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(Chest. 2002;121:836-840.)
© 2002 American College of Chest Physicians

Short-term Course and Outcome of Treatments of Pleural Empyema in Pediatric Patients*

Repeated Ultrasound-Guided Needle Thoracocentesis vs Chest Tube Drainage

David Shoseyov, MD; Haim Bibi, MD; Gila Shatzberg, MD; Aaron Klar, MD; Jacob Akerman, MD; Hagit Hurvitz, MD and Channa Maayan, MD

* From the Departments of Pediatrics (Drs. Shoseyov, Shatzberg, Klar, and Hurvitz) and Radiology (Dr. Akerman), Bikur Cholim Hospital, and the Department of Pediatrics (Dr. Maayan), Hadassah University Hospital, Mt. Scopus, Hadassah Medical School, Hebrew University, Jerusalem, Israel; and the Department of Pediatrics (Dr. Bibi), Barzilai Medical Center Hospital, Ashkelon Medical School, Ben-Gurion University of the Negev, Beer-Sheva, Israel; and the Department of Pediatrics (Dr. Maayan), Hadassah University Hospital, Mt. Scopus, Hadassah-Hebrew University Medical School, Jerusalem, Israel.

Correspondence to: David Shoseyov, MD, Pediatric Pulmonology Clinic, Bikur Cholim Hospital, 5 Strauss St, P.O. Box 492, Jerusalem 91004, Israel; e-mail: dshosey{at}md2.huji.ac.il


   Abstract
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 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: Several reports have suggested that early chest tube drainage (CTD) may not be necessary in the treatment of severe pleural empyema (PE) in pediatric patients if appropriate antibiotic therapy and supportive care are provided.

Objectives: A prospective open study to compare the short-term course of two treatment protocols of severe PE in pediatric patients.

Study design: One group of 32 patients was treated with early insertion of a chest tube for CTD, and a second group of 35 patients was treated by a repeated ultrasound-guided needle thoracocentesis (RUSGT). The severity of the empyema was assessed by chest radiograph, the amount of fluid drained, the number of days the patient had experienced a fever, and the duration of antibiotic treatment.

Results: No significant differences were found between the two groups (RUSGT vs CTD) in all of the following measurements: mean (± SD) duration of a temperature >= 39°C, 6.2 ± 2.4 vs 6.5 ± 1.8 days, respectively; mean duration of a temperature >= 38°C, 9 ± 3.9 vs 8.2 ± 4.5 days, respectively; fluid drained, 35.1 + 23.8 vs 30 ± 28.2 mL/kg, respectively; duration of antibiotic treatment, 30 ± 13.2 vs 30.2 ± 7.3 days, respectively; and length of hospitalization and home IV treatment, 22 ± 7.6 vs 24.2 ± 7.5 days, respectively. A failure to respond to treatment occurred in three patients in the RUSGT-treated group and in five patients in the CTD-treated group. The failure to respond occurred in the RUSGT-treated group only in those patients with very large empyemas that caused mediastinal deviation.

Conclusion: The treatment of PE by RUSGT is as efficacious as CTD, unless PE causes mediastinal deviation.

Key Words: chest tube • fibrinolysis • pleural empyema • thoracocentesis


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Continuous closed chest tube drainage (CTD) and concomitant parenteral antibiotic therapy have been the standard of treatment of pleural empyema (PE) in children since the early 1970s.1 In adult patients, this therapeutic regimen is known to reduce the likelihood of long-term fibrothorax and restrictive lung disease. Reports2 have suggested that the placement of a chest tube may not be necessary to achieve complete clinical recovery in children with PE. Most of the publications concerning the treatment of PE in pediatric patients have been reported in the surgical literature.3 These publications indicate a more aggressive approach to treatment, suggesting the need for rapid thoracoscopic intervention or intrapleural fibrinolysis.4 5 6 7 8 9 10 11 12

CTD has side effects. It is painful, may be complicated by ascending infection, may fail to drain due to fibrin wall formation and closed pus loculations in distanced areas, and leaves a scar at the insertion area. Repeated ultrasound-guided needle thoracocentesis (RUSGT) is performed under ultrasound observation directing the needle to the largest areas with fluid collections. It has fewer side effects compared to CTD, because it is performed with a local anesthetic, leaves no scar, and the patient is free between the procedures. As long-term complete recovery is achieved in both surgical and noninvasive medical treatments,2 13 we present a prospective open study that compared the course of the disease and the short-term outcome between CTD and RUSGT treatments in 67 pediatric patients with severe PE in three hospitals.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
We performed an open prospective study to compare the short-term course and outcome of two treatment modalities for patients with severe PE in 67 pediatric patients, in three hospitals in Israel over > 6 years (September 1992 to March 1999). The local ethics committee approved the study.

