local practice, which is largely determined by the availability of medical personnel and their preferences. [80]
Consultations
Consultations may include the following:
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Pediatric pulmonologist
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Pediatric surgeon
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Interventional radiologist
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Pediatric infectious disease specialist
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Intensivist
Antibiotic Therapy
In the earlier stages of parapneumonic effusion formation (mild symptoms, short duration), institution of appropriate empiric antibiotics, based on the patient's age and the organisms and sensitivities commonly present in the community, may discourage a small effusion from developing into a complicated parapneumonic effusion. Whenever possible, a pleural fluid sampling should be performed prior to the initiation of antibiotics.
If a causative organism is identified, antibiotic choice should be guided by the sensitivity pattern of the organism.
Some groups of antibiotics (eg, penicillins, cephalosporins, aztreonam, clindamycin, and ciprofloxacin) [81, 82] exhibit more satisfactory pleural fluid penetration than others (eg, aminoglycosides). [82, 83]
In a hospitalized patient with complicated parapneumonic effusion, antibiotics are commonly administered intravenously while a thoracostomy tube is present and the patient is febrile. No data from randomized trials on an appropriate length of treatment are available, and no data on whether different organisms require different durations are noted. [20] Many centers continue with intravenous antibiotics at least 48 hours after the patient is afebrile and the chest drain is removed. Thereafter, oral antibiotics are commonly continued for 2-4 weeks.
A study by Tagarro et al that included 60 randomized children with community-acquired pneumonia and pleural effusion reported that patients receiving dexamethasone along with antibiotics had a shorter time to recovery than the placebo group. [84]
Chest Tube Drainage
Effusions that are enlarging or compromising respiratory function in a febrile, unwell child require drainage. [20] Other risk predictors indicating the need for chest tube placement include frank pus on thoracentesis, a positive pleural fluid Gram stain and culture finding, a pleural fluid pH level of less than 7, a glucose concentration of less than 40 mg/dL, or an LDH level of more than 1000 IU.
Controversy still remains about the optimum chest tube size. Although small-bore tubes (eg, pigtail catheters) are commonly used for free-flowing fluid and large-bore tubes are commonly employed for thick pus, good-quality data that can be used to recommend one size of chest tube over another are lacking. In the absence of evidence that large-bore chest drains confer any advantage, the British Thoracic Society (BTS) guidelines recommend using small-bore chest tubes (including pigtail catheters) whenever possible to minimize patient discomfort. [20] When combined with fibrinolytic therapy, the use of small chest tubes was found to have some advantages over large tubes. [85]
The timing of elective removal of the drain depends on numerous factors, including the amount of fluid draining, the child’s overall clinical condition, the presence of fever, and the radiographic and ultrasonographic appearance of the chest, as well as a fall in acute phase reactants. [20] In most cases, the chest tube may be removed when the pleural drainage becomes minimal (< 10-15 ml/24 h) and the fluid is clear or yellow. [35]
A study by Gilbert et al aimed to review outcomes in patients with hematologic malignancy undergoing indwelling tunneled pleural catheter (IPC) placement. The study reported that IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy. [86]
Chest Tube Drainage With Instillation of Fibrinolytic Agents
As the effusion becomes fibrinopurulent and subsequently organizes, chest tubes often become ineffective because fibrinous strands and loculations divide the pleural space into compartments. Fibrinolytics instilled into the pleural cavity may facilitate drainage by lysing fibrinous strands and clearing lymphatic pores.
Three fibrinolytic agents have been used: streptokinase, urokinase, and alteplase (or tissue plasminogen activator). Urokinase is no longer available in North America.
In a large double-blind study in adults, Maskell et al reported that use of intrapleural streptokinase did not improve mortality, the rate of surgery, or the length of the hospital stay. [87]
However, numerous published case series have detailed the use of fibrinolytics in children. [88, 89, 90, 91] All indicate improved pleural drainage with these agents and an overall success rate of 80-90% without the need for surgical intervention. Three randomized placebo control trials have been performed in children.
