What is the recommended management for empyema thoracis (empyema thorax) in children?

Management of Empyema Thoracis in Children

Children with empyema thoracis should be managed with antibiotics, small-bore chest tube drainage, and intrapleural urokinase fibrinolytics, with early surgical consultation if this approach fails. 1

Initial Management Approach

Antibiotics and Chest Drainage

• Start broad-spectrum intravenous antibiotics immediately targeting common pathogens (Staphylococcus aureus being most common), adjusting based on culture results 1, 2
• Insert a small-bore chest drain (including pigtail catheters) rather than large-bore drains to minimize patient discomfort, as there is no evidence that large-bore drains provide any advantage 1
• Use ultrasound guidance to determine the optimal site for drain insertion 1
• Never use substantial force or a trocar when inserting the drain 1

Chest Drain Management Specifics

• Connect all chest tubes to a unidirectional flow drainage system (underwater seal bottle) kept below the patient's chest level at all times 1
• Clamp the drain for 1 hour once 10 ml/kg are initially removed to prevent re-expansion pulmonary edema 1
• Never clamp a bubbling chest drain 1
• Check for obstruction by flushing if drainage suddenly ceases 1
• Manage patients on specialist wards with staff trained in chest drain management 1

Intrapleural Fibrinolytic Therapy

Administer intrapleural urokinase for any complicated parapneumonic effusion (thick fluid with loculations) or empyema (overt pus), as this shortens hospital stay 1

Urokinase Dosing Protocol

• 40,000 units in 40 ml 0.9% saline for children ≥10 kg 1
• 10,000 units in 10 ml 0.9% saline for children <10 kg 1
• Administer twice daily for 3 days (6 doses total) 1
• Urokinase is specifically recommended because it is the only fibrinolytic studied in a randomized controlled trial in children 1

This approach is highly effective, with studies showing that complete drainage can be achieved in many cases, though loculations may persist in approximately 64% of cases but still resolve without requiring decortication 3.

Surgical Intervention

Indications for Surgery

Initiate early discussion with a thoracic surgeon if the patient fails to respond to chest tube drainage, antibiotics, and fibrinolytics 1

Specific surgical indications include:

• Persisting sepsis with persistent pleural collection despite chest tube drainage and antibiotics 1
• Organized empyema with thick peel encasing the lung in a symptomatic child requiring formal thoracotomy and decortication 1
• Multiloculated, recurrent empyema refractory to conservative management 3

Surgical Options

• Video-assisted thoracoscopic surgery (VATS) can be effective for early intervention, allowing adhesiolysis, pleural debridement, and optimal drain placement without open thoracotomy 4
• Formal thoracotomy and decortication is reserved for organized empyema with thick pleural peel 1
• A coexisting lung abscess should not normally be surgically drained 1

Supportive Care and Monitoring

Symptomatic Management

• Provide antipyretics for fever control 1
• Ensure adequate analgesia to keep the child comfortable, particularly with a chest drain in place 1
• Do not perform chest physiotherapy as it is not beneficial in children with empyema 1
• Encourage early mobilization and exercise 1

Common Findings Not Requiring Treatment

• Secondary thrombocytosis (platelet count >500) is common but benign; antiplatelet therapy is not necessary 1
• Secondary scoliosis on chest radiograph is common but transient; no specific treatment required, but confirm resolution 1

Follow-Up

• Follow children after discharge until complete recovery and chest radiograph returns to near normal 1
• Consider underlying diagnoses such as immunodeficiency or cystic fibrosis in appropriate cases 1
• Expect pleural thickening in approximately 84% and rib crowding in 60% at discharge, which typically resolves 2

Expected Outcomes

With appropriate management using antibiotics, chest tube drainage, and fibrinolytics:

• Average duration of fever: 13-17 days 3
• Average hospitalization: 23-27 days for those responding to conservative management 3
• Most children (82%) avoid decortication with this approach 3
• Those requiring decortication have longer fever duration (24 days) and hospitalization (40 days) 3

Common Pitfall: Delaying surgical consultation when conservative management fails leads to prolonged morbidity. Early thoracic surgery involvement (within 3-5 days of failed medical management) can prevent progression to organized empyema requiring formal decortication 1, 3.