Thirty-five patients in one hospital started treatment with RUSGT, and 32 patients in the other two hospitals were treated with early CTD. All patients who met the following criteria were included in the study: (1) pleural exudate with low pH (ie, <= 7.2), low glucose level (ie, <= 40 mg/dL), and WBC count >= 1,000 cells/mm3; (2) pleural fluid volume estimated by chest radiograph to be larger than one third of the involved lung; and (3) a temperature of >= 39°C on admission to the hospital.

All patients initially received IV broad-spectrum antibiotic therapy that adequately covered resistant strains of Pneumococcus and Staphylococcus aureus. The treatment was adjusted subsequently according to antibiogram results when they became available.

Thirty-five patients were treated with RUSGT, every other day, until fluid collection thickness was < 3 cm, as demonstrated by chest ultrasound. The best locations for thoracocentesis were selected with the ultrasound. The area was infiltrated with 1 to 3 mL lidocaine 2%, including the rib periosteum. Drainage was performed with a 16-gauge needle that was connected to a two-way valve and with two syringes, of which one was connected to an extension tube for removal of the fluid from the aspirating syringe. In the other two hospitals, 32 patients were treated with early CTD.

Patients were considered to have failed to respond to RUSGT treatment if they remained septic after two or more thoracocentesis procedures, if pleural fluid returned to the previous initial level or greater after two or more procedures, or when the involved lung failed to inflate.

Patients were considered to have failed to respond to CTD if a large loculation failed to drain for > 24 h, even after intrapleural fibrinolytic therapy with urokinase.

If the patient failed to respond to RUSGT treatment, a chest tube was inserted. If a loculated area failed to drain through the chest tube, intrapleural fibrinolytic treatment with urokinase (100,000 U in 100 mL normal saline solution) was added. If the patient failed to respond to this treatment, decortication by thoracoscopy or open chest surgery was performed.

The parameters investigated were age, sex, total volume of pleural fluid drained per kilogram of weight, number of days of temperature >= 39°C, number of days of temperature >= 38°C, number of days of IV treatment, results of blood and empyemic fluid culture, and results of pulmonary function tests if possible. The chest radiograph pleural thickness score was recorded for the worst anterior-posterior projection chest radiograph during the first 4 days of the disease. The score was -1 (normal, 2; empyema in less than one third of the involved lung, 3; empyema occupying more than one third of the involved lung, 4). Empyema occupying the entire hemithorax caused mediastinal deviation.

Statistical Analysis
The results are presented as the mean ± SD and confidence intervals. A statistical analysis with unpaired t test was calculated for the parametric values, Yates corrected {chi}2 for the male-female sex distribution in the two groups, and a Wilcoxon rank sum/Mann-Whitney U test was calculated for the chest radiograph pleural thickness score. A power analysis was performed using tables14 on the difference between the means of the two groups of the days with temperature >= 39°C. We assumed that a minimum of 3 days between the means for both groups was clinically significant and considered that this parameter was more important than other measurements (eg, length of stay [LOS], days receiving antibiotic therapy, pleural fluid drained, or days with temperature >= 38°C).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
In two hospitals, 32 patients were treated with early CTD with or without intrapleural urokinase therapy, and in one hospital 35 patients were treated by RUSGT. RUSGT was performed about three times (range, one to four times; mean, 2.4 ± 0.85 times) for each patient. The parameters observed in the two groups are summarized in Table 1 . We found no significant difference between the group treated by RUSGT and the group treated by CTD in age (4.64 ± 4.4 vs 5.0 ± 4.7 years, respectively; p = 0.677), sex ([men and women] 19 and 16 vs 21 and 11, respectively; p = 0.4865), and the severity of the disease as expressed by the chest radiograph pleural thickness score (mean rank, 34.29 vs 33.69, respectively; p = 0.83 [two-tailed test]).


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  		Table 1.. Characteristics and the Short-Term Clinical Course Parameters for the Two Treatment Groups*

 
No significant differences were found between the group treated by RUSGT and the group treated by CTD in the short-term course of disease (Table 1) (duration of a temperature >= 39°C [6.2 ± 2.4 vs 6.5 ± 1.8 days, respectively; p = 0.569] and duration of a temperature >= 38°C [9 ± 3.9 vs 8.2 ± 4.5 days, respectively; p = 0.444]). No significant differences were found between the groups in terms of the amount of pleural fluid drained (35.1 ± 23.8 vs 30 ± 28.2 mL/kg, respectively; p = 0.582) and the duration of IV and oral antibiotic treatment (30 ± 13.2 vs 30.2 ± 7.3 days, respectively; p = 0.951). No significant difference between the groups was found in the duration of hospitalization or home IV treatment (30 ± 13.2 vs 30.2 ± 7.3 days, respectively; p = 0.28).

