The optimal management of paediatric empyema thoracis remains controversial
. The objective of the study was to analyse evolving experience in clinical
presentation, management, outcome and factors contributing to adverse morb
idity in thoracic empyema. Forty-seven patients presenting to a paediatric
surgical centre were studied in three consecutive 6-y periods during 1980-9
7 to compare any change in the pattern of disease influencing diagnosis and
management. Patients were categorized into two treatment groups: (i) conse
rvative management (antibiotics and/or tube thoracostomy) (ii) thoracotomy.
The median duration of illness prior to hospital admission was 10 d (range
1-42 d). Ultrasound was increasingly utilized in the diagnosis and staging
of empyema and played an important role in directing definitive management
. The presence of loculated pleural fluid determined the need for thoracoto
my. Sixteen of 20 patients (80%) who were initially treated with thoracocen
tesis or tube thoracostomy eventually needed thoracotomy. There was a posit
ive shift in management towards early thoracotomy resulting in prompt sympt
omatic recovery. Significant complications were noted in seven children who
had delayed thoracotomy. These included recurrent empyema with lung absces
s (n = 2), scoliosis (n = 2), restrictive lung disease in = i), bronchopleu
ral fistula (n = 1) and sympathetic pericardial effusion in = i). An unfavo
urable experience with delayed thoracotomy during the study period has led
us to adopt a more aggressive early operative approach to empyema thoracis.
The decision to undertake thoracotomy has been influenced by the ultrasoun
d findings of organized loculated pleural fluid. Delayed surgery was associ
ated with adverse outcome.
Whilst fibrinolytics and thoracoscopy:map provide attractive options for ea
rly empyema, thoracotomy can hasten patient recovery regardless of the Stag
e Of disease. Prospective randomized trials are required to assess the idea
l therapy for childhood empyema.