Outcome of parapneumonic empyema
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《美国医学杂志》
1 Departments of Pediatrics, M.K.C.G. Medical College, Berhampur, Orissa, India
2 Departments of Physiology, M.K.C.G. Medical College, Berhampur, Orissa, India
Abstract
OBJECTIVE: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome. METHODS: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases. RESULTS: 0.8% (C.I. 0.6-1.0) of total pediatric admission had empyema, who were more likely to be females (P<0.05), under-weight (P<0.05) compared to children admitted for other reasons. Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases. CONCLUSION: Chest tube drainage is a safe, efficacious primary method of empyema management.
Keywords: Parapneumonic empyema; Empyema thoracis
[Abbreviation used in the text : CTD : Chest Tube Drainage]
Empyema thoracis is still a common entity in developing countries along with high incidence of pneumonia because of multiple factors. The principle of management has been appropriate antibiotic therapy alongwith early and effective drainage procedure. There is debate over superiority of conservative chest tube drainage versus more aggressive surgical approach of thoracotomy decortication or thoracoscopic adhesiolysis as the initial method of choice. There are many reports[1],[2],[3],[4],[5],[6] with variable opinions over this issue. Although most of the studies suggest better efficacy of surgical drainage in multiloculated and late cases, opinion is divided over its use as a primary way management in all cases of empyema.
Universal applicability of primary surgical methods like thoracotomy or thoracoscopic surgery may be difficult in many parts of resource poor developing countries due to higher cost of treatment and inadequate facilities.
This study was undertaken to study current demography of the empyema cases and to evaluate the efficacy of conservative way of management like chest tube drainage and failure rates requiring salvage thoracotomy surgery.
Materials and methods
A prospective simple random study of all the parapneumonic empyema cases admitted during July, 2001 to June 2003 to pediatric ward of MKCG Medical College, the only referral centre of south Orissa catering to mostly rural population. Neonates and other secondary cases of empyema were excluded. Cases were defined by presence of frank pleural pus or parapneumonic exudates with high polymorphs or presence of organism with evidence of pneumonia. In all cases basic investigations, chest radiography, pleural fluid analysis, culture and blood culture were done. Ultrasonography or C.T. Scan of chest was done in cases with clinical or radiologic suspicion of multiloculation or non improvement following therapy. All cases except multiloculated cases were managed with chest tube drainage under local anaesthesia, in combination with intravenous antibiotics and supportive treatments like maintenance of hydration, oxygenation, nutrition etc. Chest tube was removed after clinical improvement when no drainage was documented for more than 24 hours. Cases who showed definite multiseptations, bronchopleural fistula or non-improvement with previous regimen were subjected to thoracotomy surgery. Patients were discharged after clinical recovery, with oral antibiotics whenever needed. Follow up was advised at one, three and six months for clinical, radiological and lung function test by Medspiror.
Figures of total pediatric admission, demographic profile and weight for age during study period were retrieved from hospital records. Data analysis was done with application of statistical method. Numerical variables normally distributed were compared by student's 't' test whereas categorical variables were compared by Chi-square test. 'P' value less than 0.05 was considered statistically significant.
Results
Fifty-three cases of empyema table1 were recorded out of total pediatric admission of 6571 during the study period (0.8%, 95% C.I. 0.6 - 1.0). Mean age of cases was 4.68 ± 3.34 years, maximum (37.7%) being above five years. No statistically significant particular age group risk was observed in hospitalised children (P = 0.89), Females showed higher risk for empyema than males in hospitalised cases (R.R=1.7, Chi test P=0.046), though number of cases studied was apparently similar. Thirty- four cases (64.2%) had empyema who had also weight below 3rd centile of expected normal. Patients with empyema were more likely to be undernourished compared to those admitted for other reasons (R. R = 1.8, Chi square test 'P' = 0.031).
Persistent high fever (77.3%), dyspnoea (88.6%), cough (71.6%) and chest pain (24.5%) were common features. All cases received oral/parenteral antibiotics for a period ranging 1 to 39 days prior to hospitalisation (mean 8.81 ± 6.99 days). Blood or pleural fluid culture showed positivity only in 14 cases (26.4%), Staphylococcus aureus being the commonest isolate (13.2%).
