ORIGINAL CONTRIBUTION

Outcome of Pediatric Empyema Thoracis

Managed by Tube Thoracostomy
Maria Lorena Corazon V Rodriguez, MD, Gisel T Catalan, MD
Department of Surgery
University of the Philippines
Philippine General Hospital
Manila, Philippines

ABSTRACT

The proper management of empyema thoracis in children continues to be a source of

debate. This study assessed the clinical profile and outcome of patients managed by tube
thoracostomy. Chart review was performed in 31 patients managed from January 1989 to
December 2003. Outcome measures were duration and outcome of thoracostomy, number
of days to radiologic lung re-expansion, length of hospitalization, and microbiologic
flora involved. The mean age was 9 years (male/female, 2:1) and the most commonly
affected group were those aged 1 year and below. Staphylococcus aureus was the
most frequent infecting organism. A few (6%) achieved lung re-expansion 1 week
postoperatively, but 64% did not achieve full lung re-expansion even after 3 weeks.
Most (71%) of the thoracostomies were converted to open drainage. Half (52%) of
the patients were hospitalized for at least 5 weeks. There were 3 recurrences and
3 deaths, 2 of which were most likely associated with empyema. Empyema managed
by tube thoracostomy alone showed evidence of delayed lung re-expansion, prolonged
drainage and hospitalization, and unfavorable outcome.
(Asian Cardiovasc Thorac Ann 2006;14:98101)

TT is successful, drainage is 83% complete in

3 days.2 However, complicated cases will require
multiple chest tubes and there is a 25%80%
chance of treatment failure. 3,4 Open drainage is
achieved by drain tube thoracostomy, rib resection,
an Eloessers flap, or a Heimlich valve. These
maneuvers enable continuous drainage without
hampering ambulation. The incidence of permanent
sequelae in empyema thoracis is low to absent 5.
Pleural opacity resolve by 216 months. 6,7 There
is no permanent lung function abnormality, and the
long-term prognosis is excellent.2 The current mode
of therapy in our institution is conservative, utilizing
TT alone. Although there are now reports that favor
early aggressive surgical therapy, there is still no
internationally accepted protocol nor randomized
controlled trials of the management of pediatric
empyema. This study assessed the outcome of TT
for thoracic empyema in our institution.

INTRODUCTION

Thoracic empyema continues to have a high mortality

rate (1016%).1 It occurs when bacteria invade and
propagate in the normally sterile pleural space, and
proceeds in 3 phases. The exudative phase is caused
by increased permeability of the inflamed pleura. The
fibrinopurulent phase is characterized by accelerated
fibrin deposition, giving rise to loculations and pus
formation. The organizational phase begins 1 week
after infection and is characterized by multiloculated
empyema and pleural peel, with subsequent lung
entrapment. The predominant organisms involved
are Staphylococcus, Streptococcus, and Mycoplasma
species. The clinical features are nonspecific: dyspnea,
fever, cough, and chest pain. Various treatments have
been employed, including antibiotics, thoracentesis,
tube thoracostomy (TT), intrapleural fibrinolytics,
open-window thoracostomy, video-assisted
thoracoscopic surgery, and thoracotomy. When

For reprint information contact:

Maria Lorena Corazon V Rodriguez, MD Tel: 63 2 524 8484 Fax: 63 2 524 8484 Email: yoyi_rodriguez@yahoo.com
Department of Surgery, University of the Philippines, Philippine General Hospital, Taft Avenue, Manila, Philippines.
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Outcome of Thoracostomy for Pediatric Empyema

Rodriguez

PATIENTS AND METHODS

A chart review was carried out of all 31 pediatric patients

diagnosed with empyema thoracis and referred to our
department from January 1999 to December 2003. For
each patient, the outcome measures identified were:
duration and outcome of treatment with intercostal TT,
number of days to radiologic lung re-expansion, and
length of hospital stay. The microbiologic flora was
also noted. Fibrinolytics were not used in any of the
patients. Twelve (39%) were infants, 6 (19%) were aged
2 to 10 years, and 13 (42%) were aged 11 to 18 years.
The mean age was 9 years, and the male-to-female
ratio was 2:1.

