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ORIGINAL ARTICLE Table of Contents   
Year : 2014  |  Volume : 11  |  Issue : 3  |  Page : 206-210
Empyema thoracis in children: Still a challenge in developing countries


1 Department of Surgery, G.G.G.S. Medical College, Faridkot, Punjab, India
2 Department of Anaesthesia, G.G.G.S. Medical College, Faridkot, Punjab, India
3 Department of Surgery and Paediatric, G.G.G.S. Medical College, Faridkot, Punjab, India
4 Department of Paediatric, G.G.G.S. Medical College, Faridkot, Punjab, India

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Date of Web Publication22-Jul-2014
 

   Abstract 

Background: To evaluate the effectiveness of surgical intervention in managing empyema thoracis in children. Patients and Methods: A total of 70 patients aged 1-14 years diagnosed to have empyema thoracis and who underwent tube thoracostomy from January 2010 to December 2013 were studied. All patients of which 12 patients needed decortication. Results: The mean age of the study group was 5.44 years and 48.6% were male and 51.4% were female. The most common symptoms at admission were fever (90%), dyspnoea (73%), cough (70%) and chest pain (23%). Pleural fluid cultures were sterile in 60% of patients. The most frequently identified micro-organisms was Staphylococcus aureus (34.2%). Treatment with chest tube drainage was successful in 55 (78.6%) patients. Three patients got expired. Twelve patients had decortications, all of which were successful. The lung re-expansion time was 8.00 ± 1.68 days (range: 5-13 days) in those patients in whom chest tube drainage was successful, whereas it was 7.50 ± 2.623 days (range: 4-14 days) in patients in whom decortication was done. The post-procedure stay was 10.00 ± 1.809 days (range: 7-15 days) in patients with successful chest tube drainage and 9.5 ± 2.902 days (range: 6-17 days) in case of decortication cases. Conclusion: Tube thoracostomy should be done in all cases of empyema thoracis regardless of stage, as this leads to reduction in septic load. Decision of decortication should be taken without any delay.

Keywords: Decortication, empyema thoracis, tube thoracostomy

How to cite this article:
Goyal V, Kumar A, Gupta M, Sandhu HP, Dhir S. Empyema thoracis in children: Still a challenge in developing countries. Afr J Paediatr Surg 2014;11:206-10

How to cite this URL:
Goyal V, Kumar A, Gupta M, Sandhu HP, Dhir S. Empyema thoracis in children: Still a challenge in developing countries. Afr J Paediatr Surg [serial online] 2014 [cited 2019 Sep 22];11:206-10. Available from: http://www.afrjpaedsurg.org/text.asp?2014/11/3/206/137326

   Introduction Top


Hippocrates defined empyema thoracis as a collection of pus in the pleural cavity. [1] It is a significant cause of paediatric hospital admissions and paediatrics morbidity, especially in developing countries where hospital resources are scarce. [2],[3],[4] The proper management of empyema thoracis in children continues to be a source of debate. It continues to have a high mortality rate (10-16%). [5] Pleural effusion and empyema are known complications of bacterial pneumonia. Effusion occur in at least 40% of bacterial pneumonias, with up to 60% of effusions resulting in the formation of empyema in all age groups. [6],[7]

It occurs when bacteria invade and propagate in the normally sterile pleural space. The American Thoracis Society has described three stages of empyema, namely exudative, fibrinopurulent, and organized. [8] The exudative phase (1-3 days) is caused by increased permeability of the inflamed pleura. The fibrinopurulent phase (4-14 days) is characterised by accelerated fibrin deposit, becomes purulent leading to empyema and loculations and the organising stage (after 14 days) is characterised by thickened pleura, producing an inelastic membrane 'the peel,' which restrict lung movement termed as trapped lung. It is postulated that most appropriate therapy depends on stage of disease at presentation.

Staphylococcus aureus is the most common cause in the developing world, while the Streptococcus pneumoniae in the developed world. [9],[10] The reported rates of identifying an infectious cause from pleural fluid vary from between 8% and 76%, respectively. Pleural fluid is sterile due to widespread early use of antibiotics. [11],[12] Other causes are Streptococcus pyogenes, Haemophilus influenza, Mycobacterium species, Escherichia coli etc.

