Empyema Thoracis in Children: A 5-Year Experience in a Tertiary Care Institute.

OBJECTIVE: Empyema thoracis (ET) in children is a disease of significant morbidity and mortality. In the event of failure to resolute following intercostal chest tube drainage (ICD), thoracotomy decortication (TDC) remains the treatment of choice. We have reviewed the outcome of management of 96 cases of ET with the intent to establish the scope of ICD as primary form of the management.
MATERIALS AND METHODS: This is a retrospective study of 96 patients of ET who were managed in pediatric surgery department over a period of 5 years (April 2013 - March 2018). Ninety-six patients at a single center met inclusion criteria for having ET and underwent ICD. We excluded the cases where video-assisted thoracoscopic surgery was provided as primary treatment. The patients were categorized into complicated and uncomplicated groups. Those with pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET were assigned as complicated group. There were two treatment groups: (I) those responded with ICD alone (II) those with ICD followed by TDC.
RESULTS: All 96 cases received ICD as primary management. There were 54 uncomplicated cases and 42 complicated cases. Out of 42 complicated cases, 26 patients recovered with ICD alone and 16 patients needed TDC. A total of 80 (83.33%) patients (54 uncomplicated ± 26 complicated) recovered with ICD alone. Significant complications were encountered in follow-up of patients who underwent delayed thoracotomy in the form of overriding of the ribs (n = 3) and postoperative air leak (n = 4). There was no mortality in our series.
CONCLUSION: Early initiation of management of ET with intercostal tube drainage is simple, safe, effective even in complicated cases, and has less complications. Thoracotomy with decortication should be reserved for ICD failure cases.

INTRODUCTION

Empyema thoracis (ET) is known since Hippocrates' time; nonetheless, incidence is still rising all over the world.[1] The disease can produce significant morbidity in children if inadequately treated. Treatment ranges from intravenous antibiotics, intercostal chest tube drainage (ICD), video-assisted thoracoscopic surgery (VATS) to thoracotomy decortication (TDC). Early initiation of intravenous antibiotics and ICD procedure promote smooth recovery and lung expansion in up to 86% of cases.[2] ICD with intravenous antibiotics may fail to clear the pus in loculated ET, bilateral empyema, thickened pleura, and chronic ET with lung trapping. Failed cases should be investigated promptly for planning of surgical intervention. Thus, close monitoring of the responses to ICD procedure is essential in the management of ET. The current study evaluates the treatment and outcome of 96 patients with ET highlighting the indications for TDC.

MATERIALS AND METHODS

We conducted a retrospective study of 96 children who received treatment for ET over a period of 5 years in the department of pediatric medicine and pediatric surgery in our institute. We included the patients who had clinicoradiological evidence of ET and received ICD as initial treatment procedure. In our study, indications for ICD were persistent fever inspite of parenteral antibiotic treatment more than 48 h or respiratory distress due to ET. We excluded the cases where primary VATS was done for the management of ET.

The age range of cohort was 0–12 years, youngest patient being –2 months and the oldest being 11 years [Table 1]. Thirty-six patients (37.5%) were below 2 years of age, 32 (33.3%) were between 3 and 5 years, and 28 (29.16) were above 5 years of age. In this study, male and female distribution was 58 and 38, respectively. Forty-eight (50%) patients had right-sided disease while forty-six patients (47.91%) had left-sided disease; two (2.08%) patients were suffering from bilateral disease. In sixty-five (67.7%) patients, fever was the predominant symptom while 31 (32.29%) patients had respiratory distress in addition to fever and chest pain.

