From
Dr. Daniel Ostlie
Panel discussion on fibrinolytic therapy versus VATS for pediatric empyema management
With Dr. Dan Osley · hosted by Dr. Todd Ponsky
Chapter 1 of 5
Empyema case
Case presentation and initial management debate for stage 2 empyema
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Stage 2 empyema is defined as loculated pleural effusion with greater than 100,000 white cells
Once empyema is defined with loculations and high white cell count, antibiotics alone are probably not the right choice and intervention is needed to remove fibrinous exudate
The meta-analysis comparing treatment approaches had temporal bias, with VATS cases concentrated in later years, making it an apples-to-oranges comparison
Two independent trials demonstrate fibrinolysis works in 85% of empyema patients
Patients remain sick after VATS debridement because of underlying pneumonia, not because of pleural material
The Kansas City trial used intention-to-treat analysis, so the 6.8-day length of stay includes all patients who failed fibrinolytic therapy and required subsequent VATS
In the immediate VATS arm, two children required ECMO and one developed renal failure requiring hemodialysis; these complications did not occur in the fibrinolytic arm
Percutaneous Seldinger technique chest tubes can be placed at bedside under local anesthesia with minimal sedation in approximately two minutes and are well tolerated
Ultrasound can sometimes be misleading and show large effusion when disease is actually intraparenchymal necrotic lung that should be treated with antibiotics only
For spontaneous pneumothorax, there is a 50% failure rate with chest tube alone
Teenagers with spontaneous pneumothorax have a characteristic asthenic body habitus with thin chest capacity, and virtually all have blebs in the upper lung
Deflating and reinflating the lung during VATS can help identify blebs, particularly on the edges of the lower lobe
A combined study of 350 patients who had lung procedures without chest tube placement showed no complications, though these were not spontaneous pneumothorax patients
Re-entering a chest that has had talc pleurodesis is extremely difficult and may require retropleural approach
A meta-analysis of 170 patients comparing chest tube with fibrinolytic, chest tube with fibrinolytic and delayed thoracoscopy, versus primary VATS showed the primary VATS arm (M3) did better than other approaches
A trial of 60 empyema patients comparing urokinase with small drain, saline with small drain, urokinase with large drain, and saline with large drain (no operations) showed small tube with urokinase performed best
The London trial using urokinase showed length of stay 6 days, cost £13,000 versus £11,300, and 16% failure rate
The Kansas City trial using TPA showed length of stay 6.8 days in both arms, cost $11,600 versus $11,300 and $7,500 versus $9,000, and 15% failure rate
A Cochrane review with one randomized controlled trial (including patients age 16 and up) showed simple aspiration had 59% immediate success rate for pneumothorax, equivalent to chest tube outcomes
In the aspiration trial, 11 patients failed aspiration, 9 received chest tubes, only 2 required VATS, and 50% avoided hospitalization with no difference in overall hospital stay or recurrence rate