DISCUSSION
Our results show a remarkable difference in the use of pleural drainage in two comparable hospitals caring for similar pediatric populations with PPE/PE. Unexpectedly, LOS was longer in the center that performed pleural drainage more frequently. Differences in both the use of pleural drainage and LOS appeared to be independent of disease severity. In fact, LOS was also different in patients with PPE/PE−, none of whom required pleural drainage.
The only initial difference was that HA patients with PPE/PE+ were admitted earlier and transferred more frequently from peripheral hospitals, while HB patients spent more time with fever and oral antibiotics before hospital admission, and admissions originated more frequently from its own emergency department. These differences are possibly due to social and geographical factors, and we do not believe that they had a significant impact on the main outcome measures, given that the duration of fever and antibiotic treatment prior to admission to the tertiary hospital were similar between centers. The similar needs for oxygen therapy, mechanical ventilation, surgery, and the presence of pneumothorax also suggests that disease severity was comparable in the two centers. Pleural drainage was placed and managed in the PICU in HB, but not necessarily in HA, which explains the differences observed in the proportion of patients admitted to the PICU. The duration of antibiotic treatment was longer in HB, which probably contributed to the longer hospital stay.
The shorter duration of fever during hospitalization in HB patients might suggest that pleural drainage accelerates healing. However, fever was often intermittent and particularly difficult to account for retrospectively. Data on fever could have been recorded differently in the two hospitals, as suggested by the fact that its median duration was shorter in HB, including in the PPE/PE− patients who did not require drainage. On the other hand, when quantifying the total duration of fever from the onset of disease, before hospitalization, differences were only observed in PPE/PE+2 patients, who may have benefited most from pleural drainage. Therefore, differences in the duration of fever between the two centers should be interpreted with caution. Prolonged fever is common in patients with PPE/PE. Although it is often interpreted as a sign of treatment failure, it may also be due to underlying inflammation, prompting the addition of corticosteroids to the treatment 9-10.
In conclusion, this study adds weight to others 6-8,11suggesting that restricting the use of pleural drainage is safe and does not prolong LOS, which may be more conditioned by the routines at each center. Controlled studies are needed to identify patients who may benefit from the use of pleural drainage procedures, as many treatment decisions are heavily based on subjective interpretation of data and local habits.