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Tubes, Scopes, or Scalpels: The Dilemma of Treating Empyema in Children. Jeffrey C. Pence, MD, FACS, FAAP Associate Professor of Surgery Division of Pediatric Surgery Children’s Medical Center Dayton, OH. Objectives.

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tubes scopes or scalpels the dilemma of treating empyema in children

Tubes, Scopes, or Scalpels:The Dilemma of Treating Empyemain Children

Jeffrey C. Pence, MD, FACS, FAAP

Associate Professor of Surgery

Division of Pediatric Surgery

Children’s Medical Center

Dayton, OH

  • Review the epidemiology and pathophysiology of parapneumonic effusion and empyema
  • Discuss the advent and application of video-assisted thoracoscopic surgery (VATS) in the treatment of pediatric empyema.
  • Offer discourse regarding the various treatment paradigms employed for pediatric empyema.
  • Suggest a standardized protocol for the multidisciplinary treatment of empyema at the Children’s Medical Center
  • Incidence of pneumonia in children ranges from 1.0 to 4.5 cases per 100 children per year
  • Approximately 0.6% of childhood pneumonias progress to empyema
  • Overall prevalence of empyema is estimated at 3.3 cases per 100,000 children
  • The prevalence of parapneumonicempyema has been increasing over the past decade despite the introduction of Prevnar in 2001 (Byington, et al, 2010)
    • 2001: 8.5/100,000 children
    • 2007: 12.5/100,000 children (p=0.006)
    • Ninety-eight percent were due to nonvaccineserotypes
    • Primarily due to serotypes 1, 3, 19A, and 7F
the pleural space
The Pleural Space
  • Continuous pleural circulation
  • Space between visceral and parietal pleural surfaces
  • Interspace volume of 0.3 mL/kg body weight
  • Balanced
    • Secretion: apical lymphatic channels
    • Absorption: basal lung and cardiac pleural lymphatic pores
  • Parenchymal disease evokes pleural inflammation
  • Immune cellular-mediated cytokine release
    • Increased vascular permeability
    • Increased pleural fluid production
    • Increased procoagulant activity
    • Decreased fibrinolysis
    • Decreased pleural resorption
  • Clinical sequelae
    • Parapneumonic effusion
    • Dyspnea
    • Fever
    • Pleuritic pain

Stage I

  • Exudative stage
  • Uncomplicated parapneumonic effusion
  • <7 days following parenchymal disease
  • Simple effusions
  • Sterile
  • Intervention for symptoms only

Stage II

  • Fibrinopurulent stage
  • Complicated parapneumonic effusion
  • 7-14 days following parenchymal disease
  • Fibrin deposition on pleural surfaces
  • Loculations
  • Potential colonization (empyema)
  • Therapeutic intervention generally required

Stage III

  • Organizing stage
  • >14 days following parenchymal disease
  • Dense fibrin deposition on pleural surfaces
  • Fibrosis
  • Potential lung entrapment
  • Therapeutic intervention generally required
goals of effective therapy
Goals of Effective Therapy
  • Break the proinflammatory cycle
  • Reestablish the pleural circulation
  • Reexpand the pulmonary parenchyma
  • Optimize parenchymal circulation
treatment modalities
Treatment Modalities
  • Antibiotics
  • Thoracentesis
  • Chest tube or pigtail catheter
  • Chest tube or pigtail catheter with fibrinolytic instillation
  • Thoracoscopy (VATS = Video-assisted Thoracic Surgery)
  • Thoracotomy/ Mini Thoracotomy
the treatment of empyema is controversial
The treatment of empyemais controversial.
  • Abundant data supporting the use of fibrinolysis in children to facilitate earlier resolution of empyema
  • Abundant data to support the utility of VATS as the optimal treatment modality in empyema
  • Retrospectiveinferences favor one treatment strategy over the other
  • As such, referring and treating physicians typically hold 1 of 2 opposing views
  • Treatment of empyema evokes both individual (experiencial) and institutional bias
first known reference to empyema
First Known Reference to Empyema

“As time goes on, the fever becomes more severe, coughing begins, the side begins to pain, the patient can not lie any more on the healthy side but on the diseased side, the feet and the eyes swell.”

Hippocrates, c. 400 BC (from de morbis, authenticity questioned by many authorities)

hippocratic succussion emypema necessitans and the first thoracotomy
Hippocratic SuccussionEmypemaNecessitans and the First Thoracotomy?

“When the fifteenth day after the rupture has appeared, prepare a warm bath, set him upon a stool, which is not wobbly, someone should hold his hands, then shake him by the shoulders and listen to see which side a noise is heard. And right at this place, preferably on the left – make an incision, then it produces death more rarely.”

the advent of video assisted thoracoscopic surgery vats for empyema in children
The Advent of Video-Assisted Thoracoscopic Surgery (VATS) for Empyema in Children
  • Dr. Bradley Rodgers first reports the utility of VATS for the treatment of empyema in children in 1993
  • 9 children (ages 2-16 years) treated from 1981 to 1992
  • All patients had failed chest tube drainage over 1-17 days
  • No postoperative complications
  • No need for further surgical intervention
  • VATS reduced the operative morbidity of open thoracotomy while hastening recovery

Kern JA and Rodgers BM, J PedSurg, 28 (9), 1993, pp 1128-1132



This extended retrospective study further affirms the efficacy of early VATS in the primary treatment of fibrinopurulent to organizing parapneumonic effusion in pediatric patients. These data support the expedient recognition, prompt referral, and effectual thoracoscopic drainage of advanced parapneumonic effusions for the purpose of optimizing clinical outcomes. The comparable efficacy of primary intrapleuralfibrinolytic therapy, not addressed herein, awaits further prospective study.