Two cases on chest tube drainage died one due to associated pyogenic meningitis and the other due to malnutrition and septic shock where pseudomonas was isolated from blood.
All the cases showed thickened pleura radiologically during discharge. Forty six cases turned up for at least two of the follow ups. By six months all of them improved radiologically excepting one who showed mild pleural thickening with scoliosis. One child had features of mild hyperreactive airway disease
Pulmonary function test could be done on follow up at six months in six elderly children who could co-operate. In five cases (4 CTD and 1 thoractotomy group) FVC, FEV1, FVC / FEV1 ratio and PEFR were near normal to their calculated predicted values for height in Indian chidlren[7]. In one child who had salvage thoracotomy and a protracted hospital course lower value of FVC and FEV1 with near normal ratio was observed suggesting mild restrictive lung disease.
Discussion
Incidence of empyema was 0.8% of total pediatric admissions which is lower than previous study by Padmini et al.[8] in 1980s. No specific age predilection was seen in this study contrary to the former where higher incidence in younger age was seen. Though sex distribution of cases was apparently similar, females were at higher risk than males (RR 1.7, P = 0.046) for empyema as seen in hospitalised children. Total female admission was also lower compared to males which may be indicative of sex bias in seeking prompt medical care in the socially backward population in the area leading to higher complication rate in females. Empyema cases were seen more often in under-weight children (P=0.031) similar to some previous observations in India[8] and Turkey[6]. However, this is difficult to say whether this is because of undernutrion per se or due to associated social factors leading to inadequate and delayed treatment of pneumonia.
All the children in the series received oral and/or parenteral antibiotics before hospitalisation for variable periods, which possibly lead to poor culture yield (24.6%) from pleural fluid and blood. Still Staphylococcus aureus seems to be the predominant organism similar to many previous observations of eighties[9],[10] and recent study from Turkey.[6] On the contrary pneumococcus was the commonest isolate in recent American and European studies[11],[12].
On comparison of two groups of cases regarding efficacy of management mode there was no significant difference in period of defervescence of fever, duration of hospital stay between tube thoracostomy and thoracotomy cases, except duration of antibiotic therapy needed was less in surgical group (P < 0.05). This observation is contrary to studies by Chen LE et al[2] and Huang et al[4] who opined thoracoscopic drainage or thoracotomy decortication to be a better initial option because of shorter hospital stay, and quicker recovery. But the cases in their series were mostly loculated or delayed needing surgery. In the present series only 9.4% cases required thoracotomy and the failure rate of CTD was also small, comparable to some previous studies.[3],[5],[6] Two cases in the present study died due to reason unrelated to option of management. Complication rate was minimal on follow-up up to six months. Most cases showed complete recovery irrespective of severity or mode of management except one case of salvage thoracotomy who showed scoliosis and evidence of restrictive lung disease. Only one case following CTD had hyperreactive airway, which improved with treatment. Similar favourable results were seen recently with tube thoracostomy by many other authors from Asia and Europe[3],[5],[6]. However, the limitations of the present series lie in smaller number and non-randomisation of cases in surgical group.
Although early surgical intervention appears to be a better option in loculated empyema, its advantages over CTD are marginal in most of the free flowing empyema considering the higher cost, need for general anaesthesia and more invasive nature of the procedure. CTD is simpler and the immediate and long term outcome is satisfactory in most of the cases of non-loculated empyema.
Conclusion
Chest tube drainage in parapneumonic empyema is safe and efficacious and long term outcome is comparable to primary surgical drainage in most of the cases. However, a prospective well randomised trial is recommended.
References
1. Shankar KR, Kenny SE, Okoye BO, Carty HM, Lloyd DA, Losty PD. Evolving experience in the management of empyema thoracis. Acta Pediatr 2000; 89(4): 417-420.
2. Chen LE, Langer JC, Dillon PA, Foglia RP, Huddleston CB, Mendeloff EN et al. Management of late stage parapneumonic empyema. J Pediatr Surg 2002; 37(3): 371-374.
3. Meier AH, Smith B, Raghvan A, Moss RL. Rational treatment of empyema in children. Arch Surg 2000; 135 (8): 907-912.
4. Huang FL, Chen PY, Ma JS, Yn HW, Lu KC, Chi CS et al. Clinical experience in managing empyema thoracis in children. J Microbiol Immunol Infect 2002; 35(2): 115-120.
