Controversies in paediatric empyema management: Fibrinolytics or surgery?
Chest drain with fibrinolytics is as good as video-assisted thoracoscopic surgery (VATS) in the management of childhood empyema, with fibrinolytics being a cheaper option than VATS, according to a presentation at the APSR 2017 Congress.
Being highlighted was a prospective randomized study which showed that the primary endpoint of length of hospital stay was similar following chest drain with intrapleural urokinase or VATS (median, 6 vs 6 days; p=0.311) among the 60 children enrolled. [Am J Respir Crit Care Med 2006;174:221-227]
There were also no significant differences in other secondary endpoints such as total hospital stay (median, 13 vs 14 days; p=0.65), treatment failure rate (five in each group), and days with chest drain (median, 5 vs 4 days; p=0.055). The mean treatment cost per patient in the VATS arm was £6,322 compared with £5,071 in the urokinase arm (p<0.05).
These findings were corroborated by another prospective randomized study which showed no therapeutic or recovery advantages with VATS vs fibrinolysis with tissue plasminogen activator (tPA) for treating empyema. [J Pediatr Surg 2009;44:106-111] Furthermore, using fibrinolytics as first-line treatment for paediatric empyema demonstrated that the mean length of hospital stay was 7.2 days, with no major side effects, [J Pediatr Surg 2013;48:1312-1315] indicating that real-life experience with fibrinolysis yields similar results to randomized controlled trials.
“The take-home message is that urokinase or tPA small chest drain is as good as VATS … and also cheaper,” said Professor Adam Jaffe from the School of Women’s and Children’s Health at University of New South Wales in Sydney, Australia.
With regards to risk factors predictive of treatment failure with fibrinolytics in children, a positive blood culture (odds ratio [OR], 2.7) and immediate admission to intensive care (OR, 2.1) have been associated with an increased risk of treatment failure. [J Pediatr Surg 2016;51:832-837]
“There is no need for routine CT scan [before placement of drains],” added Jaffe, as the additional information obtained from a CT scan did not alter management and were not predictive of clinical outcome. [Thorax 2008;63:897-902] “The choice of radiological assessment is ultrasound, which is also safer in children.”
Nonetheless, pleural drainage is not always necessary, according to Jaffe, as some children with empyema can have reasonably short length of hospital stay with intravenous antibiotics alone. Among 182 children hospitalized with empyema, 52 percent who received antibiotics alone had a significantly shorter length of hospital stay than the 45 percent who subsequently underwent drainage procedures (mean, 7 vs 11 days). [Pediatr Pulmonol 2010;45:475-480]
The strongest predictors of requiring pleural drainage include admission to intensive care, a large effusion size filling up to more than half of the thorax, and younger age; while pleural fluid loculation is not a predictor. [Pediatr Pulmonol 2010;45:475-480]