Treatment of pleural effusions and empyema: chest tubes, fibrinolytics, and VATS

Israel EN, Blackmer AB. Tissue plasminogen activator for the treatment of parapneumonic effusions in pediatric patients. Pharmacotherapy. 2014 Jan 4. [Epub ahead of print]

“Intrapleural fibrinolysis has been investigated for the treatment of pleural effusion for several decades. Fibrinolytics have the ability to break up fibrin and loculations that characterize complicated pleural effusions, facilitating drainage. Older fibrinolytics such as urokinase and streptokinase have been replaced by tissue plasminogen activator (tPA) for this indication due to product availability and a more favorable safety profile. The literature supports tPA as a treatment approach for this indication in adult patients, and the use of tPA has become a standard management approach in this population. Over the past decade, data on the efficacy of intrapleural fibrinolytic therapy in children have also been generated, which now support the use of fibrinolysis as a treatment alternative to more invasive therapeutic options such as surgical intervention. In this review, we discuss the pathophysiology, diagnosis, and treatment of parapneumonic effusion and empyema, with a focus on intrapleural fibrinolysis, specifically tissue plasminogen activator, in the pediatric population. Recent articles provide sufficient evidence to support the use of this drug in pediatric patients for the management of pleural effusions; however, due to study heterogeneity, questions remain that may be addressed in future studies.”

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Kelly MM, Shadman KA, Edmonson MB. Treatment trends and outcomes in U.S. hospital stays of children with empyema. Pediatr Infect Dis J. 2013 Dec 18. [Epub ahead of print]

“In conclusion, this population-based analysis demonstrates a strong (and increasing) tendency towards procedural management in hospital stays in children with empyema in the U.S. VATS became the most commonly performed drainage procedure during 2009, and discharges coded for VATS are associated with lower transfer-out rates but no statistically significant reduction in LOS after accounting for patient and hospital factors. Results of our populationbased study are consistent with recently published practice guidelines [19] and recommendations [20] that endorse chest tube drainage as an acceptable first treatment option for most children with empyema.”

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Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg. 2012 Nov;47(11):2101-10.

“The timing of intervention, by fibrinolysis or VATS, is an important consideration in the treatment of empyema. A retrospective series in children with empyema documented that VATS performed within 48 hours of diagnosis reduced hospital stay by 4 days on average [14]. Another retrospective study showed a delay between diagnosis and surgery of more than 4 days was significantly correlated with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications [66]. Similarly, a retrospective comparison in adults found that patients with empyema have a more efficient course if treated with primary VATS compared tube thoracostomy alone with VATS reserved for failure [67]. In a prospective trial of 18 children with empyema, 10 patients who underwent VATS upon diagnosis were compared to 8 initially managed with chest tube drainage [38]. Of those initially managed nonoperatively, the effusion failed to resolve in 7 patients who were then treated successfully with instillation of tPA into the chest tube for up to 5 days. The protracted staggered pathway resulted in an extra week in the hospital for the patients treated initially with tube thoracostomy compared to those treated with definitive mechanical debridement upon diagnosis. This study underscores the importance of definitive management upon diagnosis of empyema without an initial attempt of chest tube drainage alone.”

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Paraskakis E, Vergadi E, Chatzimichael A, Bouros D. Current evidence for the management of paediatric parapneumonic effusions. Curr Med Res Opin. 2012 Jul;28(7):1179-92.

“A literature search of randomized and retrospective studies that pinpoint methods of evaluation and treatment of PPE was carried out in Medline and Scopus databases. Chest X-ray, ultrasound as well as microbiology and biochemical characteristics of the pleural fluid will facilitate decision-making. Small uncomplicated effusions resolve with antibiotics alone, larger ones require small-bore chest tube drainage and in case of complicated loculated PPE, fibrinolysis or VATS should be considered. Both methods promote faster drainage, reduce hospital stay and obviate the need for further interventions when used as first-line approach. However, primary treatment with VATS is not advised by the majority of studies as a first choice intervention, unless medical treatment has failed.”

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Shah SS, Hall M, Newland JG, et al. Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood. J Hosp Med. 2011 May;6(5):256-63.

“In conclusion, emphasis on evidence driven treatment to optimize care has led to an increasing examination of unwarranted practice variation.42 The lack of evidence for best practice makes it difficult to define ‘unwarranted’ variation in the treatment of complicated pneumonia. Our study demonstrates the large variability in practice and raises additional questions regarding the optimal drainage strategies. Published randomized trials have focused on comparisons between chest tube placement with fibrinolysis and VATS. However, our data suggest that future randomized trials should include chest tube placement without fibrinolysis as a treatment strategy. In determining the current best treatment for patients with complicated pneumonia, a clinician must weigh the impact of needing an additional procedure in approximately one-quarter of patients undergoing initial chest tube placement (with or without fibrinolysis) with the risks of general anesthesia and readmission in patients undergoing initial VATS.”

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McBride SC. Management of parapneumonic effusions in pediatrics: current practice. J Hosp Med. 2008 May;3(3):263-70.

“Pneumonia with associated complex pleural disease is a cause of significant morbidity among hospitalized children. The management of this patient population continues to be a challenge and varies even among single institutions. The article presented here reviews the management goals for pediatric patients hospitalized with complex parapneumonic effusions and provides updated summaries of both medical and surgical therapies.”

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Hampson C, Lemos JA, Klein JS. Diagnosis and management of parapneumonic effusions. Semin Respir Crit Care Med. 2008 Aug;29(4):414-26.

“Parapneumonic effusions affect many patients and are associated with considerable morbidity and mortality. It is necessary to differentiate complicated effusions requiring intervention from uncomplicated effusions. Differentiation is achieved using clinical, pleural fluid, and imaging parameters. Intervention takes the form of blind catheter placement and drainage, image-guided catheter placement and drainage, and surgical decortication [video-assisted thoracoscopic surgery (VATS) or open thoracotomy]. Image-guided drainage and management of complicated effusions in adults and pediatric patients are safe and highly effective in select patients. The use of intrapleural fibrinolytic agents to facilitate resolution of complicated effusions is widespread and considered effective by many despite a lack of conclusive data supporting this method. We propose an algorithmic approach to patients with parapneumonic effusions and advocate image-guided drainage and management in patients likely to benefit from this treatment.”

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Cremonesini D, Thomson AH. How should we manage empyema: antibiotics alone, fibrinolytics, or primary video-assisted thoracoscopic surgery (VATS)? Semin Respir Crit Care Med. 2007 Jun;28(3):322-32.

“Empyema is a well-recognized complication of pneumonia and its prevalence is increasing in the childhood population. The management of these patients requires a strategy for diagnosis and treatment that results in prompt resolution of infection and discharge with minimal morbidity. Traditionally conservative treatment has been the standard with insertion of a chest drain and intravenous antibiotics and, for those who fail to respond, an open thoracotomy and formal decortication. Since the 1990s two new treatment modalities have been described; fibrinolysis (promoting pleural drainage and circulation) and early VATS (video-assisted thoracoscopic surgery). Many institutions are now using one of these methods as first-line therapy. Both of these treatments result in shorter hospital stay and fewer complications than the conservative approach. In this review we will appraise the evidence for all three treatments and consider which treatment is optimal in children.”

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More PubMed results on treatment of pleural effusions and empyema.

Created 01/28/14; reviewed 08/18/15 – new articles added to PubMed collection. 

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