5. Chan PW, Crawford O, Wallis C, DinWiddie R. Treatment of pleural empyema. J Pediatr Child Health 2000; 36 (4): 375-377.
6. Yilmaz E, Dogan Y, Aydinoglu AH, Gurgoze MK, Aygun D. Para pneumonic empyema in children : Conservative approach. Turkey J Pediatr 2002; 44(2): 134-138.
7. Raju PS, Prasad KVV, Venkata Ramana Y, Ahmed SK, Murthy KJR. Study of lung function tests and prediction equations in Indian male children. Indian Pediatr 2003; 40: 705-711.
8. Padmini R, Srinivasan S, Puri RK, Nalini P. Empyema in infancy and early childhood. Indian Pediatr 1990; 27: 447-452.
9. Kumar L, Gupta AP, Mitra S, Yadav K, Pathak IC, Walia BS, Kumar V, Ayagari A. Profile of childhood empyema thoracis in north India. Indian J Med Res 1980; 72: 854-859.
10. Arya LS, Khalju AZ, Fazal MI, Singh M. A study of empyema thoracis in children. Indian Pediatr 1982; 19: 917-920.
11. Paz F, Cespedes F, Cuevas M, Lecorre N, Navarro N. Pleural effusion and complicated empyema in children, evolution and prognostic factors. Rev Med Chil 2001; 129(11): 1289-1296.
12. Hardie W, Bokulic R, Garcia VF, Reising SF. Pneumococcal pleural empyemas in children. Clin Infect Dis 1996; 22(6): 1057-1063.(Satpathy SK, Behera CK, N)
2 Departments of Physiology, M.K.C.G. Medical College, Berhampur, Orissa, India
Abstract
OBJECTIVE: Empyema thoracis is known to have variable age group affection, causative agents and controversy regarding primary mode of management. To look into current demography, bacteriology and treatment outcome. METHODS: Prospective study made on admitted cases of parapneumonic empyema from July 2001 to June 2003. All cases were treated with chest tube drainage, parenteral antibiotics or thoracotomy in multiloculated or non-improving cases. RESULTS: 0.8% (C.I. 0.6-1.0) of total pediatric admission had empyema, who were more likely to be females (P<0.05), under-weight (P<0.05) compared to children admitted for other reasons. Staphylococcus aureus is still the commonest isolate (13.2%). All cases received antibiotics prior to hospitalisation. Majority of cases (90.5%) could be successfully managed with antibiotics and chest tube drainage alone. 9.4% cases needed thoracotomy. 5.8% cases needed salvage thoracotomy following non-improvement with chest tube drainage. Fever remission time and duration of hospital stay were comparable in both groups. Thoracotomy cases required antibiotics for shorter period (P=0.04). Two cases died due to reasons other than mode of management. Radiological and lung function recovery was excellent in most of the cases. CONCLUSION: Chest tube drainage is a safe, efficacious primary method of empyema management.
Keywords: Parapneumonic empyema; Empyema thoracis
[Abbreviation used in the text : CTD : Chest Tube Drainage]
Empyema thoracis is still a common entity in developing countries along with high incidence of pneumonia because of multiple factors. The principle of management has been appropriate antibiotic therapy alongwith early and effective drainage procedure. There is debate over superiority of conservative chest tube drainage versus more aggressive surgical approach of thoracotomy decortication or thoracoscopic adhesiolysis as the initial method of choice. There are many reports[1],[2],[3],[4],[5],[6] with variable opinions over this issue. Although most of the studies suggest better efficacy of surgical drainage in multiloculated and late cases, opinion is divided over its use as a primary way management in all cases of empyema.
Universal applicability of primary surgical methods like thoracotomy or thoracoscopic surgery may be difficult in many parts of resource poor developing countries due to higher cost of treatment and inadequate facilities.
This study was undertaken to study current demography of the empyema cases and to evaluate the efficacy of conservative way of management like chest tube drainage and failure rates requiring salvage thoracotomy surgery.