Various treatments have been employed including antibiotics, thoracocentesis, tube thoracostomy, intrapleural fibrinolytics, open window thoracostomy, video-assisted thoracoscopic surgery (VATS) and thoracotomy. Unfortunately, results with these treatments have been highly variable. [13],[14],[15],[16] This study is carried out to evaluate the effectiveness of surgical intervention in managing empyema thoracis in children.


   Patients and Methods Top


A prospective study of 70 children in the age group of 1-14 years diagnosed to have empyema thoracis, admitted from January 2010 to December 2013 in our medical college, which is catering the needs of the border and rural area of Punjab. The diagnosis was established on the basis of history, examination, and investigations, including X-ray chest [Figure 1] and culture and sensitivity of pleural fluid. Ultrasonography (USG) and computed tomography (CT) scan were done in selected cases only. All cases having empyema thoracis (pus on aspiration from the pleural cavity) were included. Patients diagnosed to be having tuberculosis or other associated lung diseases such as interstitial, malignancy were excluded. Any patient found tubercular during the study was also excluded. Written informed consent was taken and the respective procedures were well-explained to patients parents or whosoever was available. The demographic characteristics of patients were noted.
Figure 1: Chest roetgenogram showing a large left empyema


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All patients underwent closed intercostal tube drainage with size 20-24 Fr. The chest tube was inserted in the operating room under full monitoring equipment. Chest tubes were usually put by residents under the guidance of consultants. As a routine empirical intravenous antibiotics and supportive treatment mainly maintenance of hydration, oxygenation, nutrition, blood transfusion, and nursing care were given to all patients. The progress of the patients was assessed on the day-to-day basis, in terms of respiratory rate, fever charting, drain output, and serial chest X-rays.

The chest tube was removed after clinical improvement, that is when no or below 30 ml drain output was documented for more than 24 h, and the radiological lung re-expansion, in both cases that is tube thoracostomy and decortications. Antibiotics were changed based on culture and sensitive reports.

Decortication was subjected to the cases who showed definitive multi-septations, thick peel encasing the collapsed lung, pleural debris with persistent fever, cough, respiratory distress, or persistent bronchopleural fistula. Decortication was done by professor unit head with posterolateral thoracotomy with or without resection of ribs [Figure 2]. The intrapleural debris, fibrinous and all pus was evacuated. The thick pleural peel was carefully removed from the surface of the entire lung releasing encased lung. Peel was removed down to diaphragm. If thick peel was noted along the costodiaphragmatic surface, then peel was removed with blunt dissection taking care of the diaphragm and phrenic nerve. However, if peel was difficult to remove, it was left. All significant air leaks were meticulously closed with vicryl. Necrotic lung tissue was removed and bronchopleural fistulas were closed. Two chest tubes were placed one anteriorly and other posteriorly in every case as our unit protocol, which were attached to chest tube bags. No negative suction was used. Daily recovery and drain removal criteria were same as for tube thoracostomy. There was no treatment performed with fibrinolysis, thoracoplasty, VATS or pneumonectomy.
Figure 2: Operating scene of decortication


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Data were analysed using computer software SPSS version 16 of IBM. Descriptive statistics were used to calculate mean, median, and standard deviation for variable such as lung re-expansion and hospital stay. Frequency was used to calculate bacteriological profile, sex, symptoms etc.


