Asian Cardiovasc Thorac Ann 2000;8:137-140
© 2000 Asia Publishing EXchange Pte Ltd
Management of Parapneumonic Empyema in Children
Ahmet Çekirdekçi, MD,
O
uz Köksel, MD,
Turul Göncü, MD,
Oktay Burma, MD,
Ali Rahman, MD,
Ihsan Sami Uyar, MD,
Erhan Ayan, MD,
Ayhan Uysal, MD
Department of Thoracic and Cardiovascular Surgery
Firat University Medical Faculty
Elazi , Turkey
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For reprint information contact: Ahmet Çekirdekçi, MD Tel: 90 424 237 4588 Fax: 90 424 238 8096 email: oko{at}hotmail.com Department of Thoracic and Cardiovascular Surgery, Firat University Medical Faculty, Elazi 23200, Turkey.
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Abstract
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Empyema is a serious complication of bacterial pneumonia in children. Between July 1992 and July 1998, 53 children aged 7 months to 12 years (mean age, 5.5 years) were treated for empyema complicating pneumonia. After diagnostic thoracentesis, closed tube drainage was carried out with appropriate antibiotic therapy and other treatment strategies such as pleural lavage, intrapleural enzymatic debridement, decortication, or pulmonary resection, according to the effectiveness of drainage and clinical status. There was one death from toxic shock. It was concluded that early decortication in the chronic stage of the disease is a safe and effective treatment modality.
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Introduction
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Thoracic empyema in the pediatric age group is a complication of bacterial pneumonia in 50% to 75% of cases.1 Low socioeconomic status, inappropriate antibiotic use, malnutrition, and delay in seeking treatment are contributing factors to the development of empyema in patients with pneumonia. This study retrospectively evaluated patients under 13 years old with parapneumonic empyema who were treated in our clinic.
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Patients and Methods
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Between July 1992 and July 1998, 605 patients were admitted to our pediatric clinic with nonspecific bacterial bronchopulmonary infections and 53 (9%) of them were diagnosed with parapneumonic empyema, of whom 12 (23%) developed empyema during hospitalization; the others had empyema on admission. There were 32 boys (60%) and 21 girls (40%). The youngest was 7 months old and the eldest was 12 years old (mean age, 5.5 years); 53% of patients were in the age group 0 to 3 years. Most of the children (82%) came from rural areas in our region of Eastern Anatolia, from large families with a low socioeconomic level, and their symptoms developed on average 7 days before administration (range, 3 to 12 days). Terrorist activity and transportation difficulties played major roles in the delay before seeking treatment. Many (74%) had not received any medication before administration and the others had been given irregular doses of antibiotics. The signs and symptoms of parapneumonic empyema are listed in Table 1
. Empyema was diagnosed on the basis of clinical findings, chest radiography, and purulent fluid aspiration by thoracentesis. Broad-spectrum antibiotics were given until microbiological culture and sensitivity results were available.
The empyema was located in the left hemithorax in 37 patients (70%), in the right hemithorax in 14 (26%), and it was bilateral in 2 cases (4%). Initial chest radiographs showed that 18 patients (34%) had massive pleural effusion (hemithorax obliterated almost totally), 11 (21%) had moderate effusion (more than one-third of the hemithorax obliterated), and 24 (45%) had mild effusion (less than one-third of the hemithorax obliterated). Other radiological findings were hydropneumothorax in 6 patients (11%), mediastinal shift in 5 (9%), and pulmonary infiltration in 18 (34%). Bacteriological examinations of the aspirated fluid from each patient showed that 13 (25%) were negative and the other 40 were positive. The patients were sent to our thoracic clinic 2 or 3 days after admission to the pediatric clinic. In the first stage of therapy, tube thoracostomy was applied and further treatment strategies were chosen according to the effectiveness of drainage and the clinical status of the patient (Figure 1). Pleural lavage with povidone-iodinated serum physiologic fluid via the chest tube was carried out in 26 patients. Enzymatic debridement was performed in 17 patients with multiloculated empyema; 75 to 125 mL streptokinase (Streptase; Hoechst, Istanbul, Turkey) in a concentration of 25,000 units per liter of normal saline was infused into the pleural space and the tube was closed for 4 to 6 hours.
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Results
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Staphylococcus aureus was the most common etiologic agent. Haemophilus influenzae was more frequent in the 0 to 4 years age group compared to the older age groups. Clinical symptoms disappeared very quickly in 26 patients with effective drainage and pleural lavage. Extubation was performed when the lungs had expanded fully (as shown by chest radiography) and no fever was observed for 48 hours. The mean duration of intubation was 11 days. In 17 patients, effective drainage was not achieved and their fever did not subside. These patients were evaluated by radiology (Figure 2) and computed tomography (Figure 3) and found to have multiloculated empyema with a thick fibrin coating. Enzymatic debridement was applied in these 17 cases for 3 to 7 days, according to individual patient responses. Extubation was carried out in 13 of these patients after satisfactory radiological (Figure 4) and clinical findings. The mean duration of intubation was 14 days in this group. Decortication was carried out in the other 4 patients after 4 to 6 days of enzymatic debridement because it was evident that they were not responding to the treatment. Decortication was also performed in 10 patients who did not respond to drainage, or in whom drainage was not attempted because of thickened pleural pile determined by diagnostic thoracentesis, and in those whose lungs could not be opened due to bronchopleural fistula.
