Asian Cardiovasc Thorac Ann 2006;14:98-101
© 2006 Asia Publishing EXchange Ltd
Outcome of Pediatric Empyema Thoracis Managed by Tube Thoracostomy
Maria Lorena Corazon V Rodriguez, MD,
Gisel T Catalan, MD
Department of Surgery, University of the Philippines, Philippine General Hospital, Manila, Philippines
For reprint information contact: Maria Lorena Corazon V Rodriguez, MD Tel: 63 2 524 8484 Fax: 63 2 524 8484 Email: yoyi_rodriguez{at}yahoo.com, Department of Surgery, University of the Philippines, Philippine General Hospital, Taft Avenue, Manila, Philippines.
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ABSTRACT
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The proper management of empyema thoracis in children continues to be a source of debate. This study assessed the clinical profile and outcome of patients managed by tube thoracostomy. Chart review was performed in 31 patients managed from January 1989 to December 2003. Outcome measures were duration and outcome of thoracostomy, number of days to radiologic lung re-expansion, length of hospitalization, and microbiologic flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly affected group were those aged 1 year and below. Staphylococcus aureus was the most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks. Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of the patients were hospitalized for at least 5 weeks. There were 3 recurrences and 3 deaths, 2 of which were most likely associated with empyema. Empyema managed by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged drainage and hospitalization, and unfavorable outcome.
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INTRODUCTION
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Thoracic empyema continues to have a high mortality rate (10–16%).1 It occurs when bacteria invade and propagate in the normally sterile pleural space, and proceeds in 3 phases. The exudative phase is caused by increased permeability of the inflamed pleura. The fibrinopurulent phase is characterized by accelerated fibrin deposition, giving rise to loculations and pus formation. The organizational phase begins 1 week after infection and is characterized by multiloculated empyema and pleural peel, with subsequent lung entrapment. The predominant organisms involved are Staphylococcus, Streptococcus, and Mycoplasma species. The clinical features are nonspecific: dyspnea, fever, cough, and chest pain. Various treatments have been employed, including antibiotics, thoracentesis, tube thoracostomy (TT), intrapleural fibrinolytics, open-window thoracostomy, video-assisted thoracoscopic surgery, and thoracotomy. When TT is successful, drainage is 83% complete in 3 days.2 However, complicated cases will require multiple chest tubes and there is a 25% 80% chance of treatment failure.3,4 Open drainage is achieved by drain tube thoracostomy, rib resection, an Eloesser’s flap, or a Heimlich valve. These maneuvers enable continuous drainage without hampering ambulation. The incidence of permanent sequelae in empyema thoracis is low to absent5. Pleural opacity resolve by 2–16 months.6,7 There is no permanent lung function abnormality, and the long-term prognosis is excellent.2 The current mode of therapy in our institution is conservative, utilizing TT alone. Although there are now reports that favor early aggressive surgical therapy, there is still no internationally accepted protocol nor randomized controlled trials of the management of pediatric empyema. This study assessed the outcome of TT for thoracic empyema in our institution.
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PATIENTS AND METHODS
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A chart review was carried out of all 31 pediatric patients diagnosed with empyema thoracis and referred to our department from January 1999 to December 2003. For each patient, the outcome measures identified were: duration and outcome of treatment with intercostal TT, number of days to radiologic lung re-expansion, and length of hospital stay. The microbiologic flora was also noted. Fibrinolytics were not used in any of the patients. Twelve (39%) were infants, 6 (19%) were aged 2 to 10 years, and 13 (42%) were aged 11 to 18 years. The mean age was 9 years, and the male-to-female ratio was 2:1.
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RESULTS
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Of the 31 patients, 19 (61%) had follow-up records. Mean duration of follow-up was 61 days (range, 9–105 days). Two patients were readmitted for recurrence, and one experienced a recurrence during the same admission. One patient had persistent empyema necessitating insertion of a second tube. Thus, 35 tube thoracostomies were performed. Six (19%) patients had sterile pleural fluid upon analysis. Staphylococcus aureus was the most frequently isolated pleural fluid pathogen (8 isolates; 32%). Other pathogens isolated are shown in Table 1
. Staphylococcus aureus was more often found in the younger age groups (0–10 years old), whereas Streptococcus species and Pseudomonas were more common among adolescents (11–18 years old).