Table 1. Bacteriology Profile

Age (years) Culture Growth
<1

2 to 10

11 to 18

No.of Patients

Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia alvei
Staphylococcus aureus
Hemophilus influenzae
Streptococcus pneumoniae
Escherichia coli
Burkholderia alvei
Staphylococcus aureus
Hemophilus influenzae
Enterobacter agglomerans
Alcaligenes faecalis
Pseudomonas aeruginosa
Streptococcus pneumoniae
Streptococcus viridans
Staphylococcus aureus
Acinetobacter
Hafnia alvei

3
1
1
2
1
1
1
1
3
1
1
1
2
2
1
1
1
1

RESULTS

Of the 31 patients, 19 (61%) had follow-up records.

Mean duration of follow-up was 61 days (range, 9105
days). Two patients were readmitted for recurrence,
and one experienced a recurrence during the same
admission. One patient had persistent empyema
necessitating insertion of a second tube. Thus, 35 tube
thoracostomies were performed. Six (19%) patients had
sterile pleural fluid upon analysis. Staphylococcus aureus
was the most frequently isolated pleural fluid pathogen
(8 isolates; 32%). Other pathogens isolated are shown in
Table 1. Staphylococcus aureus was more often found
in the younger age groups (010 years old), whereas
Streptococcus species and Pseudomonas were more
common among adolescents (1118 years old).

Table 2. Time to Radiologic Lung Re-expansion in

31 Patients Treated by Tube Thoracostomy
Time (days)

No. of Cases

No re-expansion
1 to 7
8 to 14
15 to 21
22 to 28
Unknown

19
2
3
1
1
5

61
6
10
3
3
16

Post-TT surveillance of the 34 cases of empyema

thoracis in 31 patients revealed that 61% did not show
radiologic evidence of lung re-expansion (Table 2),
even if the duration of thoracostomy was prolonged to
more than 3 weeks. The duration of treatment with tube
thoracostomy extended from 1 to > 7 weeks (Table 3),
usually lasting for 2 weeks. If complete pleural drainage

Table 3. Duration of Drainage, Time to Conversion to Open Thoracostomy, and Hospital Stay in Cases Treated
by Tube Thoracostomy
Variable
(days)

Duration of drainage
(n = 35)

Conversion to open drainage

(n = 26)

Duration of hospitalization
(n = 33)

17
814
1521
2228
29
57
85
Unknown

4 (11%)
5 (14%)
1 (3%)
0
3 (9%)
2 (6%)
6 (17%)
14 (40%)

5 (19%)
10 (38%)
7 (27%)
1 (4%)
1 (4%)
2 (8%)

0
2 (6%)
4 (12%)
9 (27%)
17 (52%)
1 (3%)

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Outcome of Thoracostomy for Pediatric Empyema

Rodriguez

CT Inserted (31)

CT Removed
(8)

CT Inserted for
Recurrence (1)

Discharged
(6)

Demise (1)

CT Converted to
Open Tube (22)

Demise (1)

Converted to
Open Tube

Discharged

Open Tube
Removed (2)

Discharged
(19)

Demise (1)

Discharged (1)

Open Tube Removed (18)

CT Inserted for
Persistence (1)

Readmitted for Recurrence,

CT Inserted (1)

Converted to
Open Tube

Converted to
Open Tube

CT Removed

Discharged

Open Tube
Removed

Open Tube
Removed

Discharged

Readmitted for Recurrence,

CT Inserted

Converted to
Open Tube

Discharged

Open Tube
Removed

Figure 1. Outcome of 31 Pediatric Empyema Thoracis Managed by Tube Thoracostomy. CT = chest tube.

and lung re-expansion was not achieved after two weeks,

it was converted to an open drain. The drain was then
gradually mobilized and spontaneously extruded. The
outcome of the treated cases is shown in Figure 1.
Three patients (10%) died due to staphylococcal septic
shock, progressive bronchopneumonia, and right atrial
thrombus formation.

