Management of parapneumonic effusion and empyema.

AIMS: To gather data on the clinical presentation of parapneumonic effusion and empyema and to examine the effect of different management strategies on short term outcomes. METHODS: Retrospective case note review of 48 children admitted to a tertiary unit between January 1998 and March 2001. Effusions were classified into three stages dependent on ultrasound findings. RESULTS: The stage of effusion was not associated with duration of previous symptoms or length of previous admission. An interventional procedure was performed on median day 2 of admission in 46 children: eight (17%) had an intercostal drain alone, 14 (29%) had an intercostal drain followed by intrapleural fibrinolytic therapy, and 24 (50%) had a thoracotomy. Three children who had an initial intercostal drain alone returned to theatre for thoracotomy, and two children who had intrapleural fibrinolysis returned for thoracotomy. Median length of stay (interquartile range) for each initial procedure was 15 days (6-20) for intercostal drain alone, 8 days (6-12) for fibrinolytic therapy, and 6.5 days (5-9) for thoracotomy. Stay for intercostal drain alone was significantly longer than for thoracotomy. CONCLUSION: Early surgical management of empyema is associated with a favourable outcome.     

Outcome of parapneumonic empyema

Objective: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome.Methods: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases.Results: 0.8% (C.I. 0.6–1.0) of total pediatric admission had empyema, who were more likely to be females (P<0.05), under-weight (P<0.05) compared to children admitted for other reasons.Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases.Conclusion: Chest tube drainage is a safe, efficacious primary method of empyema management.     

Development of parapneumonic empyema in children

AIM: The aim of the study was to find clinical predictors for parapneumonic empyema in children. METHODS: Thirty-seven children treated for parapneumonic empyema at the Department of Pediatrics, Turku University Hospital, were retrospectively evaluated. Two distinct comparison groups of children with uncomplicated community-acquired pneumonia with alveolar consolidation (n = 37 in both groups) were included. Clinical and laboratory data on admission as well as fever kinetics and inflammatory markers during hospitalization were analyzed. RESULTS: In a multivariate analysis, a history of prolonged fever, tachypnoea and pain on abdominal palpation on admission were the most significant clinical predictors for empyema. On admission, serum C-reactive protein levels were higher among children with empyema than among those with uncomplicated pneumonia (means, 234 mg/L vs. 178 mg/L; p = 0.037). During hospitalization, prolonged fever and persistence of high serum C-reactive protein levels were associated with empyema. At the initial evaluation, pleural fluid was not reported in 35% of children with empyema. CONCLUSIONS: Early recognition of developing empyema is challenging. Children with pneumonia presenting with prolonged fever, tachypnoea, pain on abdominal palpation and high serum C-reactive protein levels are at risk for parapneumonic empyema.     

Imaging of parapneumonic pleural effusions and empyema in children

Pleural empyema in children is increasing in incidence. The British Thoracic Society published guidelines for the management of empyema in children in 2005, including recommendations regarding imaging. In this article we review the pathophysiology, treatment options and imaging findings of complicated parapneumonic effusion and empyema in children. We also review the published evidence that supports the roles imaging is called upon to play in the management of these conditions. Imaging in the form of chest radiography and US is recommended to identify and guide drainage of complicated parapneumonic effusions. CT is recommended in special circumstances only. Imaging techniques have not been shown to accurately stage empyema, predict outcome or guide decisions regarding surgical versus medical management.     

Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema

BACKGROUND: Pediatric pneumococcal parapneumonic empyema (PPE) has become increasingly common. In the last decade, Utah has had one of the highest rates of PPE in the United States, 14/100,000 children, attributed primarily to Streptococcus pneumoniae serotype 1. Our objective was to describe the temporal trends in PPE in Utah before and after the availability of the 7-valent pneumococcal conjugate vaccine (PCV-7). METHODS: The Intermountain Health Care (IHC) data warehouse was queried for all cases of empyema in children younger than 18 years, defined as International Classification of Diseases, 9th revision, Clinical Modification code 510.9, for the study period March 1996-June 2005. We also retrieved and serotyped all blood and pleural fluid isolates of S. pneumoniae from children younger than 18 years with a diagnosis of PPE at Primary Children's Medical Center (PCMC) between March 1996 and June 2005. The pre-PCV-7 period (PRE) included 57 months (March 1996-December 2000) and the post-PCV-7 period (POST) included 54 months (January 2001-June 2005). RESULTS: We identified 776 cases of pediatric empyema in the IHC system, and 478 (62%) were managed at PCMC. In the years 1996-2000, we managed a mean of 38 cases of empyema per year compared with 71.5 cases per year between 2001 and 2004 (P = 0.006). At PCMC, there were 295 cases of invasive pneumococcal disease (IPD), and 74 (25%) were PPE. During the PRE period, PPE represented 24 of 137 (17.5%) cases of IPD compared with 50 of 158 (32%) in the POST period (P = 0.008). One-half of the children with PPE required intensive care and 4 died. During the PRE and POST periods, PPE was most often caused by serotype 1 (46 and 34%, respectively), but in the POST period serogroups 3 (20%), and 19A (14%) were also prevalent. PPE in PCV-7-immunized children was caused exclusively by nonvaccine serotypes. CONCLUSIONS: PPE in the post-PCV-7 era is more common, representing one-third of the IPD in children in UT. PPE is associated with significant morbidity and mortality. Serotype 1 remains the most common cause of PPE, but serotypes 3 and 19A are emerging.     

