Operative Versus Percutaneous Drainage with Fibrinolysis for Complicated Pediatric Pleural Effusions: A Nationwide Analysis


      Purpose: Management of complicated pleural effusions and empyema using tube thoracostomy with intrapleural fibrinolysis versus surgical drainage has been debated for decades. However, there remains considerable variation in management with these approaches in the pediatric population. This study aims to compare the nationwide outcomes of pediatric patients with complicated pleural effusions.
      Methods: Patients <18 years old with a diagnosis of pleural effusion or empyema associated with pneumonia were identified from the Nationwide Readmissions Database (2016-2018). Demographics, hospital characteristics, and complications were compared among patients undergoing isolated percutaneous drainage (PD), percutaneous drainage with intrapleural fibrinolysis (PDF), or operative drainage (OD) using standard statistical tests.
      Results: 5,424 patients (age 4 [IQR 1-11] years) were identified with a pleural effusion or empyema who underwent percutaneous or surgical intervention. PD (22%) and OD (24%) were utilized more frequently than PDF (3%). Index complications, including bleeding and postprocedural air leak, were similar between groups. Those receiving PDF had lower index length of stay (LOS) and admission costs. Thirty-day and overall readmission rates were highest in patients receiving PD (15% and 24%) and OD (12% and 23%) versus PDF, all p<0.001. Those receiving OD had fewer readmission complications including recurrent effusion or empyema, pneumonia, and bleeding. Overall readmission cost was highest in those receiving PD (p=0.005).
      Conclusion: In this nationwide cohort, PDF was associated with lower index admission cost, shorter LOS as well as lower rates of readmissions compared to OD. This knowledge should be used to improve selection of these treatments in this patient population.


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        • Byington C.L.
        • Spencer L.Y.
        • Johnson T.A.
        • Pavia A.T.
        • Allen D.
        • Mason E.O.
        • et al.
        An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations.
        Clin Infect Dis. 2002; 34: 434-440
        • Bradley J.S.
        • Byington C.L.
        • Shah S.S.
        • Alverson B.
        • Carter E.R.
        • Harrison C.
        • et al.
        The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.
        Clin Infect Dis. 2011; 53: e25-e76
        • Freij B.J.
        • Kusmiesz H.
        • Nelson J.D.
        • McCracken G.H.
        Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases.
        Pediatr Infect Dis. 1984; 3: 578-591
        • Hoff S.J.
        • Neblett W.W.
        • Edwards K.M.
        • Heller R.M.
        • Pietsch J.B.
        • Holcomb G.W.
        • et al.
        Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections.
        Pediatr Infect Dis J. 1991; 10: 194-199
        • Ferguson A.D.
        • Prescott R.J.
        • Selkon J.B.
        • Watson D.
        • Swinburn C.R.
        The clinical course and management of thoracic empyema.
        QJM. 1996; 89: 285-289
        • Elemraid M.A.
        • Thomas M.F.
        • Blain A.P.
        • Rushton S.P.
        • Spencer D.A.
        • Gennery A.R.
        • et al.
        Risk factors for the development of pleural empyema in children.
        Pediatric Pulmonology. 2015; 50: 721-726
        • Piccolo F.
        • Popowicz N.
        • Wong D.
        • Lee Y.C.G.
        Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection.
        J Thorac Dis. 2015; 7: 999-1008
        • Gates R.L.
        • Caniano D.A.
        • Hayes J.R.
        • Arca M.J.
        Does VATS provide optimal treatment of empyema in children? A systematic review.
        J Pediatr Surg. 2004; 39: 381-386
        • Balfour-Lynn I.
        • Abrahamson E.
        • Cohen G.
        • Hartley J.
        • King S.
        • Parikh D.
        • et al.
        BTS guidelines for the management of pleural infection in children.
        Thorax. 2005; 60 (i1–21)
        • Oyetunji T.A.
        • Dorman R.M.
        • Svetanoff W.J.
        • Depala K.
        • Jain S.
        • Dekonenko C.
        • et al.
        Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis.
        J Pediatr Surg. 2020; 55: 2352-2355
        • St. Peter S.D.
        • Tsao K.
        • Harrison C.
        • Jackson M.A.
        • Spilde T.L.
        • Keckler S.J.
        • et al.
        Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial.
        J Pediatr Surg. 2009; 44: 106-111
        • Sonnappa S.
        • Cohen G.
        • Owens C.M.
        • van Doorn C.
        • Cairns J.
        • Stanojevic S.
        • et al.
        Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema.
        Am J Respir Crit Care Med. 2006; 174: 221-227
        • Kurt B.A.
        • Winterhalter K.M.
        • Connors R.H.
        • Betz B.W.
        • Winters J.W.
        Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage.
        Pediatrics. 2006; 118: e547-e553
        • Bishay M.
        • Short M.
        • Shah K.
        • Nagraj S.
        • Arul S.
        • Parikh D.
        • et al.
        Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study.
        J Pediatr Surg. 2009; 44: 337-342
        • Shah S.S.
        • DiCristina C.M.
        • Bell L.M.
        • Ten Have T.
        • Metlay J.P.
        Primary early thoracoscopy and reduction in length of hospital stay and additional procedures among children with complicated pneumonia: results of a multicenter retrospective cohort study.
        Arch Pediatr Adolesc Med. 2008; 162: 675-681
        • Redden M.D.
        • Chin T.Y.
        • van Driel M.L.
        Surgical versus non‐surgical management for pleural empyema.
        Cochrane Database Syst Rev. 2017; 2017: CD010651
        • Scarci M.
        • Zahid I.
        • Billé A.
        • Routledge T.
        Is video-assisted thoracoscopic surgery the best treatment for paediatric pleural empyema?.
        Interact Cardiovasc Thorac Surg. 2011; 13: 70-76
        • Avansino J.R.
        • Goldman B.
        • Sawin R.S.
        • Flum D.R.
        Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis.
        Pediatrics. 2005; 115: 1652-1659
        • Pacilli M.
        • Nataraja R.M.
        Management of paediatric empyema by video-assisted thoracoscopic surgery (VATS) versus chest drain with fibrinolysis: Systematic review and meta-analysis.
        Paediatric Respiratory Reviews. 2019; 30: 42-48
        • Li S.-T.T.
        • Gates R.L.
        Primary operative management for pediatric empyema: decreases in hospital length of stay and charges in a national sample.
        Arch Pediatr Adolesc Med. 2008; 162: 44-48
        • Livingston M.H.
        • Mahant S.
        • Connolly B.
        • MacLusky I.
        • Laberge S.
        • Giglia L.
        • et al.
        Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema.
        JAMA Pediatr. 2020; 174: 332-340
      1. NRD Overview n.d. (accessed October 14, 2021).

        • Nelson T.R.
        Practical strategies to reduce pediatric CT radiation dose.
        J Am Coll Radiol. 2014; 11: 292-299
        • Kanter D.M.
        • Molteni R.A.
        • Andreae M.C.
        • Bradley J.F.
        • Brewer E.D.
        • et al.
        Pediatric Application of Coding and Valuation Systems.
        Pediatrics. 2019; 144e20192498