Materials and methods
A prospective simple random study of all the parapneumonic empyema cases admitted during July, 2001 to June 2003 to pediatric ward of MKCG Medical College, the only referral centre of south Orissa catering to mostly rural population. Neonates and other secondary cases of empyema were excluded. Cases were defined by presence of frank pleural pus or parapneumonic exudates with high polymorphs or presence of organism with evidence of pneumonia. In all cases basic investigations, chest radiography, pleural fluid analysis, culture and blood culture were done. Ultrasonography or C.T. Scan of chest was done in cases with clinical or radiologic suspicion of multiloculation or non improvement following therapy. All cases except multiloculated cases were managed with chest tube drainage under local anaesthesia, in combination with intravenous antibiotics and supportive treatments like maintenance of hydration, oxygenation, nutrition etc. Chest tube was removed after clinical improvement when no drainage was documented for more than 24 hours. Cases who showed definite multiseptations, bronchopleural fistula or non-improvement with previous regimen were subjected to thoracotomy surgery. Patients were discharged after clinical recovery, with oral antibiotics whenever needed. Follow up was advised at one, three and six months for clinical, radiological and lung function test by Medspiror.
Figures of total pediatric admission, demographic profile and weight for age during study period were retrieved from hospital records. Data analysis was done with application of statistical method. Numerical variables normally distributed were compared by student's 't' test whereas categorical variables were compared by Chi-square test. 'P' value less than 0.05 was considered statistically significant.
Results
Fifty-three cases of empyema table1 were recorded out of total pediatric admission of 6571 during the study period (0.8%, 95% C.I. 0.6 - 1.0). Mean age of cases was 4.68 ± 3.34 years, maximum (37.7%) being above five years. No statistically significant particular age group risk was observed in hospitalised children (P = 0.89), Females showed higher risk for empyema than males in hospitalised cases (R.R=1.7, Chi test P=0.046), though number of cases studied was apparently similar. Thirty- four cases (64.2%) had empyema who had also weight below 3rd centile of expected normal. Patients with empyema were more likely to be undernourished compared to those admitted for other reasons (R. R = 1.8, Chi square test 'P' = 0.031).
Persistent high fever (77.3%), dyspnoea (88.6%), cough (71.6%) and chest pain (24.5%) were common features. All cases received oral/parenteral antibiotics for a period ranging 1 to 39 days prior to hospitalisation (mean 8.81 ± 6.99 days). Blood or pleural fluid culture showed positivity only in 14 cases (26.4%), Staphylococcus aureus being the commonest isolate (13.2%).
Two cases on chest tube drainage died one due to associated pyogenic meningitis and the other due to malnutrition and septic shock where pseudomonas was isolated from blood.
All the cases showed thickened pleura radiologically during discharge. Forty six cases turned up for at least two of the follow ups. By six months all of them improved radiologically excepting one who showed mild pleural thickening with scoliosis. One child had features of mild hyperreactive airway disease
Pulmonary function test could be done on follow up at six months in six elderly children who could co-operate. In five cases (4 CTD and 1 thoractotomy group) FVC, FEV1, FVC / FEV1 ratio and PEFR were near normal to their calculated predicted values for height in Indian chidlren[7]. In one child who had salvage thoracotomy and a protracted hospital course lower value of FVC and FEV1 with near normal ratio was observed suggesting mild restrictive lung disease.
Discussion
Incidence of empyema was 0.8% of total pediatric admissions which is lower than previous study by Padmini et al.[8] in 1980s. No specific age predilection was seen in this study contrary to the former where higher incidence in younger age was seen. Though sex distribution of cases was apparently similar, females were at higher risk than males (RR 1.7, P = 0.046) for empyema as seen in hospitalised children. Total female admission was also lower compared to males which may be indicative of sex bias in seeking prompt medical care in the socially backward population in the area leading to higher complication rate in females. Empyema cases were seen more often in under-weight children (P=0.031) similar to some previous observations in India[8] and Turkey[6]. However, this is difficult to say whether this is because of undernutrion per se or due to associated social factors leading to inadequate and delayed treatment of pneumonia.
All the children in the series received oral and/or parenteral antibiotics before hospitalisation for variable periods, which possibly lead to poor culture yield (24.6%) from pleural fluid and blood. Still Staphylococcus aureus seems to be the predominant organism similar to many previous observations of eighties[9],[10] and recent study from Turkey.[6] On the contrary pneumococcus was the commonest isolate in recent American and European studies[11],[12].