Comparison of Urokinase and Video-assisted ThoracoscopicSurgery for Treatment of Childhood Empyema

SamathaSonnappa, Gordon Cohen, Catherine M. Owens, Carin van Doorn, John Cairns, SanjaStanojevic, Martin J. Elliott, and Adam Jaffe´

Department of Respiratory Medicine, Department of Cardio-Thoracic Surgery, and Department of Radiology, Great Ormond Street Hospital

for Children NHS Trust; PortexAnaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health; and Department of Public

Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom

American Journal of Respiratory & Critical Care Medicine, v. 174 issue 2, 2006, p. 221-7

sonnappa et al 2006
Sonnappa, et al. (2006)

Study Design

  • Prospective randomized trial over 3 years
  • 60 children (30 per study arm)
  • Percutaneous drain with intrapleuralurokinase or VATS
  • Primary outcome measured number of hospital days following intervention
  • Secondary outcome measures were chest drain days, total hospital stay, failure rate, radiologic outcome at 6 months, and total treatment costs
sonnappa et al 200627
Sonnappa, et al. (2006)



Hospital days 6 (4-25) 6 (3-16) 0.31

Chest drain days -1 d 0.55

Total inpatient days 7 (4-25) 8 (4-17) 0.64

Failure rates 5 (16%) 5 (16%)

Abnormal CXR 18/20 21/24 0.27

Cost (median, USD) 6914 10146 <0.001

sonnappa et al 200628
Sonnappa, et al. (2006)



  • Chest drain dislodgement in 4 patients requiring reinsertion (prolonging hospitalization)
  • Five patients (16.6%) required secondary VATS for definitive therapy


  • Four patients (13%) required conversion to mini-thoracotomy
sonnappa et al 200629
Sonnappa, et al. (2006)


  • No difference in clinical outcome between intrapleuralurokinase and VATS for the treatment of childhood empyema
  • Urokinase is a more economical treatment option
  • Intrapleuralurokinase should be the primary treatment choice for the treatment of childhood empyema

Thoracoscopicdecorticationvstube thoracostomy with fibrinolysis for empyemain children: a prospective, randomized trial

Shawn D. St. Peter, KuojenTsao, Christopher Harrison, Mary Ann Jackson, Troy L. Spilde, Scott J. Keckler, Susan W. Sharp, Walter S. Andrews, George W. Holcomb III, Daniel J. Ostlie

Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA

Department of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO 64108, USA

Journal of Pediatric Surgery, 44, 2009, p. 106-111

st peter et al 2009
St. Peter et al. (2009)
  • Prospective randomized trial
  • March 2006 to November 2007
  • 36 children
  • Percutaneous drain with intrapleural recombinant human tissue plasminogen activator (tPA) or VATS
  • Primary end point measured length of postoperative hospitalization
  • Secondary clinical outcome variables
st peter et al 200932
St. Peter et al. (2009)


Clinical Outcomes VATS FibrinolysisP

(n = 18) (n = 18)

Length of posttherapy 6.9 ± 3.7 6.8 ± 2.9 .96

hospitalization (d)

Posttherapy days 2.3 ± 1.7 2.3 ± 2.1 .90

of O2 support

Days to afebrile after 3.1 ± 2.7 3.8 ± 2.9 .46


Analgesia doses 22.3 ± 28.5 21.4 ± 12.0 .90

Hospital charges (x1000) $11.7 ± $2.9 $7.6K ± $5.4 .02

st peter et al 200933
St. Peter, et al. (2009)


  • Three patients (16.6%) in the fibrinolysis group required VATS for definitive therapy
  • Two patients in VATS group required ventilator therapy post intervention
  • One patient in VATS group required temporary dialysis due to progressive sepsis
st peter et al 200934
St. Peter, et al. (2009)


  • No difference in days of hospitalization after intervention
  • Nodifference in oxygen requirement, days until afebrile, or analgesic requirements
  • VATS is associated with significantly higher charges
  • Fibrinolysis may pose less risk of clinical deterioration
  • tPA should be the primary treatment for childhood empyema

Proposed Algorithm



Parapneumonic effusion

Ultrasound (+/- decubitus x-rays)

Simple /free-flowing Complex/loculated

Symptomatic Asymptomatic Ultrasound-guided percutaneous catheter (PTC)

Thoracentesis Observe tPA (0.1 mg/kg/dose in 30 mL NS) IP q24 hr x 3

Symptomatic Asymptomatic

CT chest

Persistent pleural space disease