[size=20px]You are asked to see a 5 year-old boy in the emergency department with persistent fevers despite 4 days of oral amoxicillin for community-acquired pneumonia. Temperature is 39.2 degrees, heart rate is 132/min, blood pressure is 92/67, respiratory rate is 32, and oxygen saturation is 93% on room air. He appears alert but flushed. There are decreased breath sounds in the right chest. Chest x-ray demonstrates a moderate-sized right pleural effusion. Chest ultrasound shows a right pleural effusion with internal septations. The recommended treatment strategy for this condition is:

 

A Percutaneous chest tube insertion

 

B Percutaneous chest tube insertion and intrapleural fibrinolytics

 

C Percutaneous chest tube insertion and intrapleural fibrinolytics and dornase (DNase)

 

D Video-assisted thoracoscopic surgery (VATS)​[/size]

C

correct answer

B Percutaneous chest tube insertion and intrapleural fibrinolytics

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Multiple randomized controlled trials have compared outcomes for chest tube insertion and intrapleural fibrinolytics versus decortication via video-assisted thoracoscopic surgery (VATS) for children with empyema. Length of stay in hospital and risk of needing additional drainage procedures are similar with these two approaches, but VATS is more expensive.​

 

​Similarly, a multicenter randomized controlled trial of children with empyema treated with chest tube insertion compared outcomes for intrapleural fibrinolytics alone (i.e., tissue plasminogen activator 4 mg) versus intrapleural fibrinolytics and DNase. This trial showed no benefit to the addition of DNase, unlike a previous randomized controlled trial in adults with empyema which showed improved outcomes with combined treatment.​