On comparison of two groups of cases regarding efficacy of management mode there was no significant difference in period of defervescence of fever, duration of hospital stay between tube thoracostomy and thoracotomy cases, except duration of antibiotic therapy needed was less in surgical group (P < 0.05). This observation is contrary to studies by Chen LE et al[2] and Huang et al[4] who opined thoracoscopic drainage or thoracotomy decortication to be a better initial option because of shorter hospital stay, and quicker recovery. But the cases in their series were mostly loculated or delayed needing surgery. In the present series only 9.4% cases required thoracotomy and the failure rate of CTD was also small, comparable to some previous studies.[3],[5],[6] Two cases in the present study died due to reason unrelated to option of management. Complication rate was minimal on follow-up up to six months. Most cases showed complete recovery irrespective of severity or mode of management except one case of salvage thoracotomy who showed scoliosis and evidence of restrictive lung disease. Only one case following CTD had hyperreactive airway, which improved with treatment. Similar favourable results were seen recently with tube thoracostomy by many other authors from Asia and Europe[3],[5],[6]. However, the limitations of the present series lie in smaller number and non-randomisation of cases in surgical group.
Although early surgical intervention appears to be a better option in loculated empyema, its advantages over CTD are marginal in most of the free flowing empyema considering the higher cost, need for general anaesthesia and more invasive nature of the procedure. CTD is simpler and the immediate and long term outcome is satisfactory in most of the cases of non-loculated empyema.
Conclusion
Chest tube drainage in parapneumonic empyema is safe and efficacious and long term outcome is comparable to primary surgical drainage in most of the cases. However, a prospective well randomised trial is recommended.
References
1. Shankar KR, Kenny SE, Okoye BO, Carty HM, Lloyd DA, Losty PD. Evolving experience in the management of empyema thoracis. Acta Pediatr 2000; 89(4): 417-420.
2. Chen LE, Langer JC, Dillon PA, Foglia RP, Huddleston CB, Mendeloff EN et al. Management of late stage parapneumonic empyema. J Pediatr Surg 2002; 37(3): 371-374.
3. Meier AH, Smith B, Raghvan A, Moss RL. Rational treatment of empyema in children. Arch Surg 2000; 135 (8): 907-912.
4. Huang FL, Chen PY, Ma JS, Yn HW, Lu KC, Chi CS et al. Clinical experience in managing empyema thoracis in children. J Microbiol Immunol Infect 2002; 35(2): 115-120.
5. Chan PW, Crawford O, Wallis C, DinWiddie R. Treatment of pleural empyema. J Pediatr Child Health 2000; 36 (4): 375-377.
6. Yilmaz E, Dogan Y, Aydinoglu AH, Gurgoze MK, Aygun D. Para pneumonic empyema in children : Conservative approach. Turkey J Pediatr 2002; 44(2): 134-138.
7. Raju PS, Prasad KVV, Venkata Ramana Y, Ahmed SK, Murthy KJR. Study of lung function tests and prediction equations in Indian male children. Indian Pediatr 2003; 40: 705-711.
8. Padmini R, Srinivasan S, Puri RK, Nalini P. Empyema in infancy and early childhood. Indian Pediatr 1990; 27: 447-452.
9. Kumar L, Gupta AP, Mitra S, Yadav K, Pathak IC, Walia BS, Kumar V, Ayagari A. Profile of childhood empyema thoracis in north India. Indian J Med Res 1980; 72: 854-859.
10. Arya LS, Khalju AZ, Fazal MI, Singh M. A study of empyema thoracis in children. Indian Pediatr 1982; 19: 917-920.
11. Paz F, Cespedes F, Cuevas M, Lecorre N, Navarro N. Pleural effusion and complicated empyema in children, evolution and prognostic factors. Rev Med Chil 2001; 129(11): 1289-1296.
12. Hardie W, Bokulic R, Garcia VF, Reising SF. Pneumococcal pleural empyemas in children. Clin Infect Dis 1996; 22(6): 1057-1063.(Satpathy SK, Behera CK, N)