Management of parapneumonic collections in infants and children

doi:10.1016/S0022-3468(00)90022-8

Journal of Pediatric Surgery

Volume 35, Issue 2, February 2000, Pages 265-270

Presented at the 30th Annual Meeting of the American Pediatric Surgical Association, Rancho Mirage, California, May 16-19, 1999.

https://doi.org/10.1016/S0022-3468(00)90022-8 Get rights and content

Abstract

Background/Purpose: Video-assisted thoracoscopic surgery (VATS) has a recognized role in treatment of empyema thoracis. The purpose of this report is to show the value of initial VATS as the primary treatment of parapneumonic collections. Methods: A retrospective review was done of 139 children who required surgical consultation for parapneumonic collections between January 1992 and July 1998. Management options were (M1) thoracentesis, chest tube drainage, or fibrinolytic therapy and delayed thoracotomy for unresolved collections; (M2) thoracentesis, chest tube drainage, fibrinolytic therapy with delayed VATS if the child remained ill; or (M3) primary VATS. Comparative data included age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, number of procedures performed per patient, duration of chest tube drainage, complications, and length of stay. Kruskal-Wallis 1-way analysis was used, with significance at P less than.05. Results: A total of 60 children were treated by M1, 38 by M2, and 41 by M3. Age, duration of prehospital illness, oxygen requirements, white blood cell count, bacterial culture results, and complication rates were comparable. The median length of stay was 12 days for M1, 11 days for M2, and 7 days for M3, with M3 significantly shorter at P <.001. The number of procedures was a median of 2 in M1, 2 in M2, and 1 in M3, with M3 significantly fewer at P <.001. Duration of chest tube drainage was a median 5 days for M1 and 3 days for M2 and M3, with M1 significantly longer at P <.001. There were 9 thoracotomies in the M1 group, 3 in the M2 group, and none in the M3 group. One child in M3 required a second VATS. Conclusions: Primary VATS has significantly decreased the number of procedures, duration of chest tube drainage and length of stay for children with parapneumonic effusions. Primary VATS appears to be of value in management of bacterial pneumonia with effusion. J Pediatr Surg 35:265-270. Copyright © 2000 by W.B. Saunders Company.

Section snippets

Materials and methods

From January 1992 through June 1998, surgical consultations were obtained on 139 children with pneumonia complicated by parapneumonic effusion admitted to Children's Medical Center of Dallas. Review included data collection of the following: age, comorbid processes, duration and mode of prehospital treatment, laboratory values (including white blood cell count with differential and cultures), type, timing and result of invasive procedures, and hospital course. Hospital course data included

Results

There were 139 consultations for empyema over the 6-year period. The median age of the group was 49 months, with a range from 3 to 189 months. There were no deaths in the group. There were 60 children in the M1 group treated with thoracentesis, chest tube placement with or without fibrinolytic administration, and thoracotomy as indicated. There were 38 children in the M2 group who were treated with thoracentesis, chest tube placement with or without the administration of fibrinolytics, and with

Discussion

Bacterial pneumonia is commonly diagnosed and managed on an outpatient basis. Much has been published in the pediatric literature over the last 20 years regarding optimal management of empyema thoracis secondary to bacterial pneumonia. The management options are varied and zealously defended. Advocates of conservative therapies argue that intravenous antibiotics and chest cavity drainage will cure the majority of empyemas, making operations unnecessary. In the 1980s, successful resolution using

Acknowledgements

The authors thank Linda Hynan, PhD, in the Department of Academic Computer Services, University of Texas Southwestern Medical Center, Dallas, Texas, for assistance with statistical analysis.