In a multicenter, double-blind, randomized study in children on the use of fibrinolytics for empyema, Thompson and colleagues reported that urokinase resulted in a modest decrease in length of stay (7.39 d vs 9.49 d) and lower treatment failure. The study involved 60 children who were administered either intrapleural urokinase or saline. [85]
In a second study, in which 60 children were randomized to receive either percutaneous chest drain with intrapleural urokinase or video-assisted thoracoscopic surgery (VATS), the authors concluded that urokinase treatment is the better economic option and should be the primary treatment of choice. Treatment costs were significantly lower ($9127 vs $11,379) in the urokinase group than in the VATS patients, while no difference in clinical outcome between the 2 groups was noted. [92] The median duration of hospital stay was 6 days for both groups, with a range of 4-25 days for the urokinase group and 3-16 days for the patients treated with VATS.
In a prospective, randomized trial, St. Peter and colleagues concluded that fibrinolysis should be the first modality selected in children with empyema and that rescue can be done with VATS if necessary. In the study, VATS with decortication was compared with chest tube insertion and administration of tissue plasminogen activator. Eighteen children with empyema were in each group. [93]
The investigators found no difference between the groups with regard to days of hospitalization after intervention, days of oxygen required, days until the children were afebrile, or analgesic requirements. VATS was associated with significantly higher charges. The failure rate for fibrinolysis was 16.6%.
Adverse effects of fibrinolytic agents are usually minor and include discomfort during intrapleural injection, transient blood staining of the drainage fluid, fever, and, rarely, massive bleeding. [20] Rare immediate hypersensitivity reactions have been reported in adults after intrapleural urokinase. Streptokinase that is administered intrapleurally generates a systemic antibody response similar to that found when the drug is given systemically. [94]
Fibrinolytics should not be used in patients with bronchopleural fistula or bubbling chest tube (suggestive of an air leak).
Surgical Care
Whether surgery should be the initial treatment of choice or should be reserved for failed medical management is not definitively known. Historically, children with empyema and parapneumonic effusion who failed to improve with antibiotic therapy (with or without drainage) subsequently underwent operative management. Other indications for surgery include persistent sepsis in association with a persistent pleural collection (despite antibiotics, chest tube drainage, and fibrinolytics), complex empyema with significant lung pathology (eg, delayed presentation with a significant peel and trapped lung), and bronchopleural fistula with pyopneumothorax. [20]
Three surgical options are noted for management of children with parapneumonic effusion and empyema:
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VATS
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Minithoracotomy
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Open thoracotomy with decortication.
VATS
VATS has emerged as the preferred procedure to treat empyema in children and is being increasingly used as primary therapy. VATS is much less invasive than open thoracotomy and is associated with a more favorable outcome.
In a nonrandomized study, VATS use (compared with open thoracotomy with decortication) was associated with shorter duration of analgesia use, postoperative length of hospital stay, time to normothermia, and number of chest tube days. [95]
In a small, prospective, randomized trial, early VATS use (compared with conventional thoracostomy drainage) was associated with few complications and short hospital stays (approximately 7 d). [96]
In a retrospective, 10-year study, Padman et al reported their experience and clinical course of 109 children; 50 patients had VATS, and 59 did not. [97] The use of VATS within 48 hours of admission lead to significant reduction of hospital stay (by 4 days), compared with delayed use of VATS after 48 hours of admission.
A review of 49 pediatric patients with pneumonia complicated by parapneumonic effusion or empyema suggested that patients treated by primary VATS had shorter stay and hospital charges than patient treated by chest tube and antibiotics alone. [98]
Several authors have reported that early VATS is safe and effective and that it shortens hospital stay in the management of empyema in children and adults. [99, 100, 101] However, two prospective studies (mentioned above) comparing early VATS with chest tube and instillation of fibrinolytics [92, 93] suggested that therapy with a chest tube and instillation of fibrinolytics may be more cost effective, may pose less risk of acute clinical deterioration, and should be the first-line therapy for children with empyema.