In order to calculate the appropriate number of patients required to show no difference, a power analysis was performed on the difference between the two groups of the mean number of days with a temperature >= 39°C. We assumed that a minimum difference of 3 days (between the averages) was clinically significant (RUSGT group, 35 patients; CTD group, 32 patients) with an SD of 2.17 (based on the empirical data of our study) and that the significance level of {alpha} = 5% of the power of the statistical test (two-sided) would be 99%. It has been shown that in the above sample size with {alpha} = 5% and power = 80%, a mean difference of >= 1.48 days would have been statistically significant. As we can see in our study, the difference between the means was 0.2 days.

In three patients who failed to respond to RUSGT, treatment was changed to CTD with intrapleural urokinase therapy, and two patients underwent open chest decortication. These five patients remained septic after the second RUSGT, and the amount of pleural fluid recollected was the same or had increased. All five patients presented with a mediastinal deviation to the other side of the chest on hospital admission. Two patients from the CTD-treated group required fibrinolytic therapy, and three patients underwent open chest thoracotomy due to the persistence of fever and multiloculated pus collections that had failed to drain through the chest tube.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The standard treatment of PE includes antibiotic therapy and drainage by thoracocentesis, thoracostomy tube (chest tube), and thoracoscopic or open chest decortication.4 It has been shown that long-term complete recovery is achieved in both surgical and medical treatments.2 However, the optimal approach to improve the short-term course and outcome of children with acute, severe PE has not been established.4 13

In our study, we compared early CTD and RUSGT and showed that there were no significant differences in the clinical course and short-term outcome of the two treatment modalities. PE was severe in both groups, according to our inclusion criteria and according to the empyema severity score described by Hoff et al.8 Failure to respond to treatment occurred in both groups. Five of the 35 patients treated by RUSGT failed to respond. Three patients required CTD with intrapleural fibrinolytic therapy (ie, urokinase), and two patients underwent pleural decortication. Of the 32 patients who were treated with early CTD therapy, two required intrapleural urokinase therapy and three required pleural decortication. The mortality rate was not recorded in either group. Six months after hospital admission, all patients were clinically healthy and their chest radiographs were normal. These data are compatible with those from a report about the follow-up of postempyema pleural peel in adults by chest CT scan, which showed complete resolution of symptoms 12 weeks after percutaneous drainage.13

The placement of a thoracostomy tube has been the standard therapy for PE since 1970s.5 Multiloculation of the pleural space is the most significant cause of drainage failure.8 10 Radiology-guided and ultrasound-guided catheter placement have assumed important roles in the drainage of multiloculated empyema and have proved to be effective in 80 to 90% of cases even after the failure of the patient to respond to CTD.15 16 Despite that, the use of radiology-guided drainage has not gained wide acceptance by thoracic surgeons and physicians.17

Comparing the clinical course described in our study with data from the medical literature, we obtained the same results. The LOSs for the RUSGT-treated group and the CTD-treated group were 22 ± 7.9 vs 24.2 ± 7.5 days, respectively. In other studies, patients treated by permanent chest tube placement were discharged from the hospital on the 28th hospital day,18 between days 27 and 40,19 and 22 ± 14.5 days.20 In another study,21 patients with severe PE who had been treated with CTD had even longer LOSs compared to the patients treated with antibiotics alone. Children treated by early decortication were discharged from the hospital after a mean of 12.4 days.22 The shorter LOS reported in children treated by early decortication22 is impressive, but it cannot be readily compared to the results of our study since essential information about the method of care, such as the number of days before admission to the surgery department and the number of days receiving continuous home IV therapy, was missing from the article. Open chest decortication is a far more invasive procedure that requires surgery, which has undesirable cosmetic effects and may limit the treatment options if future surgery is needed.23 Thoracoscopy is less invasive, but studies have not shown any advantage over the more conservative modalities. The surgical approach should be reserved for those patients who have failed to respond to conservative treatment.

When comparing the number of days with a temperature >= 39°C and the number of days with a temperature >= 38°C, there are also no significant differences, as most studies mentioned above reported the total number of days with a fever and did not divide it into high fever (ie, >= 39°C) and fever (ie, >= 38°C).

Some studies4 10 24 25 26 27 have proved the effectiveness of the intrapleural fibrinolytic treatment of loculated empyema with streptokinase28 or urokinase. In our study, five patients required intrapleural urokinase therapy (RUSGT group, three patients; early CTD group, two patients). In all five patients, an increase of drainage volume was observed after fibrinolysis, along with the disappearance of most of the loculations, as described in the above studies. Four of these five patients have bee reported elsewhere.10

We conclude that RUSGT is safe and effective in children with severe PE as continuous chest drainage, unless PE causes a mediastinal shift. RUSGT is less invasive, and the clinical course and short-term outcomes are the same as for patients treated with CTD. We suggest that RUSGT should be the preferred treatment, rather than CTD.


   Footnotes
 
Abbreviations: CTD = chest tube drainage; LOS = length of stay; PE = pleural empyema; RUSGT = repeated ultrasound-guided needle thoracocentesis

Received for publication April 2, 2001. Accepted for publication August 14, 2001.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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