   Results Top


The mean age of the study group was 5.44 years and 48.6% were male and 51.4% were female. Nutritional status was assessed as per Indian Academy of Paediatrics (IAP) classification of malnutrition. About 10% were normal, 14.3% were in Grade 1, 15.7% in Grade 2, 28.5% were in Grade 3, 31.4% in Grade 4 malnutrition. At admission, the most common symptoms were fever (90%), dyspnoea (73%), cough (70%), and chest pain (23%). There were 57% right sided, 39% left sided and 4% bilateral effusions. Mean duration of illness in these children was 9.08 ± 3.89 days. Mean serum albumin was 2.95 ± 0.38 g/dl. Mean total leucocyte count (TLC) was 15,387.14 ± 3167.69/mm 3 . Mean erythrocyte sedimentation rate was 13.84 ± 5.51 mm/1 st h. Pallor was common with mean hemoglobin (Hb) was 7.38 ± 1.52 g/dl. All patients had been previously treated with antibiotics. Pleural fluid cultures were sterile in 60% of patients. The most frequently identified micro-organism was S. aureus (34.2%), out of which 15.7% had methicillin-resistant S. aureus (MRSA). Other micro-organisms were E. coli (4.2%), Enterococcus fecalis (1.4%) [Table 1]. At the time of admission, 18 patients were in Stage 1, 45 patients were in Stage 2, and 7 patients in Stage 3. Mean pH was 7.16 ± 0.11, mean TLC was 756.35 ± 365.3/mm 3 , glucose was 64.38 ± 8.33 mg/dl, and mean lactate dehydrogenase was 850.27 ± 252.69 of pleural fluid.
Table 1: Bacteriological profi le/pus culture result

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Treatment with chest tube drainage was successful in 55 (78.6%) patients. Bilateral chest tubes were placed in three patients. USG guided tubes were placed in nine patients to drain the loculated collection. Wound infection and wound dehiscence were the most common complication of tube thoracostomies. Wound infection was seen in 20% of patients and wound dehiscence was seen in 10% of patients. In one patient, chest tube was within lung parenchyma, for which lobectomy of necrotic lung was done. USG guided aspiration was done in six patients to drain post thoracostomy residual collection. In cases in which chest tube drainage failed, decortication was applied to 12 patients. The mean time taken to convert tube thoracostomy to decortication was 11 days.

Empyema was treated successfully in all patients to whom decortication was applied (n = 12). Two patients developed bronchopleural fistula after decortication, which were treated conservatively. Three patients got expired due to septicaemia.

The lung re-expansion time was 8.00 ± 1.68 days (range: 5-13 days) in those patients in whom chest tube drainage was successful, whereas it was 7.50 ± 2.623 days (range: 4-14 days) in patients in whom decortication was done.

The post-procedure stay was 10.00 ± 1.809 days (range: 7-15 days) in patients with successful chest tube drainage and 9.5 ± 2.902 days (range: 6-17 days) in case of decortication cases [Table 2].
Table 2: Lung re-expansion and post-procedure stay in tube thoracostomy and decortication

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   Discussion Top


Empyema thoracis is a life-threatening emergency. Though the incidence of empyema thoracic has declined in the west due to the effective use of broad spectrum antibiotics but it still remains a significant health problem in developing countries due to low socioeconomic status, malnutrition, and delay in diagnosis of pneumonia, delayed referral to higher centre. Furthermore, the appropriate management of paediatric empyema thoracis remains controversial. [17],[18],[19] 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. Also, the availability of non-operative alternatives frequently results in delayed surgical consultation, and ultimately, increased patient morbidity and mortality. [13],[14],[15] In early stage of empyema thoracis, antimicrobial therapy with or without chest tube drainage remains main choice of treatment in children. [20] Tube drainage is recommended in children because of its reliability, rather than multiple thoracentesis. Several reports have documented successful drainage of multiloculated empyema using intrapleural fibrinolytic agents and VATS. [16],[21],[22],[23] Several study reports shows early decortication decreases hospital stay and morbidity and mortality. [24],[25] It is for these reasons that we decided to analyse our experience with management of empyema in children.