Mini-thoracotomy
Mini-thoracotomy achieves debridement and evacuation in a similar manner to VATS but is an open procedure. [20]
Decortication
Decortication is a major thoracic operation requiring full thoracotomy. It involves an open, posterolateral thoracotomy and removal of all the fibrous tissue from the visceral pleural peel, with all pus being evacuated from the pleural space. It is rarely needed in children with empyema. The BTS guidelines suggest that decortication should be reserved for children with organized empyema, in which a thick, fibrous peel is restricting lung expansion and causing chronic sepsis with fever. [20] [stopped]
Diet and Activity
Diet
A dietitian should be consulted early in patients with chylothorax and in those with complicated pleural effusion and empyema, for whom the course may be prolonged.
Chylothorax may respond to a diet with fat supplied as medium-chain triglycerides (MCTs), with a resolution of the chylous effusion at the end of 2 weeks. MCT oil is absorbed directly into the portal circulation and does not contribute to chylomicron formation. Its use may decrease lymph flow by as much as 10-fold. If chylothorax persists, a trial of intravenous (IV) alimentation for 4-5 weeks may be considered.
Children with complicated pleural effusion and empyema may have clinically significant anorexia and increased needs. High-calorie, high-protein foods that appeal to the child should be provided early, and nasogastric feeds should be considered early, particularly in young children.
Activity
Pain and chest-tube placement may limit the patient's motility. Analgesia can facilitate cough and clearance of the airway, especially in the presence of an underlying pneumonic process.
Follow-Up
For transudative effusions, further outpatient therapy is directed at the underlying etiology of the pleural effusion.
Children with parapneumonic effusion or empyema should be seen for follow up within 4–6 weeks of discharge; the timing depends on the child’s clinical status at discharge. [20] Chest radiography findings are inevitably abnormal at discharge, and a radiograph should be obtained at 4-6 weeks. [20] Complete radiological resolution is usually expected by 3-6 months. [102, 103]
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Upright chest radiograph in a 3-year-old child with dyspnea and fever obtained 1 day before the development of the pleural effusion reveals pneumonia on the left side.
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Upright chest radiograph in a 3-year-old child with dyspnea and fever reveals a large opacity on the left, with obliteration of the left costophrenic angle and a fluid stripe.
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Left lateral decubitus image in a 3-year-old child with dyspnea and fever reveals minimal layering of the fluid, which indicates a loculated effusion.
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Upright posteroanterior chest radiograph of a child with a right-sided pleural effusion.
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Lateral view in a child with right-sided pleural effusion reveals a pleural effusion and a fluid level.
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Right lateral decubitus radiograph in a child with a right-sided pleural effusion. Image reveals partial layering of the fluid in the right side.
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Posteroanterior view in a patient with reaccumulated pleural effusion in the left side of the chest.
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Left lateral view in a patient with reaccumulated pleural effusion on the left side of the chest reveals layering of the effusion.
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Anteroposterior view of the chest reveals a large chylothorax on the right side of the chest in a neonate.
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Anteroposterior view in a neonate reveals reaccumulation of the chylothorax in the right hemithorax after a chest tube has been removed.
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Right lateral decubitus radiograph in a neonate reveals layering of the chylothorax effusion after a chest tube has been removed.
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Ultrasonogram of the pleural effusion in a 3-year-old child with dyspnea and fever reveals many septa (arrowheads) and several large, loculated portions of fluid (arrows).
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Ultrasonogram of the effusion in a 3-year-old child with dyspnea and fever reveals several fluid loculations (arrows) separated by septa (arrowheads). The lung is seen under the effusion.
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CT scan of the chest in a 3-year-old child with dyspnea and fever reveals a left-sided effusion and underlying parenchymal infiltrate and atelectasis.