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A multicenter study on the epidemiology of complicated parapneumonic effusion in the era of currently available pneumococcal conjugate vaccines
2023, Vaccine
Parapneumonic effusion (PPE) is a common complication of pneumonia. Streptococcus pneumoniae is the most common cause of bacterial pneumonia. A reduction in pneumonia hospitalizations has been observed since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). Despite this apparent benefit, an increase in the incidence of PPE was recorded in some countries following PCV7 implementation. As the 13-valent pneumococcal conjugate vaccine (PCV13) was expected to provide a wider protection against PPE, the aim of the present study was to evaluate the impact of PCV13 introduction on the epidemiology of complicated parapneumonic effusion (c-PPE) among children in the Athens greater area.
All cases of community-acquired pneumonia (CAP) with PPE requiring chest tube insertion (complicated PPE, c-PPE) hospitalized in the 3 public Children’s hospitals in Athens between 01/01/2004 and 31/12/2019 were included in the study.
A total of 426 cases of c-PPE associated with pneumonia were recorded of which 198 were admitted during 2004–2010 (period A, prePCV13/PCV −7 introduction period) and 228 during 2011–2018 (period B, post - PCV13 period). A definite bacterial etiology was established in 44.4 % of all cases and of those 25.4 % were caused by S. pneumoniae. An increasing trend in c-PPE incidence was observed during period A; although, a significant decrease on c-PPE annual rates was observed during the period B (p = 0.011), a remarkable increase in serotype 3 cases was recorded.
A decreasing time trend in c-PPE cases among children was shown after the introduction of PCV13 in our area. However, serotype 3 is nowadays a common cause of PPE. Hence, continuous surveillance is imperative in order to follow c-PPE epidemiology over time.
The diagnosis and management of empyema in children: A comprehensive review from the APSA outcomes and clinical trials committee
2012, Journal of Pediatric Surgery
Citation Excerpt :
The failure rate for fibrinolysis was 16.6% in both studies. The failure rate was similar to previous studies investigating the utility of fibrinolysis [46,54,59,60,62,65,68,70]. An example of a first-line fibrinolysis therapeutic approach is outlined Fig.
The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.
The results of treatment of complicated pleural empyema with VATS combined with the use of fibrinolytic agents
2012, Pediatria Polska
Citation Excerpt :
Reported average lengths of hospitalization range from 20 to 23 days [8–11]. Treatment of fibropurulent empyema in children with thoracoscopy is reported to be associated with average hospitalizations of 7–25 days, average thoracostomy tube dwell times of 3–21 days, and treatment success rates of 89%–100% [3, 8, 12]. Among our patients VATS combined with use of fibrinolytics resulted in 100% success rate.
This study summarizes the effects of treatment of complicated PE.
In the period of 2004–2010, 11 children with PE aged 1–19 needed surgical treatment. Before having been referred to our department, all children were managed for sustained pneumonia by local pediatricians using broad-spectrum antibiotics. Next, children were ineffectively treated in general hospitals using conventional pleural drainages maintained for 1 week to 2 months.
In 7 cases, a single video-assisted thoracoscopy (VATS), debridement, placement of pleural tubes under visual control, active suction drainage, and rehabilitation resulted in lung expansion, efficient ventilation, rapid relief of symptoms, and full recovery. Starting from the 2nd post-operative day, all children received fibrinolytics 3–6 times via chest tubes. In 3 patients, lack of lung expansion made the second VATS debridement necessary. In 1 patient in organizing stage of PE, re-VATS was supported by mini-thoracotomy allowing effective decortication and lung expansion. The average hospitalization time was 17 days. Surprisingly, even in the most neglected patients of our group, the follow-up CT scans done 3–4 months after discharge, were almost uneventful. The majority of spirometric parameters normalized within 6 months, and no child claimed dyspnoe due to physical strain.
Early VATS combined with early rehabilitation offers excellent results, radically improving the outcome in both the fibrinopurulent, as well as in organizing stages of PE in children, nonetheless surgeon should be experienced in the minimally invasive technique. The method seems to be successful even in very neglected cases, if not, patient could benefit from fibrinolytic therapy.
Pediatric empyema: Outcome analysis of thoracoscopic management
2009, Journal of Thoracic and Cardiovascular Surgery
Thoracoscopy has become a favored modality in treating pediatric empyema. However, the factors affecting the outcome of thoracoscopic management remain unclear. In this study, we report our experience using thoracoscopy to treat empyema in pediatric patients and investigate the factors affecting outcome.
We retrospectively reviewed the demographic data, clinical presentation, radiographic findings, laboratory studies, and hospital course of 101 pediatric patients who underwent thoracoscopy for empyema between 1995 and 2008.
Empyema was due to pneumococcus infection in 64 patients (63.4%), and 69% of the cultured microorganisms were penicillin nonsusceptible. Chest computed tomography scan was performed in 96 patients, in whom necrotizing pneumonia was noted in 35 (36.5%). Preoperative intensive care unit admission was required for 33 patients (32.7%). Preoperative chest tube drainage was performed in 36 patients (35.6%), and thoracoscopy was used as the primary treatment in the remaining 65 patients. Complications occurred in 10 patients (9.9%); there were no mortalities. The median postoperative hospital stay was 13 days. Multivariate analyses showed that necrotizing pneumonia was significantly associated with the presence of complications, and that necrotizing pneumonia, preoperative intensive care unit admission, and preoperative chest tube drainage were independent risk factors for a longer postoperative hospital stay.
The clinical presentations of empyema in children requiring thoracoscopy are diverse. Patients with necrotizing pneumonia and those requiring preoperative intensive care unit admission and undergoing preoperative chest tube drainage are at high risk for developing complications and requiring longer hospital stay after thoracoscopy.
Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study
2009, Journal of Pediatric Surgery
A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery.
A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications.
114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths.
Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.
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^☆: Address reprint requests to Philip C. Guzzetta Jr, MD, Professor and Chairman, Division of Pediatric Surgery, Children's Medical Center of Dallas, 1935 Motor St, H310, Dallas, TX 75235.

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Management of parapneumonic collections in infants and children☆

Abstract

Section snippets

Materials and methods

Results

Discussion

Acknowledgements

Am J Med

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Chest

Ann Thorac Surg