The evaluation and cluster analysis of parapneumonic effusion in childhood

We studied 80 children with parapneumonic effusion (PPE) with respect to the clinical manifestations and treatment alternatives as well as prospective follow-up for 1 year. Out of the 80 patients, 59 per cent were male. The mean age of the patients was 4.0 +/- 3.1 years. Mild effusion was successfully treated by antibiotic alone in 33 per cent of the patients. Tube thoracostomy (TT) was utilized in 63 per cent of the patients. In this group, 11 healed completely, 13 patients required surgical treatment, and 25 required fibrinolytic therapy (FT). FT was successful in 18, and no complication due to FT was observed. Six patients who received FT required surgical therapy later in the course of treatment. Cluster analysis revealed a group of patients with rapid progression and a short history of symptoms (4-6 days) that showed significantly higher rate of complicated prognosis (p<0.05). Successful FT prevented surgical operation in 22 per cent of the patients who were candidates for surgical treatment. The follow-up for one year revealed sequelae on chest X-ray in 28 per cent of the patients most of whom had an operation for necrotizing pneumonia. Pulmonary function tests performed over seven years of age were abnormal in 57 per cent of the patients.     

Thoracoscopy with mediastinoscope in pediatric complicated parapneumonic effusion

OBJECTIVE: To evaluate our experience with thoracoscopy with small mediastinoscope in complicated parapneumonic effusion in children.METHODS: From July 1995 to June 1997, seven children with complicated parapneumonic pleural effusion underwent thoracoscopy with mediastinoscope at Hospital de Clínicas de Porto Alegre. The procedure was carried out with a small mediastinoscope built in our hospital.RESULTS: There were six girls and one boy. The procedure was preformed under general anesthesia, without selective intubation. Six patients had previous intercostal tube drainage; one underwent thoracoscopy as a primary procedure. No complication was observed after the procedure. During follow-up, two children underwent pleurotomy due to residual pleural effusion with persistent fever; two others presented asymptomatic small pleural effusion.CONCLUSION: Thoracoscopy with small mediastinoscope is safe, efficient and without severe complications. It is very useful to remove loculated complicated parapneumonic effusion at fibrinopurulent stage and to enable lung expansion.     

儿童复杂性肺炎旁胸腔积液危险因素分析

目的探讨儿童复杂性肺炎旁胸腔积液(CPPE)发生的相关危险因素。方法回顾性分析2013年1月至2015年4月因肺炎旁胸腔积液住院的88例患儿的临床资料,根据应用抗生素治疗是否有效及相关文献分为复杂性肺炎旁胸腔积液组(CPPE组)及非复杂性肺炎旁胸腔积液(UPPE)组;对两组患儿的临床和实验室指标进行组间单因素分析,并进一步行多因素logistic回归分析,绘制受试者工作特征(ROC)曲线。结果单因素分析结果显示,两组患儿在纤维分隔形成及血清CD3~+、CD19~+水平的差异有统计学意义(Z=2.030~7.457,P均0.05);多因素logistic回归分析显示,纤维分隔形成及CD19~+为CPPE发生的独立危险因素(OR=3.386~4.000,P0.05);logistic回归模型的ROC曲线下面积(AUC)=0.707,具有中等诊断准确度(P=0.001)。结论伴有纤维分隔形成及血清CD19~+含量30%的PPE患儿发展为CPPE的可能性大。     

Five-fold increase in pediatric parapneumonic empyema since introduction of pneumococcal conjugate vaccine

A retrospective review of medical records for all pediatric parapneumonic empyema (PPE) patients admitted to our hospital from 1996 to 2006 revealed that PPE increased 5-fold in the post-heptavalent pneumococcal conjugate vaccine (PCV7) period (2001-2005) relative to the pre-PCV7 period (1996-2000), from 13 cases to 65. Most of this increase was associated with culture-negative empyema, which accounted for 61% of all post-2000 cases; 19% was culture-positive pneumococcal empyema. Our analysis indicates that non-PCV7 serotypes became more prevalent at our institution after introduction of the vaccine.     

Management of parapneumonic pleural effusions

Pleural effusion in children is most often due to bacterial pneumonia. Between 0.6 and 2% of pneumonias are complicated by empyema and approximately 40% of children hospitalized with pneumonia have a pleural effusion. In recent years Streptococcus pneumoniae is the most prevalent organism. Treatment is based on the early and judicious use of antibiotics, imaging techniques, thoracocentesis, pleural drainage, fibrinolytics, thoracoscopy and thoracotomy. Indications for early pleural drainage are gross pus, positive Gram stain in pleural fluid, pleural glucose less than 50mg/dL, pleural fluid pH of less than 7 and sonographic evidence of loculations. Local fibrinolytics may decrease the need for surgical treatment, with a success rate between 38 and 100%, according to the effusion stage. Thoracoscopic debridement is useful in the fibrinopurulent stage with loculations, with favorable results in 30-100% of patients, also depending on the effusion stage.     

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.