Table 1

Clinicopathological spectrum of empyema thoracis in children (n=96)

Parameters	Subparameters	Number of cases (%)
Age	<2 years 36 patients
	Male	24 (25)
	Female	12 (12.5)
	2-5 years 32 patients
	Male	30 (31.25)
	Female	2 (2.08)
	>5 years 28 patients
	Male	26 (27.09)
	Female	2 (2.08)
Symptoms	Fever	54 (56.25)
	Respiratory distress	26 (27.08)
	Chest pain + respiratory distress	16 (16.67)
Site of involvement	Unilateral
	Left	46 (47.91)
	Right	48 (50)
	Bilateral	2 (2.09)
Duration of ICD (days)	<7	56 (58.33)
	>7	40 (41.67)
Pleural fluid color	Clear	5 (5.2)
	Reddish	20 (20.83)
	Straw	25 (26.04)
	Purulent	46 (47.92)
Pleural fluid growth	No growth	91 (94.8)
	GrowthAcinetobacter baumanniiStaphylococcus aureusStaphylococcus haemolyticusSphingomonas paucimobilisGram-negative bacilli	5 (5.2)
Complications of ICD (14 patients)	Accidental came out	1 (1.04)
	Displacement	2 (2.08)
	Blockage	8 (8.34)
	Kinking	2 (2.08)
	Pneumothorax	1 (1.04)
Failure	ICD (post-ICD needed decortication)	16 (16.66)
	Decortication	None

ICD: Intercostal chest drainage

After confirmation of ET by chest X-ray (CXR) and ultrasonography (USG), all patients underwent ICD placement under local anesthesia with needle aspiration beforehand. Depending on the pathology (loculated empyema in the same side or bilateral empyema), one or two ICDs were inserted. Immediately after the ICD placement, a CXR was performed to see the position of the ICD. After 24 h, clinical assessment of empyema resolution is done by resolution of fever, respiratory distress, and general wellbeing of the patients. In addition to that, a series of follow-up CXR were taken at 3, 5, and 7 days, according to need.

RESULTS

All 54 uncomplicated empyema patients responded to ICD alone while 26 patients with complicated empyema resolved with ICD alone. Complicated empyema category comprised patients with pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET. The mean age of the patient at ICD placement was 46.47 months and range 2–122 months. The average time of keeping the ICD was 8.66 days, range 3–19 days and the mean duration of keeping the ICD after thoracotomy was 10 days, range 5–14 days. There was no difficulty in placing or inadvertent removal of ICD in any patient. The culture of the aspirated pleural fluid was positive for Gm/acid-fast bacilli stain in 4 patients (4.16%).

Complications of ICD were seen in 14 patients (14.54%) in the form of pneumothorax 1 patient, displacement and/or kinking of the tube in 9 patients, and tube blockade due to thick pus in 4 patients. The mean duration of hospital stay was 5 days for ICD and 8 days for decortication. Redo ICD was needed in two cases. Out of 42 complicated cases, 16 patients did not improve satisfactorily with ICD procedure. They (7 patients with pyopneumothorax, 4 patients with encysted empyema, 4 patients with multiloculated empyema, and one patient with thickened pleura with trapped lung) underwent further investigation in the form of computed tomography (CT) followed by TDC [Table 2]. Out of these 16 patients of decortication, 4 patients had severe fibrosis where we encountered excessive bleeding while peeling the visceral pleura off. These patients required blood transfusion postoperatively. All patients of TDC were put under pressure support ventilation electively for the first 48 h in the postoperative period. Out of the decorticated group, three patients had overriding of the ribs and four patients had minimal air leak which resolved with time. All patients resumed full oral feeds by 3rd postoperative day. There were no major complications related to TDC or death in this series.

Table 2

Clinicoradiological profile of children underwent thoracic decortication (n=16)

