Management of Empyema Thoracis in

Children: Tube Thoracostomy Versus

Early Decortication
Empiema toraks merupakan keadaan yang sering terjadi akibat komplikasi tindakan pembedahan
dari pneumonia. Hal ini merupakaan keadaan yang sangat mempengaruhi morbiditas pediatric.
Berbagai cara pengobatan telah dijabarkan untuk mengatasi kondisi tersebut. Namun,
pengobatan untuk tatalaksana empiema thorakis pada anak masih merupakan perdebatan. Angka
kejadian empiema toraks terus meningkat sehingga memiliki angka mortalitas yang tinggi (1016%). Hal ini terjadi saat bakteri menginvasi dan menyebar ke dalam rongga pleura yang normal.
Proses ini terjadi dalam tiga fase. Fase ekseduatif disebabkan oleh peingkatan permeabilitas
inflamasi pleura. Fase firbunopurulen ditandai dengan peningkatan pengendapan fibrin, yang
mengakibatkan lokulasi dan akumulasi pus. Fase organisasi dimulai satu minggu yang ditandai
dengan terjadinya pembentukan kulit fibrinosa pada membran pleura, membentuk jaringan yang
mencegah ekspansi pleura dan membentuk lokulasi intrapleura yang menghalangi jalannya tuba
torakostomi untuk drainase. Kulit pleura yang kental terbentuk dari resorpsi cairan dan
merupakan hasil dari proliferasi fibroblas. Parenkim paru menjadi terperangkap dan terjadi
pembentukan fibrotoraks. Bakteri utama yang menyababkan antara lain staphylococcus,
streptococcus, dan mycoplasma.
Pneumonia bacterial merupakan penyebab terbanyak dari empiema toraks pada pasien anak.
Terdapat beberapa pilihan pengobatan namun sayangnya hasil dari beberapa tes regimen sangat
bervariasi. Bagaimanapun, alternative pengobatan empiema tanpa operasi
There are many treatment options but unfortunately
results with these treatment regimens have been
highly variable. As a result, the optimum therapeutic
strategy for empyema has yet to be elucidated.
Moreover, the availability of non-operative
alternatives frequently results in delayed surgical
consultation, and ultimately, increased patient
morbidity and mortality.8,9,10 Determination of the
stage of the empyema has been reported to be
crucial in choosing an appropriate therapeutic option.
Duration of symptoms has been suggested as one
of the means of estimating the stage of the
empyema.9
In complicated para-pneumonic effusion, both serial

thoracentesis and chest tube drainage can be

advocated as a first-line therapy. There have been
some reports of the effectiveness of this procedure
after early diagnosis.11,12 Tube drainage is
recommended in children because of its reliability,
rather than multiple thoracentesis.13 Pleural lavage
via the chest tube is useful for augmenting drainage
and mechanical clearance and various antimicrobial
agents can be added to the washing fluid.8,11 LeMense
et al14 have suggested that this decreases the severity
of pleural sepsis while instituting further therapy.
We have not used any agent for lavage purposes
after chest tube placement.
Because of the low reported success rate of tube
thoracostomy for loculated empyema, alternative
approaches have been developed. Intrapleural
fibrinolytic agents (IPFA) have been used in the
treatment of thoracic empyema.15 Several reports
have documented successful drainage of multiloculated
empyema using streptokinase and
urokinase.13,16 Temes17 used IPFA in all 26 patients
sent for decortication. More than two-thirds of patients
with traditional indication for decortication for
empyema thoracis were treated successfully. We
have no experience of using this mode of treatment
which appears feasible in early stages of the disease.
The presence of a thick rind with trapped lung are
indications for operation and decortication.8,11,14 The
inability to evacuate fibrinous debris via chest tube
is also an indication for decortication. Decortication
should be performed as soon as possible if drainage
is not effective. It may be an initial treatment instead
of wasting time by performing tube thoracostomy.
When the patient's status is suitable for surgery, we
recommend this approach because of the decrease
in mortality and morbidity, reduction of hospital stay,
and discharge of the patient without an open wound.
Postoperative complications such as atelectasis and
delayed expansion are mainly from parenchymal
disease. The results of our study are comparable to
that of Brohi et al18 but are somewhat different from
that of Light et al.10
5. Majid F, Zubair M. Management of empyema thoracis in children: tube thoracostomy versus
early decortication. Journal of Surgery Pakistan (International). 2011

