Chest Tube with Fibrinolytics vs VATS for the Treatment of Pleural Empyema in Children: A

Systematic ReviewSummer 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

RCT 60 29 Primary 9.5 days 7.4 days 0.027 9.7%(2.6% - 26%)

6.9%(0.9% - 23%)

Barbato 2003

RC 28 17 Primary 24 days 17 days 0.02 81.8%(51% - 96%)

29.4% (13% - 53%)

Yao 2004 PC 42 20 Primary 18.2 days 16.6 days NS 40% (23% - 61%)

10%(1.6% - 31%)

<0.05

Khalil 2006

RC 38 17 Primary 21 days 11 days NS 50%(9.5% - 91%)

17.6%(5.4% - 42%)

NS

Aydogan 2008

RC 53 29 Primary 19.1 days 21.9 days NS 8.3%(3.5% - 32%)

20.6%(9.5% - 39%)

NS

Demirhan 2008

RC 111 22 Primary 11.5 days 9.1 days 0.04 10.1%(5.2% - 18%)

45.5%(27% - 65%)

Hilliard 2003

RC 22 14 Primary 15 days 8 days NS 38%(13% - 70%)

14%(2.8% - 41%)

Chen 2006

RC 26 13 Salvage 24.4 days 15.5 days 0.002 15.4%(3.1% - 43%)

0% NS

Ho 2007 RC 21 10 Salvage 24 days 21.5 days NS 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 Design N fibrinolytics

N VATS LOS CT + Fibrinolytics

LOS VATS P value

Gates 2004 RC 24 6 8.4 days 12.4 days 0.048

Li & Gates 2008

RC 27 121 12.4 days 13.2 days NS

Kurt 2007 RCT 7 10 13.2 days 5.8 days 0.004

Sonnapa 2008 RCT 30 30 5.8 days 8 days NS

St Peter 2009 RCT 18 18 8 days 6.9 days NS

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.

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