Rational treatment of empyema in children

Hypothesis: Efficacious and cost-effective treatment of pediatric empyema c an be accomplished following a protocol based on its radiographic appearanc e. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and video-assisted thoracoscopic debridem ent (VATD). Design: Retrospective case series. Setting: Tertiary referral center. Results: From 1995 through 1999, 31 children were treated ranging in age fr om 11 months to 18 years (mean age, 5.1 years). Twenty seven (87.10%) under went TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed i n 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days: salvage VATD, 20.0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gastrointestinal bleeding (1 patient [3.2%]). There were no ana phylactic reactions or bleeding episodes due to urokinase. Two patients (7. 4%) treated with TTD and FT developed an air leak that resolved spontaneous ly. The mean hospital charges were $78832 (TTD with or without FT, $75450, salvage VATD, $107476; primary VATD, $69634). The procedural charges were h ighest for salvage VATD. Conclusions: Most cases of pediatric empyema can be treated by TTD with or without FT. This therapy is safe and effective for children with nascent di sease. Primary VATD is preferred in children with advanced disease. Cost-ef fectiveness could be further improved through bet ter prediction of those p atients likely to fail TTD and require salvage VATD. An algorithmic approac h based on findings from computed tomography or (better) ultrasonography of the chest may be the best way to make this distinction and rationalize car e.