Management of Postpneumonic Empyemas in Children

Parapneumonic effusion is any pleural effusion secondary
to pneumonia (bacterial or viral) or lung abscess.
Approximately 0.6% of childhood cases of pneumonia
are complicated by the formation of pleural empyema.
The incidence of empyema ranges from 4 to 6 per
100,000 children (1). It is recommended that a stepwise
approach be taken with patients with parapneumonic
effusions. The treatment options are observation, therapeutic
thoracentesis, tube thoracostomy, tube thoracostomy
with intrapleural fibrinolytics, thoracoscopy and
thoracotomy with decortication, and open drainage
procedures. Unfortunately, results with these treatment
regimens have been highly variable (2, 3). The aim of
this study was to assess different treatment options in the
management of postpneumonic pediatric empyemas.
Discussion
Low socio-economic level, delay in diagnosis of
pneumonia,
unsuitable antibiotic treatment, immunodeficiency
and malnutrition are contributing factors to the development
of empyema in patients with pneumonia.
Bacterial pneumonia is the most common cause of
pleural effusions or empyema in the pediatric age
group (2, 3). The treatment of empyema in children still
remains controversial. However, the treatment objectives
outlined by MAYO (5) are 1) to save life, 2) to eliminate
the empyema, 3) to re-expand the trapped lung,
4) to restore mobility to the chest wall and diaphragm,
5) to return the respiratory function to normal, 6) to
eliminate complications or chronicity, and 7) to reduce
the duration of hospital stay.
The reported rate of identifying an infectious organism
from pleural fluid varies markedly, from 8% to 76%.
However, in present day practice, pleural fluid culture is
often negative due to use of antibiotics before obtaining
a pleural fluid sample (6). In our study, pleural fluid cultures
were positive in 49.55% of the patients. As in many
other studies (1, 3, 6, 7) the most frequently identified
micro-organism in our study was Staphylococcus
aureus.
Chest tube thoracostomy is considered to be the

appropriate treatment modality for stage II thoracic

empyema (especially for non-multiloculated cases). The
British Thoracic Society recommends that all patients
with significant pleural infection should be treated with
antibiotics and drainage of the pleural fluid (6). In many
studies the rate of success of chest tube thoracostomy
was reported as being between 61% and 100% (8-12).
Chest tube thoracostomy rate of success was 89.9% in
our study. Although chest tube thoracostomy is a treatment
with a high rate of success, the hospital stay is
long. This period is reported to be approximately 8-14
days (range 3-35 days) in the literature (8-10, 12, 13).
Likewise in the present study, the duration of hospital
stay in group I was 11.46 3.79 days (range 6-22 days).
The hospital stay and chest tube removal time in group I
was a little longer than in group II, however there was no
statistically significant difference between the two
groups (P = 0.040, P = 0 .019 respectively).
We applied fibrinolytic treatment with chest tube thoracostomy
to patients in whom multiloculation was
found by US and CT. Intrapleural fibrinolytic drugs may
lyse the fibrinous strands in loculated empyemas.
Several reports have documented successful drainage of
multiloculated empyema using streptokinase and urokinase
(11, 14-17). However, MASKELL and associates (18)
reported that (multi-centre, randomised, double-blind
study) there was no benefit from streptokinase in terms
of mortality, rate of surgery, radiographic outcomes, or
duration of the hospital stay. Moreover BALCI et al. (7)
have concluded that fibrinolytic treatment is not an alternative
to surgery, especially in loculated empyemas in
children. We have performed tube thoracostomy with
intrapleural fibrinolytic treatment on 22 patients. Nine
(40.9%) of them were successful and 13 (59.1%), on
whom treatment was unsuccessful, underwent decortication.
Both BALCI et al. (7) and MASKELL and associates
(18) agreed that fibrinolytic treatment does not
reduce hospital stay or the need for surgery.
Video-assisted thoracoscopic surgery (VATS)
achieves debridement of fibrinous pyogenic material,
breakdown of loculations, and drainage of pus from the
pleural cavity under direct vision. Many authors have
reported that VATS can be performed safely and effectively
in children with stage II empyema. In addition,
VATS was associated with a lower mortality rate, lower
open surgery rate, shorter hospital stay, and chest tube

drainage, compared with non-operative treatment (1, 2,

11, 18, 19). Unfortunately we do not have any experience
with VATS.
Decortication has to be performed on patients where
conservative treatment is radiologically and clinically
proven to be insufficient. We applied decortication on 19
of our patients (9 of group I and 10 of group II patients)
who did not show clinical recovery and who had thick
pleural peel with trapped lung and multiple loculations
at control CT. The chest tube removal time was 5.00
2.43 days and hospital stay was 6.32 2.54 days in
group III. Both OZCELIK and associates (3) and POTHULA
et al. (20) have reported that decortication decreases
chest tube drainage and hospital stay. In addition, decortication
has low morbidity and mortality rates (3, 7, 20).

Dapus
3. OZCELIK C., LK R., ONAT S., OZCELIK Z., INCI I., SATICI O.
Management of postpneumonic empyemas in children. Eur J
Cardiothorac Surg, 2004, 25 : 1072-1078.
BALCI A. E., EREN S., LK R., EREN M. N. Management of multiloculated
empyema thoracis in children : thoracotomy versus
fibrinolytic treatment. Eur J Cardiothorac Surg, 2002, 22 : 595598.
7.

A. Kosar, M.D.
Sureyyapasa Chest Disease and Chest Surgery Training and Research
Hospital
Department of Thoracic Surgery
Ataturk cad. Murat Apt. 46/16
34734 Erenkoy, Istanbul, Turkey
Tel. : + 90 216 386 35 90
Fax : + 90 216 459 68 59
E-mail : altugkosar@yahoo.com

The Changing Face of Pleural Empyemas in Children:

Epidemiology
and Management
L. Kaplan and Mary L. Brandt
Karen D. Schultz, Leland L. Fan, Jay Pinsky, Lyssa Ochoa, E. O'Brian Smith, Sheldon
Pediatrics 2004;113;1735
journal of the American Academy of Pediatrics

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