In our study, 90% of the children were malnourished as per IAP classification [26] and mean Hb was 7.38 ± 1.52 g/dl. Serum albumin averaged was 2.95 ± 0.38 g/dl. Empyema cases were seen more often in malnourished children similar to other studies conducted in developing countries. [27],[28]

In our cases, pleural fluid cultures showed bacterial growth in 40% of patients and no growth in 60% of patients. Most common organism isolated was S. aureus which is comparable to previous studies. [14],[29] MRSA was seen in 15.7% of patients, which is similar to other studies. [9]

In this study, chest tube drainage was successful in 78.6% of patients which is similar to other studies [28],[30],[31] and post-procedure stay was 10.00 ± 1.809 days. Decortication was done in 12 patients and was successful in all cases. Post-procedure stay was 9.5 ± 2.902 days in case of decortication. The mean time for conversion from tube thoracostomy to decortication was 11 days. Similarly previous studies have shown that early decortication decreases hospital stay and morbidity. [24],[25]

Furthermore, CT scan should be used cautiously and its routine use in children is not recommended, especially in developing countries where resources are limited though few studies say otherwise. [32]

Our experience suggested that tube thoracostomy should be done in all cases of empyema thoracis regardless of stage, as this leads to reduction in septic load, and serial chest X-rays should be performed to evaluate the lung expansion. Decision of decortication should be taken without any delay. The clinical and radiological improvement after decortication is dramatic with immediate lung re-expansion and improved clinical course.

We believe that the early adequate surgical treatment in patients with empyema thoracis results in low morbidity, shorter hospital stay and good long-term outcome. However more prospective studies are needed with more number of cases and hence that proper guidelines are standardised for treatment of empyema thoracis in children.

 
   References Top

1.Adams F, LLD. The genuine works of Hippocrates translated from the Greek with a preliminary discourse and annotations: New York, W. Wood and Company: 1849.  Back to cited text no. 1
    
2.Maziah W, Choo KE, Ray JG, Ariffin WA. Empyema thoracis in hospitalized children in Kelantan, Malaysia. J Trop Pediatr 1995;41:185-8.  Back to cited text no. 2
    
3.Mishra OP, Das BK, Jain AK, Lahiri TK, Sen PC, Bhargara V. Clinico-bacteriological study of empyema thoracis in children. J Trop Pediatr 1993;39:380-1.  Back to cited text no. 3
[PUBMED]    
4.Asindi AA, Efem SE, Asuquo ME. Clinical and bacteriological study on childhood empyema in south eastern Nigeria. East Afr Med J 1992;69:78-82.  Back to cited text no. 4
    
5.Anstadt MP, Guill CK, Ferguson ER, Gordon HS, Soltero ER, Beall AC Jr, et al. Surgical versus nonsurgical treatment of empyema thoracis: An outcomes analysis. Am J Med Sci 2003;326:9-14.  Back to cited text no. 5
    
6.Strange C, Tomlinson JR, Wilson C, Harley R, Miller KS, Sahn SA. The histology of experimental pleural injury with tetracycline, empyema, and carrageenan. Exp Mol Pathol 1989;51:205-19.  Back to cited text no. 6
    
7.Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med 1998;19:363-71.  Back to cited text no. 7
    
8.The American Thoracic Society Subcommittee on Surgery. Management of nontuberculous empyema. Am Rev Respir Dis 1962;85:935-6.  Back to cited text no. 8
    
9.Narayanappa D, Rashmi N, Prasad NA, Kumar A. Clinico-bacteriological profile and outcome of empyema. Indian Pediatr 2013;50:783-5.  Back to cited text no. 9
    
10.Finley C, Clifton J, Fitzgerald JM, Yee J. Empyema: An increasing concern in Canada. Can Respir J 2008;15:85-9.  Back to cited text no. 10
    
11.Byington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: Risk factors and microbiological associations. Clin Infect Dis 2002;34:434-40.  Back to cited text no. 11
    
12.Sarihan H, Cay A, Aynaci M, Akyazici R, Baki A. Empyema in children. J Cardiovasc Surg (Torino) 1998;39:113-6.  Back to cited text no. 12
    
13.LeMense GP, Strange C, Sahn SA. Empyema thoracis. Therapeutic management and outcome. Chest 1995;107:1532-7.  Back to cited text no. 13
    
14.Cekirdekci A, Köksel O, Göncü T, Burma O, Rahman A, Uyar IS, et al. Management of parapneumonic empyema in children. Asian Cardiovasc Thorac Ann 2000;8:137-40.  Back to cited text no. 14
    
