Home            Past Issues            About IP            About IAP           Author Information            Subscription            Advertisement              Search  

   
correspondence

Indian Pediatr 2014;51: 239-240

Pediatric Empyema Thoracis – Role of Conservative Management


We read with interest the recent article [1] regarding conservative management of empyema thoracis. The authors comment that local availability and cost, especially with surgical techniques such as videoscopy-assisted thoracic surgery (VATS), limits surgical options. However, often the advantages of surgery are not discussed with the family. Children are often referred late to the pediatric surgeon in a malnourished state [2]. The families usually end-up spending all their meager resources on consultations and prolonged courses of expensive broad spectrum antibiotics far more than the cost of surgical debridement in a government hospital.

Ultrasonography at admission showed pleural thickening in two, loculations in six and organized fluid in seven patients. However, computed tomography (CT) of the chest showed loculation, collapse and pleural thickening in all three patients where it was done. These bear out the fact that accurate staging is possible only with a contrast enhanced CT scan [2]. While we agree that patients in early stage (Stage I) do not require surgery, those in Stage II and III recover faster with surgical intervention (VATS or open surgery). Interestingly, there is no mention of staging of the disease [3] in this study. What is disturbing to note is that in this series, at discharge, pleural thickening was present in 84% with overcrowding of ribs in 60%. This persisted in 44% and 32%, respectively at 6 weeks follow-up, with 8% having scoliosis and one unexplained mortality.

We have published a large series of surgically managed Stage III pediatric empyema thoracis [4]. Our experience has been that complete removal of pus and debris – that is often too thick to come out of a standard chest tube – and the thick pleura encasing the lung surface leads to full lung expansion. This promotes early recovery and discharge from hospital [4,5]. Contrast enhanced CT scan improves decision making regarding early surgical intervention avoiding prolonged antibiotic treatment, morbidity and mortality.

Prema Menon and KLN Rao
Department of Pediatric Surgery,
Chandigarh, India.
Email: [email protected]

References

1. Kumar A, Sethi GR, Mantan M, Aggarwal SK, Garg A. Empyema thoracis in children: a short term outcome study. Indian Pediatr. 2013;50:879-82.

2. Menon P, Kanojia RP, Rao KLN. Empyema thoracis: surgical management in children. J Indian Assoc Pediatr Surg. 2009;14:85-93.

3. The American Thoracic Society Subcommittee on Surgery. Management of nontuberculous empyema. Am Rev Respir Dis. 1962;85:935-6.

4. Menon P, Rao KLN, Singh M, Venkatesh MA, Kanojia RP, Samujh R, et al. Surgical management and outcome analysis of stage III pediatric empyema thoracis. J Indian Assoc Pediatr Surg. 2010;15:9-14.

5. Shankar KR, Kenny SE, Okoye BO, Carty HM, Lloyd DA, Losty PD. Evolving experience in the management of empyema thoracis. Acta Pediatr. 2000;89:417-20.

 


Author’s Reply

These are important, interesting and expected comments from a surgical unit. We offer following clarifications:

1. Our study was not a head to head comparison between surgical and conservative treatment of empyema thoracis in pediatric patients. There are very few studies that compare various treatment modalities (repeated thoracocentesis, chest tube drainage alone, chest tube drainage with fibrinolytics, VATS and thoracotomy) used for treating empyema. The objective of our study was to evaluate whether chest tube drainage alone can be an effective method of treating empyema. In a resource poor setting, no one should be denied the benefit of effective chest tube drainage.  Patients should not be looking for a trained pediatric or thoracic surgeon instead of getting a chest tube put-in early. ‘Families spending all their resources on consultation’ can be avoided if timely drainage is offered.

2. Many studies support that pleural healing is very good in children; one recent publication [1] concludes that though MRI may show pleural scarring, irrespective of modality of treatment, the lung functions are not affected in long run. In an earlier study [2] done in patients of empyema treated with chest tube drainage, pleural thickening was present in many but ultimately all had normal lung functions.

3. It is true that children had to stay for two weeks to complete intravenous antibiotics; children with bronchopleural fistula had to stay longer. But surgical intervention is not cheaper unless offered by a public hospital free-of-cost. In a study on cost of various modalities used for empyema [3], cost of VATS was much more than intercostal drainage along with fibrinolytics. Many of these children are high risk and would require a certain degree of competence, available only in few institutes.

4. We do not get CT chest done in every case of empyema because of the radiation risk. Unless it is clinically necessary or if surgery is being contemplated, CT chest is best avoided.

5. It is appreciable that the unit concerned has published a large series of cases of thoracotomy in empyema thoracis, We agree that it may be needed in some cases but surgical intervention in all cases of empyema cannot be the standard of care. A recent retrospective study [4] concluded that it is debatable whether VATS reduces the length of stay of children with empyema and suggested that chest tube drainage should remain the primary mode of therapy.

 GR Sethi and Anil K Gupta
Department of Pediatrics,
Maulana Azad Medical College, New Delhi, India.
Email: [email protected]

References

1. Honkinen M, Lahti E, Suedstrom E, Jarti T, Virki R, Peltola V, et al. Long term recovery after parapneumonioc empyema in children. Pediatr Pulmonol. 2013; doi:10.1002/p pul.22966 [E-pub ahead of print].

2. Satish B, Bunker M, Seddon P. Management of thoracic empyema: does the pleural thickening matter. Am J Resp Med. 2002;1:441-5.

3. Cohen E, Weinstein M, Fishman DN. Cost effectiveness of competing strategies for the treatment of peditric empyema. Pediatrics. 2008;129:1250-7.

4. Kelly MM, Shadman KA, Edmonson MB. Treatment trends and outcomes in US hospital stays of children with empyema. Pediatr Infect Dis J. 2013; doi: 10.1097/INF. 000000000000013 [E pub ahead of print].


 

Copyright 1999-2014 Indian Pediatrics