n	Age	Sex	Duration of ICD before decortication (days)	CT findings	Indications	Complications
1	2 years	Male	10	(R) pyopneumothorax with collapse of lung	Nonfunctioning ICD persistent collection lung collapse	Overriding of the ribs
2	3 years	Male	5	(R) multiloculated ET, pleural thickening with lung collapse	Loculated ET not responding to ICD poor lung expansion	Nil
3	7 years	Female	21	(R) encysted ET upper zone with adjacent lung atelectasis	Nonfunctioning ICD encysted effusion poor lung expansion	Nil
4	1 month 15 days	Male	7	(L) pyopneumothorax with collapse and consolidation of lung	Referred from rural health center due to poorly resolved postpneumonic ET lung collapse	Air leak in PO period resolved with ICD
5	2 months	Female	14	(L) pyopneumothorax with encysted collection	Partially expanded lung encysted collection	Nil
6	10 months	Male	5	Thickened pleura with (L) trapped lung	Persistent respiratory distress nonfunctioning ICD poor lung expansion	Overriding of ribs
7	4 years 6 months	Male	11	(R) multiloculated thick-walled cystic SOL in the lung	Persistent fever due to lung abscess nonfunctioning ICD	Bleeding and air leak in PO period resolved within 5 days
8	6 months	Male	5	(L) pyopneumothorax, lung collapse, and contralateral mediastinal shifting	Nonfunctioning ICD poor lung expansion lung collapse and mediastinal shift	Nil
9	4 years	Male	10	Large multiloculated thick-walled cystic area in the (R) lung	Persistent fever nonfunctional ICD multiloculated ET	Air leak on PO period resolved with ICD
10	2 years	Male	6	Collapse (R) lung with encysted collection	Nonfunctioning ICD poor lung expansion poor air entry	Nil
11	11 months	Male	5	Thickened pleura with encysted collection in the (R) lung	Persistent respiratory distress nonfunctional ICD poor lung expansion	Nil
12	3 years	Male	6	(R) multiloculated ET	Nonfunctioning ICD poor lung expansion loculated collection	Air leak in PO period overriding of ribs
13	2 months	Male	10	Pyopneumothorax (L) lung	Persistent fever and respiratory distress nonfunctional ICD	Bleeding and air leak
14	7 months	Male		(L) pyopneumothorax, lung collapse, and mediastinal shifting	Nonfunctioning ICD poor lung expansion lung collapse and mediastinal shift	Nil
15	6 years	Female	18	(R) encysted pleural effusion with lung atelectasis	Nonfunctioning ICD poor lung expansion encysted collection	Nil
16	4 months	Female	12	(L) pyopneumothorax	Persistent fever nonfunctioning ICD partially expanded lung	Nil

ICD: Intercostal drainage, ET: Empyema thoracis, CT: Computed tomographic, PO: Post-Operative, SOL: Space occupying lesion

DISCUSSION

ET is defined as “pus in the chest” or presence of microorganism in the pleural fluid. Overall, 0.6% of childhood pneumonias are complicated by parapneumonic effusion which may progress to ET. It predominantly involves in the right lung and 7.1% are bilateral.[3] In developing countries, more than one-fourth of hospital-admitted patients with pneumonia eventually develop parapneumonic effusion or empyema because of delayed initiation of adequate treatment. Traumatic hemopneumothorax may progress to ET following an infection with antibiotic-resistant organisms or associated with comorbid conditions (malnutrition, immunocompromised).[4]

The course of parapneumonic effusion has been described in three stages; exudative, fibropurulent, and organized. This classification is for better understanding of pathophysiological progression of the disease. Specific management strategies according to the stages are not described clearly in English literature.[5] In exudative stage (Stage I), the effusion sprawl in the pleural space. In fibropurulent stage (Stage II), the effusion becomes stickier and pleural surfaces become thickened due to fibrin deposition. At times, the pleural surfaces adhere to each other by fibrous septae culminating into loculated effusion. Usually, loculated effusion develops within 7–10 days from the onset of the parapneumonic effusion. This fibropurulent stage may last several weeks after which there is fibrosis in the pleural surfaces, resulting in an inelastic covering of the lung, the stage of organization (Stage III).[6] There is restriction of movement of the chest wall and diaphragm with crowding of the ribs.

