Acta Chir Belg, 2008, 108, 208-211
Management of Postpneumonic Empyemas in Children
Parapneumonic effusion is any pleural effusion sec-
ondary to pneumonia (bacterial or viral) or lung abscess.
Approximately 0.6% of childhood cases of pneumonia
are complicated by the formation of pleural empyema.
The incidence of empyema ranges from 4 to 6 per
100,000 children (1). It is recommended that a stepwise
approach be taken with patients with parapneumonic
effusions. The treatment options are observation, thera-
peutic thoracentesis, tube thoracostomy, tube thoracos-
tomy with intrapleural fibrinolytics, thoracoscopy and
thoracotomy with decortication, and open drainage
procedures. Unfortunately, results with these treatment
regimens have been highly variable (2, 3). The aim of
this study was to assess different treatment options in the
management of postpneumonic pediatric empyemas.
Patients and methods
A total of 111 children (57 boys and 54 girls with ages
ranging from 18 months to 14 years) were treated for
pleural empyema at our Department of Thoracic Surgery
between April 1997 and October 2005. The mean age
was 7.07 years. The primary infection was bacterial
pneumonia in all children. There was no evidence of
tuberculosis. All children had been previously treated
with antibiotics and thoracentesis and were referred to
our Thoracic Surgery Department by the Pediatric
Diseases Department. Diagnosis was established typi-
cally by case history, clinical features, full blood count,
electrolytes, chest radiography, ultrasound chest scan
(US) and computed tomography (CT) scans. The
diagnosis of empyema required one of the following
criteria : 1) fibrinopurulent fluid with the presence of
pus, 2) positive Gram stain, 3) pleural fluid level
pH < 7.0, 4) pleural fluid glucose level of less than
50 mg/dl, 5) pleural fluid white blood cell count
> 1,000 cells/mm3, 6) pleural fluid lactic dehydrogenase
(LDH) level > 1,000 IU/L. In this study, we used the
empyema classification of the American Thoracic
Society. According to this classification, empyemas have
3 fairly distinct phases : Stage I ; an early exudative or
pre-empyema phase (exudative with swelling of the
pleural membranes), Stage II ; an intermediate fibrinop-
urulent phase (fibrinopurulent with heavy fibrin
deposits), Stage III ; a late organizing or chronic phase
(organization with ingrowth of fibroblasts and deposi-
tion of collagen) (4).
Initially, all patients underwent closed intercostal
drainage with a size 20 to 24 Fr chest tube attached to
an underwater seal system with negative suction 15-
R. Demirhan*, A. Kosar**, I. Sancakli*, H. Kiral**, A. Orki**, B. Arman*
*Lutfi Kirdar Kartal Training and Research Hospital ; **Sureyyapasa Chest Disease and Chest Surgery Training and
Research Hospital, Department of Thoracic Surgery, Erenkoy, Istanbul, Turkey.
Key words. Empyema ; chest tube thoracostomy ; fibrinolysis ; decortication.
Abstract. Objective : The optimal treatment of children with empyema remains controversial. The purpose of this
clinical retrospective study was to assess different treatment options in the management of postpneumonic pediatric
Methods : From April 1997 to October 2005, 111 consecutive children (57 boys and 54 girls) were managed for pleural
empyema. The mean age was 7.07 years (range : 18 months-14 years). Patients were divided into 3 groups depending
on the treatment received : group I, chest tube alone (n = 89) ; group II, chest tube with fibrinolytics (n = 22) ; group III,
thoracotomy with decortication (n = 19, consisting of 9 patients of group I and 10 of group II with unsuccessful treat-
Results : Chest tube alone, chest tube with fibrinolytics, and thoracotomy with decortication had complete response
rates of 89.9%, 54.5%, and 100%, respectively. The hospital stay was 11.46 ± 3.79 days for group I, 9.08 ± 2.07 days
for group II, and 6.32 ± 2.54 days for group III. There was no statistically significant difference between group I and
group II with regard to hospital stay (P = 0.040). Mild pain occurred in 4 children of group II after streptokinase
instillation. Only one atelectasis appeared in group III during the postoperative period.
Conclusion : Chest tube drainage is a safe, effective primary treatment of postpneumonic pediatric empyema. In cases
where it is insufficient, thoracotomy with decortication can be used successfully with low morbidity and mortality rates.
Management of Postpneumonic Empyemas in Children
20 cmH2O. The chest tubes were inserted in the
operating room, under intravenous sedation, using full
monitoring equipment. All patients were given empiric
antibiotics treatment. In patients with positive bacterial
culture, we continued the treatment by replacing the
medication with suitable antibiotics according to their
culture antibiogram. Eighty-nine of the patients (80.2%)
were treated by chest tube drainage (group I), 22
(19.8%) by chest tube drainage with intrapleural fibri-
nolytic treatment (group II). All were diagnosed with
stage II empyema.
