Recommended management of pediatric parapneumonic
effusions
The treatment of choice for parapneumonic effusion in children remains a
matter of controversy in the literature and in clinical practice, and
the management of this disease remains largely center dependent14.
All children with parapneumonic effusion should be admitted to the
hospital 8. The majority of the children included in
our study were hospitalized in PICU / middle care. However, contrary to
adult empyema, parapneumonic effusions in childhood are associated with
a low mortality and the vast majority of children recover completely15. The high admission rate to PICU in our cohort is
explained by our admission policies rather than by the severity of the
disease.
Although it has been reported than approximately 20 to 50% of the
parapneumonic effusions can be treated with intravenous antibiotics
alone, there is some evidence that early evacuation of the pleural
effusion may be beneficial 16,17. The role of needle
thoracocentesis in the management of pediatric parapneumonic effusions
remains unclear, and some advocate that it should be reserved for cases
where non-infective causes of parapneumonic effusions are being
considered 15. However, needle aspirations have
advantages: it less invasive than a chest tube, it is relatively easy
and safe to perform in older children who can tolerate the procedure
with a local anesthetic and sedation, and the sample collected via this
minimally invasive procedure can be analyzed for diagnostic
clarifications. Therefore, a single simple needle thoracocentesis may be
considered for the management of some free-flowing parapneumonic
effusion. However, repeated taps are not recommended, and a drain should
be inserted once it is clear a second tap is required; moreover, chest
tube is recommended over simple thoracocentesis for loculated and/or
purulent effusions 8,9. In our cohort, one fifth
(21.6%) of the children were successfully managed with simple needle
thoracocentesis, confirming that this less-invasive strategy may be
appropriate for selected cases.
In a large cohort study including 14225 pediatric empyema-related
hospital discharges aiming to describe trends in the number and type of
empyema-related procedures in the United States between 2008 and 2014,
there was an increase in the proportions of patients coded for chest
tube placement as the only procedure (from 14.6% to 20.9%), for 2
chest tube procedures (from 0.9% to 3.5%), and for chest tube
placement as part of their management along with other therapeutic
strategies (from 24.8% to 30.6%) 18. In another
cohort of 192 Australian children with a diagnosis of empyema, 174
(90.6%) were managed by primary chest drainage, among which 49 (28.1%)
required subsequent VATS. In this study, the authors failed to identify
risk markers of VATS at the time of insertion of the primary chest tube,
which highlights the difficulties in identifying patients at risk of
drainage failure. They observed, however, that each day of fever after
the chest tube insertion was associated with an increased risk of VATS19. Our results are within the range suggested by
these 2 recent studies: 70.1% of the children included in our study
were managed with a chest tube. Such discrepancies between the reported
proportion of primary chest drainage may be explained by differences in
patient characteristics, as well as differences in management strategies
since the priority of the available therapeutic interventions is not
clearly defined.
Pediatric data on intrapleural fibrinolysis are scarce, but indicate
that instillation of a fibrinolytic agent through the chest tube may be
of interest by reducing the hospital length of stay20. Therefore, intrapleural fibrinolysis is
recommended for parapneumonic effusions of thick fluid with loculations
and/or empyema (overt pus) 8. The agent, dosage,
concentration, dwell time, interval and total doses have not been proven
with comparative data and are subject for future investigation9. In our cohort, only 32/68 (47.1%) of the children
with a chest tube received intrapleural fibrinolysis, while fibrin was
found in the pleural ultrasound of 77.7% of the children and while the
median leucocyte count (IQR) of 6.8 (1.5-21.1) x
103/mm3 indicates that most of the
effusions were purulent. Our practice is thus not totally in accordance
with the aforementioned recommendation, maybe because the level of
evidence for this recommendation is weak.
Primary VATS is associated with good clinical outcomes and low rates of
reintervention 19. A recent meta-analysis suggested
that VATS may be associated with a lower reintervention rate and shorter
post-procedural length of stay than primary chest tube and fibrinolysis7. However, the level of evidence is low, and the
authors of this meta-analysis acknowledge that chest drainage with
fibrinolysis may be effective in more than 75% of cases. Furthermore,
VATS require minimally invasive surgery expertise which is not routinely
available. The place of VATS in the management of parapneumonic
effusions in children is thus not clearly defined. In our cohort, only 1
child (1% of the whole cohort) was treated with VATS. This only VATS
was required because insertion of a chest tube at the bedside was
technically challenging (morbid obesity). No child received VATS because
of a failure of non-surgical management. This proportion of children
requiring surgery is remarkably low, considering that others have
reported that the need for surgical rescue interventions for
parapneumonic empyema in children remained as high as 20%21. Our finding is probably explained by the use of
corticosteroids if chest drainage was deemed not possible
(multiloculated effusion not drainable) or as soon as chest drainage was
considered a failure (persisting fever).