of prolonged treatment for empyema, this extended

period of recovery demands continued attention to the
disease, and delays the return to normal activity. The
finding that 71% of patients eventually had their primary
TT converted to open drainage is in agreement with
earlier studies citing 25%80% treatment failure for
TT alone.3,4 With conversion to open tube drainage and
removal of the drainage bottle, patients are encouraged
to ambulate more, thus promoting better pulmonary
hygiene. This form of treatment, however, entails an
extended duration of therapy, persistent need for tube
care, continuing discomfort, and the risk of further injury
due to the presence of an indwelling intrapleural catheter.
The prolonged duration of an indwelling tube may be
contrasted with postoperative tube drains in patients who
undergo thoracotomy, which are removed within 3 days.8,9
Half of the patients had to stay in the hospital for at
least 5 weeks for their treatment which comprised TT
and intravenous antibiotics. This prolonged hospital stay
can be contrasted to that of patients given immediate
definitive therapy, who have a much shorter postoperative
hospital stay of 417 days for thoracoscopy, and 410
days for thoracotomy.713 Prolonged hospital stay increases
the patients risk of acquiring nosocomial infection.

DISCUSSION

Empyema thoracis continues to be a common disease

entity in our institution. It affects the adult and pediatric
population alike. In our study, the most commonly affected
were those aged 1 year and below. The bacteriologic
profile of empyema was dominated by Staphylococcus
aureus, in agreement with previous reports. The presence
of excess pleural fluid, loculations, and pleural peel make
it difficult for the lungs to expand fully. This compromises
the patients ventilation.
In this study, only 6% of the patients with empyema
who were treated with TT achieved lung re-expansion
after 1 week; 61% did not achieve full lung re-expansion
even after 3 weeks. This reflects the fact that although
chest tube drainage can remove free fluid in the pleural
space, it cannot drain loculated effusions, which are
characteristic of the advanced stages of empyema thoracis.
Likewise, TT by itself does not promote resolution of
the fibrinous pleural peel that restricts ventilation.
Although we do not expect permanent restrictive lung
disease development in pediatric patients as a result
ASIAN CARDIOVASCULAR & THORACIC ANNALS

In this study, 2 of the 3 deaths were associated with

TT. Earlier studies indicated that mortality rates of
empyema thoracis do not vary whether the treatment
approach is surgical or non-surgical.1 Surgical therapy
is advised in advanced stages, in cases of inadequate
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Outcome of Thoracostomy for Pediatric Empyema

Rodriguez
pleural evacuation, and in persistent pleural infection. It is
possible that these two cases might have been salvageable
if they had undergone surgery at a feasible time.
Video-assisted thoracoscopic surgery with decortication
is recommended in anerobic, tuberculous, staphylococcal,
and pneumococcal infections.15 This modality shortens the
duration of tube drainage (24 days) and hospital stay,
compared to tube thoracostomy or fibrinolytic therapy.11,13
Thoracotomy with decortication is indicated for advanced
stages of empyema thoracis, even in children.8 Performed
in a timely manner, it is associated with low morbidity,
providing rapid resolution of symptoms, with a 95%
success rate, 98% freedom from hospital re-admission,
and 100% survival rate.9,10 Eighty percent of patients
treated conservatively eventually need a thoracotomy.
Delay results in complications and consequently prolongs
hospital stay.4

REFERENCES

It is recommended that patients in an advanced stage

of empyema thoracis undergo early definitive surgical
treatment. This will improve the patients ventilatory
status earlier (with complete drainage and lung
re-expansion), shorten the duration of an indwelling
tube, and reduce hospital stay. A randomized controlled
trial may be useful to compare the treatment outcomes
between TT, thoracoscopy, and thoracotomy among
the pediatric population with empyema thoracis. This
study is limited by the incomplete patient follow-up,
and less-than-adequate documentation in some patient
charts.

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10. Balci AE, Eren S, Ulku R, Eren MN. Management of multiloculated

empyema thoracis in children: thoracotomy versus fibrinolytic
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ACKNOWLEDGMENTS

14. Chen LE, Langer JC, Dillon PA, Foglia RP, Huddleston CB,
Mendeloff EN, et al. Management of late-stage parapneumonic
empyema. J Pediatr Surg 2002;37:3714.

We extend our gratitude to: the PGH TCVS research staff

for helping us gather the patient census; the PGH medical
records staff for helping us recover the charts needed;
and the PGH patients who continually trust in us.

2006, VOL. 14, NO. 2

1.

15. Mandal AK, Thadepalli H, Mandal AK, Chettipally U. Outcome of

primary empyema thoracis: therapeutic and microbiologic aspects.
Ann Thorac Surg 1998;66:17826.

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