Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

Abstract

Purpose Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. Methods After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/μL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an α of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. Results At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy. Conclusions There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.

Increased paediatric hospitalizations for empyema in Australia after introduction of the 7-valent pneumococcal conjugate vaccine

“…29 A study in the United States yielded similar estimates. 30 Thus, the 35% increase in empyema admissions observed in Australia following the introduction of the PCV7 has brought an additional expenditure of US$ 126 160-194 220 per year to the Australian health-care system. On the other hand, the reduction in pneumonia admissions has saved the health system US$ 3.8 million-6.1 million annually (based on United Kingdom cost-analysis data for pneumonia admissions).…”

Fibrinolíticos no Tratamento de Derrames Pleurais Complicados

“…10,11 Sendo esta revisão de carácter retrospetivo com um número reduzido de doentes, e sem grupo de controlo, os resultados podem apenas comparar-se com outras séries.…”

“…9 À data da redação deste artigo, existem três estudos randomizados publicados que comparam a instilação intrapleural de fibrinolítico com a toracoscopia videoassistida (VATS), no tratamento de DPP complicados, na população pediátrica. [10][11][12] Os três concluem não haver diferenças estatisticamente significativas entre as opções terapêuticas no que diz respeito a duração de internamento, tempo de drenagem e taxa de falência terapêutica. [10][11][12] Este estudo foi realizado para avaliar e descrever os resultados da aplicação de um protocolo de utilização de fibrinolítico no tratamento de DPP complicado, nos doentes seguidos no nosso hospital.…”

Impact of fibrinolytics on the outcome of empyema in South African children

“…Two studies comparing fibrinolysis with VATS reported a fibrinolysis failure rate of 17% each. [19,20] Other prospective studies comparing fibrinolysis with normal saline or various doses of urokinase report fibrinolysis failure rates of 7 -24%. [7,8,21] A meta-analysis published in 2005 calculated the average failure rate of 64 empyema cases treated with primary fibrinolysis to be 9.3%.…”