A five-year old male presents to his pediatrician’s office with a fever and cough. A community acquired pneumonia is diagnosed on chest radiograph. He is treated as an outpatient with oral antibiotics but returns three days later with worsening dyspnea and a large left pleural effusion on repeat chest radiograph.

 

 

They are admitted and started on broad spectrum IV antibiotics with persistent fevers and an increasing oxygen requirement. A CT scan is obtained which shows a loculated pleural effusion.

 

 

[size=20px]What is the best next step in management of this patient?

 

a Chest tube alone

 

b Continued IV antibiotic therapy

 

c Chest tube/Fibrinolysis

 

d VATS and decortication[/size]

Edited January 19, 20251 yr by Admin

c.Chest tube/Fibrinolysis

C

C

A

C

C

Correct answer

c Chest tube/Fibrinolysis

 

 

Community acquired pneumonias remains one of the leading causes of morbidity and mortality worldwide in children between one month and 5 years of age. A subset of these patients develop complications including parapneumonic effusion, empyema, necrotizing pneumonia, and lung abscess. These complications are associated with significant rates of inpatient hospitalization along with a protracted disease course; however, the vast majority of these patients recover. There is no general consensus on the optimal management of many aspects of complicated community acquired pneumonia. Recommendations are largely based on expert opinion and not on high-quality, randomized controlled trials. Antibiotics are the mainstay of therapy, but in many instances an intervention to adequately treat the empyema is necessary. The patient described has a loculated fluid collection shown on the CT and would benefit from additional intervention given his persistent symptoms - IV antibiotics alone are most likely not adequate at this time.

 

 

The last decade has seen a shift in treatment strategies for empyema. In simple effusions, chest tube drainage alone may be adequate. However, in loculated fluid collections or when there is evidence of septations or debris, tube thoracostomy alone is not adequate. Video assisted thoracoscopic surgery (VATS) has been the mainstay of surgical therapy until the last decade. Several articles between 2006 and 2014 evaluated the use of tube thoracostomy with fibrinolytics compared with VATS. These studies have concluded that tube thoracostomy with fibrinolytics is as efficacious as VATS. The largest study was performed in 2014 by Marhuenda et al. The authors performed a prospective, randomized, multicenter trial to examine the treatment options. No difference was identified between postprocedural hospital days, total hospital length of stay, treatment failures and complications. Patients treated with chest tube plus urokinase did have more days with a chest tube in place (five versus four days in the VATS group). Median hospital length of stay was 13 days for the urokinase group and 14 days for the VATS group (nonsignificant difference). Recent literature has shown an increased trend in the use of tube thoracostomy with fibrinolytic for the treatment of empyema. Given the efficacy of this approach and the complications associated with VATS along with its need for general anesthetic, initial treatment with chest tube and fibrinolytics would be appropriate in this patient.