Management of parapneumonic pleural effusion in children: Is there a role for corticosteroids when conventional nonsurgical management fails? A single‐center 15‐year experience

Abstract

Objective: Description of the use of corticosteroids for the management of parapneumonic pleural effusion in children.Methods: Retrospective single-center observational study of all children hospitalized with a diagnosis of parapneumonic pleural effusion during a 15-year period.Results: We documented 97 cases of parapneumonic effusion during the study period, with a median age (interquartile range [IQR]) of 43 (33-61) months. Most of the children benefited from an evacuation of the pleural effusion (89/97, 91.8%): 21 patients (21.6%) were treated with needle thoracocentesis only, while a chest tube was inserted in 68 children (70.1%). Thirty-two patients (33%) were treated with intrapleural fibrinolysis. Fifty-five children (56.7%) received corticosteroids for persistent fever. The median time (IQR) between hospital admission and initiation of corticosteroids was 5.5 (4-7) days. When corticosteroids were initiated, children had been febrile for 9 (IQR: 8-11) days. The fever ceased in a median (IQR) of 0 (0-1) day after corticosteroids initiation. Only one patient required a video-assisted thoracoscopy that was necessary for morphological reasons (morbid obesity). No children treated with corticosteroids required surgery. All children were discharged from hospital. The median (IQR) hospital length of stay was 11 (8-14) days, with no difference between children with and those without corticosteroids. Conclusion:Our findings indicate that corticosteroids may be a part of the therapeutic armamentarium for children with parapneumonic effusion when conventional nonsurgical management fails.

Management of parapneumonic pleural effusion and empyema in children: A tale of two cities

“…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. 10,11 In conclusion, this study adds weight to others [6][7][8]12 suggesting 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.…”

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema

“…However, the attenuation of the cytokine-triggered inflammatory process seems a reasonable approach as an adjunctive treatment. Thimmesch et al 29 analyzed 97 children with PPE/PE in a retrospective single-center observational study of whom 55 received methylprednisolone as a rescue therapy. Children receiving steroids had fewer chest tube insertions (62% vs. 81%, P = 0.041) but no differences were observed in total length of fever or hospital length of stay.…”

Inflammatory rebound and postinfectious inflammatory response in children with pleural infection: A single‐center retrospective study

“…The evidence available on children is scarce, leading to great heterogeneity in clinical practice. The modalities of the antibiotic therapy and the indications and modalities of drainage procedures (chest tube alone, video‐assisted thoracoscopy [VATS] or thoracotomy, with or without fibrinolysis) vary widely from one center to another 4–6 …”

“…However, in children, a randomized controlled trial of 60 patients with parapneumonic pleural effusion (only 22 with documented PI) showed that the addition of intravenous dexamethasone (0.25 mg/kg/dose) every 6 h over a period of 48 h reduced median recovery time (a clinical composite criterion including apyrexia and normal breathing) by 2.8 days) 21 . More recently, a Belgian center reported its experience of using corticosteroids as a rescue therapy when antibiotics and pleural drainage were considered a failure 6 . Among the 97 children with parapneumonic effusion (only 50 with documented PI), they used methylprednisolone (2 mg/kg/day) in 55 children after a median time (interquartile range [IQR]) of 5.5 (4−7) days after hospitalization.…”

“…The modalities of the antibiotic therapy and the indications and modalities of drainage procedures (chest tube alone, video-assisted thoracoscopy [VATS] or thoracotomy, with or without fibrinolysis) vary widely from one center to another. [4][5][6] While antibiotics and drainage procedures aim to control the infection, another aim of PI management may be to control the inflammation induced by the infection. Indeed, an intense neutrophilic inflammation of the pleura mediated by a number of cytokines such as interleukin (IL)-1, IL-6, IL-8, tumor necrosis factor (TNF)-a, and platelet activating factor of pleural fluid occurs in PI.…”