|
|
|
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].
|
|
|
 |
|