In 22 (20%) of the patients (group II), in whose US
and CTs multiloculation appeared, fibrinolytic treatment
was started immediately after chest tube insertion. In all
patients, coagulation parameters and complete blood
count were tested prior to intrapleural fibrinolytic treat-
ment. Streptokinase was used for intrapleural fibrinolyt-
ic treatment. The chest tube was clamped and streptoki-
nase 250,000 IU in 0.9% saline was instilled into the
pleural cavity through the chest tube. The chest tube
remained clamped for 4 hours and patients were asked to
change position continuously so that the streptokinase
could thoroughly spread in the pleural cavity. At the end
of 4 hours the clamp was opened and the drainage
amount, complete blood count, and coagulation parame-
ters were then recorded daily. Patients were also
observed for signs of fever, chest pain, and anaphylaxis.
The duration of fibrinolytic treatment was 4.45 days
(range 3-5 days). In both groups (group I and group II)
the chest tube was removed from the patients whose
drainage volume went under 100 ml/day with radiologi-
cally approved recovery (If the lung is expanded and
pouch-free) in both groups. Nine (10.1%) of group I and
10 (45.5%) of group II patients whose control CTs
showed severe pleural thickenings, loculated empyema,
and trapped lung with no clinical recovery, went through
thoracotomy with decortication (group III, n = 19). In all
cases, decortication was performed via posterolateral
thoracotomy (almost always muscle-sparing). The pleur-
al space was entered through the fifth or sixth intercostal
space. As sufficient exposure was obtained, rib resection
was never performed. The intrapleural gelatinous debris,
fibrin mass and all pus were evacuated. The fibrinous
peel on the surface of the visceral and parietal pleura was
carefully removed. After complete removal of visceral
and parietal pleura, meticulous bleeding control was per-
formed. Two chest tubes were inserted into the pleural
space for underwater drainage (-15 to 20 cm H20).
Video-assisted thoracoscopic surgery was not per-
formed because of lack of technical facilities.
Statistical evaluation was performed by using SPSS 10.0
for Windows. Either the Kruskal-Wallis analysis test or
Mann-Whitney U test was used for comparison between
groups. A P-value of less than 0.01 was accepted as
The most common symptoms and signs at admission
were fever (87%), cough (79%), tachycardia (65%), dys-
pnea (58%), purulent sputum (49%), pleuretic type chest
pain (46%), abdominal pain (24%). Severe anaemia was
detected in 19 (27%) patients. The white blood cell
counts were above normal in all patients. There were 71
(64%) right-sided, and 40 (36%) left-sided pleural effu-
sions, and no bilateral effusions. Pleural fluid cultures
were positive in 55 (49.55%) patients. The most fre-
quently identifed micro-organism was Staphylococcus
aureus (32.43%). Other micro-organisms were b haemo-
lytic streptococcus (7.21%), Streptococcus pneumoniae
(6.31%), and Escherichi coli (3.60%) (Table I).
Treatment with chest tube drainage (group I) was suc-
cessful in 80 (89.9%) patients. Chest tube drainage with
intrapleural fibrinolytic treatment (group II) was suc-
cessful in 12 (54.5%) patients. In cases in which the
treatment failed, decortication was applied to 9 patients
in group I (11.1%) and 10 patients in group II (45.5%).
Empyema was treated successfully in all patients to
whom decortication was applied (group III, n = 19).
The chest tube removal time was 9.94 ± 3.58 days
(range 5-20 days) in group I, whereas it was 7.42 ± 1.88
days (range 5-10 days) in group II. In group III, chest
tube removal time was 5.00 ± 2.43 days (range 3-12
days). Although the chest tube removal time in group II
was shorter than in group I, there was no statistically
significant difference (P = 0.019).
The hospital stay was 11.46 ± 3.79 days in group I
and 9.08 ± 2.07 days in group II (Table II). In group III,
hospital stay was 6.32 ± 2.54 days. According to the
hospital stay figures, group II was shorter than group I,
although there was no apparent statistical difference
between them (P = 0.040). The chest removal time and
hospital stay was already included in the post-decortica-
tion term, therefore these 2 parameters were not com-
pared between group I and group II.
Pleural fluid cultures of the patients
b haemolytic streptococcus
In group II, patients (n = 4, 18.2%) reported mild pain
after streptokinase instillation, which was easily con-
trolled with oral analgesics. None of the other patients
developed systematic adverse effects of streptokinase,
such as fever, hypotension or allergic reaction.
In the thoracotomy group (group III) there was no
postoperative mortality. Only in one patient, did atelec-
tasia occur during the postoperative period, which was
resolved with respiratory exercise and nasotracheal aspi-
Low socio-economic level, delay in diagnosis of pneu-
monia, unsuitable antibiotic treatment, immunodeficien-
cy and malnutrition are contributing factors to the devel-
opment of empyema in patients with pneumonia.