The prime aim of treating ET is to restore the lung function. Several studies concluded that Stage I and II disease can safely be managed by antibiotics and ICD with or without fibrinolysis therapy/antiseptic lavage-irrigation of the chest tube[78] while Stage III and IV disease require surgical intervention.[9] Frank purulent or turbid pleural fluid on needle aspiration signifies early stage (I/II) of the disease which required prompt ICD. Other criteria of ICD procedure are pH <7.2 in pleural aspirate, isolation of organisms in the pleural aspirate by Gram stain and/or culture, huge nonpurulent pleural collection (for symptomatic relief), and loculated collection.[10] Satish et al. conducted a study with ICD procedure in the treatment of ET in children in a secondary-level care center and showed clinicoradiological improvement in all (100%) cases. The average duration of keeping ICD was 8 days with a median hospital stay of 14 days (maximum stay 28 days).[11] Stephen et al., Magnate et al., and Chan et al. showed the success rate as 45%, 93.22%, and 82%, respectively.[1213] In our study, ICD procedure was successful in 83.33% cases (56.96% uncomplicated group and 26.36% complicated group) with average duration of keeping the ICD – 8.66 days, range 3–19 days which is comparable to contemporary studies [Figure 1]. Theoretically, the outcome of ICD procedure depends on the initial demographic profile of the patients. A new scoring system, depending on the clinical features, laboratory findings, and initial radiographic pictures, has been evolved to predict the outcome of conservative management of ET[14] However, a few mechanical factors such as wrong position of tube, inappropriate size of tube, underutilization of vacuum suction, and unproductive breathing exercise may be the hidden causes of treatment failure with ICD.[15] In our study, 50% of ICD failure cases had loculated collection with pleural thickening. In developing countries, majority of the patients come in advanced stage with loculations where initial needle aspiration is dry. USG-guided aspiration/ICD with administration of streptokinase may be helpful in such situation.[1617] Fibrinolytic therapy is not recommended universally as the exact timing of administration for breaking septae and definite role in controlling of pleural sepsis are not clear.[18] CT chest should be done to get detailed information regarding the pleural thickening, trapped lung, endobronchial obstruction, and mediastinal pathology.[1920] However, we observed that CT chest is not obligatory in all cases. It was done in failure cases with ICD procedure for planning of further intervention. Nowadays, many centers have adopted thoracoscopic intervention instead of ICD ± fibrinolytic therapy for the treatment of Stage I and II empyema. A combination of thoracoscopy and fibrinolytic therapy reduces the requirements of open decortication.[21] However, thoracoscopic intervention is not appropriate in many of the chronic empyema (Stage III/IV) or in ICD failure cases.[2223] A few surgeons prefer thoracoscopic decortication over open decortication. Open decortication has plenty of perioperative complications such as persistent air leaks, excessive bleeding, and sepsis. These are directly related to the chronicity of the disease. Thus, early decision of TDC definitely reduces the major perioperative complications as well as morbidity and mortality.[24] Rib crowding occurs early in the course of empyema. Resection of one or two ribs provides a wide window for proper pleural toileting under supervision, easy collection of pleural tissue for biopsy and proper placement of adequately sized chest tube. In our series, rib resection was done in one case because of thick pus [Figure 2]. Although our study had a limited number of cases (n = 96), we infer TDC as the answer in chronic empyema/ICD failure cases. Open decortication still remains the best method. Moreover, decision for the TDC should be taken early considering the etiology of empyema (i.e., primary versus secondary), general condition of the patient, and stage of disease.[25]

Figure 1

(a) X-rays of a patient with (r) empyema thoracis (before and 72 h of intercostal drainage). (b) X-rays (before and 72 h of intercostal chest tube drainage procedure) in a patient with loculated (r) empyema thoracis where two drains were placed in the same side

Figure 2

Pictures of computed tomography of chest and intra-operative photographs showing loculated empyema, thoracotomy incision with pathology, lung after decortication, specimen of thick pus, and excised rib in one of the intercostal chest tube drainage failure patients

CONCLUSION

As far as our small series is concerned, ICD procedure is the most important therapeutic procedure in the management of ET cases. It is also successful in majority of the complicated ET cases. Proper timing, correct techniques, and positioning of the ICD ensure a very good functional outcome with high patient satisfaction.

CT chest is warranted where needle aspiration is dry or in the ICD failure cases for planning of TDC. Considering our result and recent literatures, we vouch that specific approaches based on institutional practice and available resources always have a positive impact in the management of ET.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.