Post-TT surveillance of the 34 cases of empyema thoracis in 31 patients revealed that 61% did not show radiologic evidence of lung re-expansion (Table 2), even if the duration of thoracostomy was prolonged to more than 3 weeks. The duration of treatment with tube thoracostomy extended from 1 to > 7 weeks (Table 3), usually lasting for 2 weeks. If complete pleural drainage and lung re-expansion was not achieved after two weeks, it was converted to an open drain. The drain was then gradually mobilized and spontaneously extruded. The outcome of the treated cases is shown in Figure 1. Three patients (10%) died due to staphylococcal septic shock, progressive bronchopneumonia, and right atrial thrombus formation.
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Table 3. Duration of Drainage, Time to Conversion to Open Thoracostomy, and Hospital Stay in Cases Treated by Tube Thoracostomy
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DISCUSSION
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Empyema thoracis continues to be a common disease entity in our institution. It affects the adult and pediatric population alike. In our study, the most commonly affected were those aged 1 year and below. The bacteriologic profile of empyema was dominated by Staphylococcus aureus, in agreement with previous reports. The presence of excess pleural fluid, loculations, and pleural peel make it difficult for the lungs to expand fully. This compromises the patient’s ventilation.
In this study, only 6% of the patients with empyema who were treated with TT achieved lung re-expansion after 1 week; 61% did not achieve full lung re-expansion even after 3 weeks. This reflects the fact that although chest tube drainage can remove free fluid in the pleural space, it cannot drain loculated effusions, which are characteristic of the advanced stages of empyema thoracis. Likewise, TT by itself does not promote resolution of the fibrinous pleural peel that restricts ventilation. Although we do not expect permanent restrictive lung disease development in pediatric patients as a result of prolonged treatment for empyema, this extended period of recovery demands continued attention to the disease, and delays the return to normal activity. The finding that 71% of patients eventually had their primary TT converted to open drainage is in agreement with earlier studies citing 25%–80% treatment failure for TT alone.3,4 With conversion to open tube drainage and removal of the drainage bottle, patients are encouraged to ambulate more, thus promoting better pulmonary hygiene. This form of treatment, however, entails an extended duration of therapy, persistent need for tube care, continuing discomfort, and the risk of further injury due to the presence of an indwelling intrapleural catheter. The prolonged duration of an indwelling tube may be contrasted with postoperative tube drains in patients who undergo thoracotomy, which are removed within 3 days.8,9 Half of the patients had to stay in the hospital for at least 5 weeks for their treatment which comprised TT and intravenous antibiotics. This prolonged hospital stay can be contrasted to that of patients given immediate definitive therapy, who have a much shorter postoperative hospital stay of 4–17 days for thoracoscopy, and 4–10 days for thoracotomy.7–13 Prolonged hospital stay increases the patient’s risk of acquiring nosocomial infection.
In this study, 2 of the 3 deaths were associated with TT. Earlier studies indicated that mortality rates of empyema thoracis do not vary whether the treatment approach is surgical or non-surgical.1 Surgical therapy is advised in advanced stages, in cases of inadequate pleural evacuation, and in persistent pleural infection. It is possible that these two cases might have been salvageable if they had undergone surgery at a feasible time. Video-assisted thoracoscopic surgery with decortication is recommended in anerobic, tuberculous, staphylococcal, and pneumococcal infections.15 This modality shortens the duration of tube drainage (2–4 days) and hospital stay, compared to tube thoracostomy or fibrinolytic therapy.11,13 Thoracotomy with decortication is indicated for advanced stages of empyema thoracis, even in children.8 Performed in a timely manner, it is associated with low morbidity, providing rapid resolution of symptoms, with a 95% success rate, 98% freedom from hospital re-admission, and 100% survival rate.9,10 Eighty percent of patients treated conservatively eventually need a thoracotomy. Delay results in complications and consequently prolongs hospital stay.4
It is recommended that patients in an advanced stage of empyema thoracis undergo early definitive surgical treatment. This will improve the patient’s ventilatory status earlier (with complete drainage and lung re-expansion), shorten the duration of an indwelling tube, and reduce hospital stay. A randomized controlled trial may be useful to compare the treatment outcomes between TT, thoracoscopy, and thoracotomy among the pediatric population with empyema thoracis. This study is limited by the incomplete patient follow-up, and less-than-adequate documentation in some patient charts.
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ACKNOWLEDGMENTS
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We extend our gratitude to: the PGH TCVS research staff for helping us gather the patient census; the PGH medical records staff for helping us recover the charts needed; and the PGH patients who continually trust in us.
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REFERENCES
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ABSTRACT
INTRODUCTION