Bacterial pneumonia is the most common cause of
pleural effusions or empyema in the pediatric age
group (2, 3). The treatment of empyema in children still
remains controversial. However, the treatment objec-
tives outlined by MAYO (5) are 1) to save life, 2) to elim-
inate the empyema, 3) to re-expand the trapped lung,
4) to restore mobility to the chest wall and diaphragm,
5) to return the respiratory function to normal, 6) to
eliminate complications or chronicity, and 7) to reduce
the duration of hospital stay.
The reported rate of identifying an infectious organ-
ism from pleural fluid varies markedly, from 8% to 76%.
However, in present day practice, pleural fluid culture is
often negative due to use of antibiotics before obtaining
a pleural fluid sample (6). In our study, pleural fluid cul-
tures were positive in 49.55% of the patients. As in many
other studies (1, 3, 6, 7) the most frequently identified
micro-organism in our study was Staphylococcus
Chest tube thoracostomy is considered to be the
appropriate treatment modality for stage II thoracic
empyema (especially for non-multiloculated cases). The
British Thoracic Society recommends that all patients
with significant pleural infection should be treated with
antibiotics and drainage of the pleural fluid (6). In many
studies the rate of success of chest tube thoracostomy
was reported as being between 61% and 100% (8-12).
Chest tube thoracostomy rate of success was 89.9% in
our study. Although chest tube thoracostomy is a treat-
ment with a high rate of success, the hospital stay is
long. This period is reported to be approximately 8-14
days (range 3-35 days) in the literature (8-10, 12, 13).
Likewise in the present study, the duration of hospital
stay in group I was 11.46 ± 3.79 days (range 6-22 days).
The hospital stay and chest tube removal time in group I
was a little longer than in group II, however there was no
statistically significant difference between the two
groups (P = 0.040, P = 0 .019 respectively).
We applied fibrinolytic treatment with chest tube tho-
racostomy to patients in whom multiloculation was
found by US and CT. Intrapleural fibrinolytic drugs may
lyse the fibrinous strands in loculated empyemas.
Several reports have documented successful drainage of
multiloculated empyema using streptokinase and uroki-
nase (11, 14-17). However, MASKELL and associates (18)
reported that (multi-centre, randomised, double-blind
study) there was no benefit from streptokinase in terms
of mortality, rate of surgery, radiographic outcomes, or
duration of the hospital stay. Moreover BALCI et al. (7)
have concluded that fibrinolytic treatment is not an alter-
native to surgery, especially in loculated empyemas in
children. We have performed tube thoracostomy with
intrapleural fibrinolytic treatment on 22 patients. Nine
(40.9%) of them were successful and 13 (59.1%), on
whom treatment was unsuccessful, underwent decortica-
tion. Both BALCI et al. (7) and MASKELL and associ-
ates (18) agreed that fibrinolytic treatment does not
reduce hospital stay or the need for surgery.
Video-assisted thoracoscopic surgery (VATS)
achieves debridement of fibrinous pyogenic material,
breakdown of loculations, and drainage of pus from the
pleural cavity under direct vision. Many authors have
reported that VATS can be performed safely and effec-
tively in children with stage II empyema. In addition,
VATS was associated with a lower mortality rate, lower
open surgery rate, shorter hospital stay, and chest tube
drainage, compared with non-operative treatment (1, 2,
11, 18, 19). Unfortunately we do not have any experi-
ence with VATS.
Decortication has to be performed on patients where
conservative treatment is radiologically and clinically
proven to be insufficient. We applied decortication on 19
of our patients (9 of group I and 10 of group II patients)
who did not show clinical recovery and who had thick
pleural peel with trapped lung and multiple loculations
at control CT. The chest tube removal time was 5.00 ±
2.43 days and hospital stay was 6.32 ± 2.54 days in
group III. Both OZCELIK and associates (3) and POTHULA
et al. (20) have reported that decortication decreases
chest tube drainage and hospital stay. In addition, decor-
tication has low morbidity and mortality rates (3, 7, 20).
Comparison of treatment modalities according to chest tube
removal time and duration of hospital stay
(n = 80)
(n = 12)
Chest tube removal time (d)
Duration of hospital stay (d)
9.94 ± 3.58
11.46 ± 3.79
7.42 ± 1.88
9.08 ± 2.07
Management of Postpneumonic Empyemas in Children
No mortality and only one complication (atelectasis)
was observed in the present study.
In our opinion, chest tube drainage is the preferred
treatment of parapneumonic pediatric empyema.
Success of fibrinolytic treatment in loculated empyema
is low. On patients with no clinical and radiological
recovery after chest tube drainage, thoracotomy with
decortication can be safely applied with low morbidity
and mortality rates.
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A. Kosar, M.D.
Sureyyapasa Chest Disease and Chest Surgery Training and Research
Department of Thoracic Surgery
Ataturk cad. Murat Apt. 46/16
34734 Erenkoy, Istanbul, Turkey
Tel.: + 90 216 386 35 90
Fax: + 90 216 459 68 59
E-mail : firstname.lastname@example.org