Chest Tube with Fibrinolytics vs VATS for the Treatment of Pleural Empyema in Children: A Systematic Review Summer Bryant, DO, Shawn Ralston, MD University of Texas Health Sciences Center San Antonio

ABSTRACT Objective: To determine whether loculated empyema should be treated with chest tube with fibrinolytics or primary video- assisted thoracoscopic surgery (VATS). Results: Length of stay for patients receiving primary fibrinolytic therapy through the chest tube had shorter length of hospital stay (although most p values showed no significant difference) and decreased rates of treatment failure than those receiving chest tube only as the primary treatment. There was essentially no difference in length of hospital stay between patients receiving chest tube with fibrinolytics and patients receiving VATS as treatment for empyema. Conclusion: Chest tube with fibrinolytics is the preferred treatment for empyema when compared to VATS. Although there was no significant difference in outcome, chest tube with fibrinolytics is the more economical option. BACKGROUND Traditionally, parapneumonic effusions secondary to pneumonia have been treated with antibiotics and drainage. Despite aggressive treatment with the aforementioned, occasionally the effusions can become loculated and require further treatments. There is currently a debate about which treatment for loculated empyema is most efficacious; primary chest tube with fibrinolytics or VATS. STUDY QUESTIONS Is primary chest tube with fibrinolytics more effective than chest tube alone in the treatment of loculated empyema? Which is the preferred treatment for loculated empyema, chest tube with fibrinolytics or VATS? METHODS A search of the PubMed database up to May 2010 was conducted using the search terms “empyema AND urokinase”, “empyema AND streptokinase”, “empyema AND fibrinolytics”, “empyema AND VATS”, “empyema AND video-assisted thorascopic surgery”, “fibrinolytics AND VATS” and “fibrinolytics AND video-assisted thorascopic surgery”. Limits were set to only include children age 0-18 years in the search. Other pertinent literature was identified based on a manual search of the bibliographies of the references found in the initial search. Inclusion criteria were any study reporting on length of stay and treatment failure for chest tube alone vs. chest tube with fibrinolytics, and length of stay for chest tube with fibrinolytics vs. VATS. Excluded studies were those that did not report on the desired outcomes. Length of stay and treatment failure rates were extracted from the papers. 95% confidence intervals were then calculated.

Table I. Characteristics of the studies reviewed and LOS for thoracostomy tube drainage alone vs thoracostamy tube with fibrinolytics Study Type of Study N N Fib Primary or Salvage LOS chest tube alone LOS Chest tube + fibrinolytics P value Treatment failure CT alone Treatment failure CT + fibrinolytics P value Thomson 2002 RCT6029Primary9.5 days7.4 days % (2.6% - 26%) 6.9% (0.9% - 23%) Barbato 2003 RC2817Primary24 days17 days % (51% - 96%) 29.4% (13% - 53%) Yao 2004PC4220Primary18.2 days16.6 daysNS 40% (23% - 61%) 10% (1.6% - 31%) <0.05 Khalil 2006 RC3817Primary21 days11 daysNS 50% (9.5% - 91%) 17.6% (5.4% - 42%) NS Aydogan 2008 RC 5329Primary19.1 days21.9 daysNS 8.3% (3.5% - 32%) 20.6% (9.5% - 39%) NS Demirhan 2008 RC11122Primary11.5 days9.1 days % (5.2% - 18%) 45.5% (27% - 65%) Hilliard 2003 RC2214Primary15 days8 daysNS 38% (13% - 70%) 14% (2.8% - 41%) Chen 2006 RC2613Salvage24.4 days15.5 days % (3.1% - 43%) 0%NS Ho 2007RC2110Salvage24 days21.5 daysNS 45.5% (21% - 72%) 0%0.02 RESULTS RCT=randomized controlled trial, RC=retrospective cohort

Table II. Characteristics of studies reviewed and LOS for thoracostomy with fibrinolytics vs. VATS Study DesignN fibrinolytics N VATS LOS CT + Fibrinolytics LOS VATSP value Gates 2004RC days12.4 days0.048 Li & Gates 2008 RC days13.2 daysNS Kurt 2007RCT days5.8 days0.004 Sonnapa 2008RCT days8 daysNS St Peter 2009RCT18 8 days6.9 daysNS CONCLUSIONS Primary chest tube with fibrinolytics is superior to chest tube alone for the treatment of empyema There is no difference in the efficacy of chest tube with fibrinolytics vs VATS for the treatment of empyema Chest tube with fibrinolytics is more cost effective than VATS for the treatment of empyema and is therefore, a better choice.

REFERENCES Aydogan M, Aydogan A, Ozcan A, et al., Intrapleural streptokinase treatment in children with empyema. Eur J Pediatr. 2008;167: Balfour-Lynn IM Abrahamson E, Cohen G, et al., BTS guidelines for the management of pleural infection in children. Thorax. 2005;60(suppl 1):i1-i21. Barbato A, Panizzolo C, Monciotti C, et al., Use of urokinase in childhood pleural empyema, Pediatr Pulmonol. 2003;35: Chen JP, Lue KH, Liu SC, et al., Intrapleural urokinase treatment in children with complicated parapneumonic effusion. Acta Paediatr Tw. 2006;47: Cochran JB, Tecklenburg FW, Turner RB. Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema. Pediatr Crit Care Med. 2003;4: Ekingen G, Guvenc BH, Sozubir S, et al., Fibrinolytic treatment of complicated pediatric thoracic empyemas with intrapleural streptokinase. Eur J Cardiothoracic Surg. 2004;26: Grijalva CG, Nuorti JP, Zhu Y, et al., Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis. 2010;50: Hilliard Ho MY, Chen HY, Yen YH, et al., Intrapleural streptokinase for the treatment of childhood empyema. Acta Paediatr Tw. 2007;48: Khalil PA, Corbett BA, Jones MO, et al., Less is best? The impact of urokinase as the first line management of empyema thoracis. Pediatr Surg Int. 2007;23: Krishnan S, Amin N, Dozor AJ, et al., Urokinase in the management of complicated parapneumonic effusions in children. Chest. 1997;112: Singh M, Matthew J, Chandra S, Katariya S, Kumar L. Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children. Acta Paediatr. 2004;93: Thomson AH, Hull J, Kumar MR, et al., Randomized trial of intrapleural urokinase in the treatment of childhood empyema. Thorax. 2002;57: Tuncozgur Yao CT, Wu JM, Liu CC, et al., Treatment of complicated parapneumonic pleural effusion with intrapleural streptokinase in children. Chest. 2004;125: