Pediatric empyema--an algorithm for early thoracoscopic intervention.

INTRODUCTION: The management of pediatric empyema remains controversial. We contend that early thoracoscopic intervention results in shorter hospital stays, decreased morbidity, and superior outcomes. We propose an algorithm using early image-guided thoracoscopy as an effective treatment for pediatric empyema. METHODS: Consecutive pediatric empyemas treated from November 1997 to April 2001 using a prospective management algorithm were reviewed. Demographic data, days to diagnosis, days to surgery, length of stay, chest tube days, complications, and follow-up were recorded. RESULTS: Twenty-two children with 24 empyemas were treated using this algorithm. Their mean age was 49 months. Mean days to diagnosis was 11 and from diagnosis to surgery was 3. Imaging included chest radiography (CXR) in all, ultrasound in 17 (77%), and computed tomography (CT) scan in 13 (59%). One thoracoscopy was converted to a mini-thoracotomy because of difficulty with ventilation. Chest tube removal averaged 3 days with an average length of stay of 13 days. One patient required a second thoracoscopy for recurrent empyema, and 1 patient developed a contralateral empyema. No other complications or deaths occurred. Follow-up in 19 of 22 (86%) children at 5 months revealed no recurrences or mortality. CONCLUSION: This treatment algorithm, using early image-guided thoracoscopy, is a safe and effective means of managing pediatric empyema, while shortening hospital stay and avoiding the morbidity of thoracotomy.