Decisions to operate were made 5 to 16 days after admission. Parenchymal resection was performed in 3 patients because of parenchymal damage and bronchopleural fistula (lingulectomy in 1, resection of the superior segment of the right lower lobe in 1, and right middle lobectomy in the other). No postoperative complications occurred in the patients who underwent thoracotomy and they were discharged after a mean hospital stay of 12 days. No additional operative procedures such as treatment with thoracentesis alone, open drainage, or thoracoplasty were applied in any case. Thoracoscopy was not performed due to lack of technical facilities.
One of the 53 patients died (mortality, 1.9%). This patient had bilateral empyema with cerebral and intraabdominal invasion and succumbed to toxic shock.
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Discussion
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Bacterial pneumonia is the most common cause of thoracic empyema in the pediatric age group. Postoperative and posttraumatic empyemas have different pathological patterns and treatment modalities and are seen in 25% and 2% to 25% of cases, respectively.2 Pleural effusion during the course of nonspecific bacterial pneumonia progresses to empyema for several reasons including malnutrition, immunodeficiency, irregular antibiotic treatment, delay in diagnosis of pneumonia, contamination during thoracentesis, the tendency for antibiotic treatment in the acute phase in pediatric clinics, and disappearance of the signs and symptoms of pneumonia.
Empyema in 12 of the 53 patients in this series developed during treatment in the pediatric clinic. The pre-hospital period was long (approximately 8.5 days) in the other patients, 75% of whom did not receive any medication and 25% had irregular antibiotic treatment. Low socioeconomic status, terrorist activity, and transportation difficulties in our region contributed to the delay. The high incidence (53%) in 0 to 3 years age group might be explained by low standards of childcare in overcrowded families. The incidence in this age group correlated with published data.3 The finding that Staphylococcus aureus was the most common infective agent agrees with other reports.4,5 However, the high incidence of Haemophilus influenzae in the 0 to 4 years age group was notable.
The stage of the parapneumonic empyema must be taken into consideration when selecting suitable treatment modalities. Thoracentesis or tube drainage is usually sufficient to expand the lung during the first (exudative) stage of empyema in which the cellular content is low and fluidity is good. However, this stage is very short (the first 24 to 48 hours) and cannot always be detected even during hospital treatment of pneumonia. We did not treat any of our patients by thoracentesis although there have been some reports of the effectiveness of this procedure after early diagnosis.6,7 Tube drainage is recommended in children because of its reliability, rather than multiple thoracentesis.8
Patients with parapneumonic empyema are usually admitted in the second (fibrinopurulent) stage in which the pleural fluid is denser and the most appropriate treatment in this period is drainage and mechanical clearance. Pleural lavage via the chest tube is useful for augmenting drainage and mechanical clearance and various antimicrobial agents can be added to the washing fluid.9 Successful results were achieved in 26 patients with povidone-iodinated serum physiologic fluid. Drainage may be ineffective in this period because of the tendency for free fluid to pool in pouches. Computed tomography should be used to assess the pouches in patients whose symptoms do not disappear in spite of drainage. When multilocular empyema is indicated by computed tomography, drainage can be enhanced by fibrinolytic agents (enzymatic debridement) and videoassisted thoracoscopy. We used streptokinase in 17 patients, which was successful in 13; decortication was performed in the other 4. Connection of multiple pouches, debridement, and decortication have been carried out as indicated by thoracoscopy in recent years but we did not have this facility.9–14
The content of the empyema pouch begins to organize after 10 days (stage III, chronic stage). Nonelastic membranes of various thickness form pleura that limit lung expansion in this period. This can be diagnosed easily by chest radiography and computed tomography in the 2nd to 4th weeks of the illness. Tube thoracostomy is not sufficient to eradicate an empyema pouch and to expand the lung at this stage but open drainage can be used. However, malnutrition may cause progressive anemia and malignant degeneration (pyothorax-associated lymphoma) and the length of hospital stay and management of the patient will be difficult.15 Early thoracotomy and decortication may be more effective than attempting drainage. In the 4 patients who were unresponsive to enzymatic debridement, we operated after 4 to 6 days, whereas decortication was carried out at 5 to 16 days in the other 10 patients. When drainage is considered ineffective or multiloculated empyema is present, decortication is recommended within 2 to 3 weeks.8,16 Others prefer more aggressive surgical intervention and wait no more than 48 hours; mortality and morbidity were reported to be decreased by early surgery.9 The only death among our patients was in a case of bilateral empyema with cerebral and intraabdominal invasion.
Thus, parapneumonic empyema in the pediatric age group should be treated early and effective drainage must be achieved before organization of the pleural fluid and progression of pulmonary parenchymal damage. If necessary, thoracoscopic and enzymatic debridement should be used to enhance drainage. Decortication should be performed as soon as possible if drainage is not effective. When the patient's status is suitable for surgery, we recommend this approach because of the decrease in mortality and morbidity, reduction of hospital stay, and discharge of the patient without an open wound.
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Abstract
Introduction