15.Light RW. Management of parapneumonic effusions. Chest 1991;100:892-3.  Back to cited text no. 15
[PUBMED]    
16.Temes RT, Follis F, Kessler RM, Pett SB Jr, Wernly JA. Intrapleural fibrinolytics in management of empyema thoracis. Chest 1996;110:102-6.  Back to cited text no. 16
    
17.Foglia RP, Randolph J. Current indications for decortication in the treatment of empyema in children. J Pediatr Surg 1987;22:28-33.  Back to cited text no. 17
[PUBMED]    
18.Tiryaki T, Abbasoglu L, Bulut M. Management of thoracis empyema in childhood: A study of 160 cases. Pediatr Surg Int 1995;10:534-6.  Back to cited text no. 18
    
19.Cham CW, Haq SM, Rahamim J. Empyema thoracis: A problem with late referral? Thorax 1993;48:925-7.  Back to cited text no. 19
    
20.McLaughlin FJ, Goldmann DA, Rosenbaum DM, Harris GB, Schuster SR, Strieder DJ. Empyema in children: Clinical course and long-term follow-up. Pediatrics 1984;73:587-93.  Back to cited text no. 20
[PUBMED]    
21.Gates RL, Hogan M, Weinstein S, Arca MJ. Drainage, fibrinolytics, or surgery: A comparison of treatment options in pediatric empyema. J Pediatr Surg 2004;39:1638-42.  Back to cited text no. 21
    
22.Yao CT, Wu JM, Liu CC, Wu MH, Chuang HY, Wang JN. Treatment of complicated parapneumonic pleural effusion with intrapleural streptokinase in children. Chest 2004;125:566-71.  Back to cited text no. 22
    
23.Fuller MK, Helmrath MA. Thoracic empyema, application of video-assisted thoracic surgery and its current management. Curr Opin Pediatr 2007;19:328-32.  Back to cited text no. 23
    
24.Gün F, Salman T, Abbasoğlu L, Salman N, Celik A. Early decortication in childhood empyema thoracis. Acta Chir Belg 2007;107:225-7.  Back to cited text no. 24
    
25.Majid F, Zubair M. Management of empyema thoracis in Children: Tube thoracostomy versus early decortication. J Surg Pak (Int) 2011;16:67-70.  Back to cited text no. 25
    
26.Nutrition Subcommittee of Indian Academy of Pediatric: Report of convener. Indian Padiatr 1972;9:360.  Back to cited text no. 26
    
27.Menon P, Rao KL, Singh M, Venkatesh MA, Kanojia RP, Samujh R, et al. Surgical management and outcome analysis of stage III pediatric empyema thoracis. J Indian Assoc Pediatr Surg 2010;15:9-14.  Back to cited text no. 27
[PUBMED]  Medknow Journal  
28.Ekpee EE, Akpan MU. Poorly treated broncho-pneumonia with progression to empyema thoracis in Nigerian children. TAF Prev Med Bull 2010;9:181-6.  Back to cited text no. 28
    
29.Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: A 10-year comparative review of hospitalised children from south Asia. Arch Dis Child 2003;88:1009-14.  Back to cited text no. 29
    
30.Ghritlaharey RK, Budhwani KS, Shrivastava DK, Srivastava J. Tube thoracostomy: Primary management option for empyema thoracis in children. Afr J Paediatr Surg 2012;9:22-6.  Back to cited text no. 30
[PUBMED]  Medknow Journal  
31.Nwofor AM, Ekwunife CN. Tube thoracostomy in the management of pleural fluid collections. Niger J Clin Pract 2006;9:77-80.  Back to cited text no. 31
[PUBMED]    
32.Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR. Differentiating lung abscess and empyema: Radiography and computed tomography. AJR Am J Roentgenol 1983;141:163-7.  Back to cited text no. 32
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Correspondence Address:
Dr. Vikas Goyal
S/O Dr. Janak Raj Goyal, House No. 74c, Street No. 5, Guru Nanak Colony, Sadiq Road, Faridkot, Punjab
India
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DOI: 10.4103/0189-6725.137326

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