Role of routine computed tomography in paediatric pleural empyema

Abstract

Background: The incidence of empyema in children is increasing worldwide. While there are emerging data for the best treatment options, there is little evidence to support the imaging modalities used to guide treatment, particularly with regard to the role of routine CT scanning. The aims of this study were to develop a radiological scoring system for paediatric empyema and to assess the utility of routine CT scanning in this disease. Methods: Children with empyema were prospectively enrolled over a 3-year period into a randomised clinical trial of video-assisted thoracoscopic surgery versus percutaneous chest drain insertion and urokinase. All children received a preoperative chest radiograph (CXR), pleural ultrasound scan (USS) and chest CT scan. In the urokinase arm the clinician inserted the drain with USS evidence only and did not have access to the CT scan at the time of insertion to reflect clinical practice. A scoring system was developed for each individual radiological modality and used to compare imaging characteristics of the pleural fluid collection and underlying parenchyma and to assess the utility of USS and CT to predict length of stay after the intervention. Results: Of the 60 subjects recruited, 46 had USS images available for review, 36 had a CT scan which met the inclusion criteria and 31 had all three radiological measurements (CT, USS and CXR) available for analysis. There was substantial interobserver agreement for USS grades (k = 0.709) and moderate agreement for total CT scores (k = 0.520). There were weak correlations between USS grade and total CT score as well as CT loculation and density scores. Of the 25 CXRs showing simple opacification of the underlying parenchyma only, CT demonstrated simple consolidation (n = 14), necrotising pneumonia (n = 7), cavitary necrosis (n = 3) and pneumatoceles (n = 1). No abnormality was detected on CT scanning which directly altered clinical management. Neither the USS score nor the CT score, nor a combination of the two, were able to predict length of hospital stay. Conclusions: CT scanning detects more parenchymal abnormalities than chest radiography. However, the additional information does not alter management and is unable to predict clinical outcome. This suggests that there is no role for the routine use of CT scanning in children if treated with urokinase and percutaneous chest drain. The omission of routine CT scanning in empyema will reduce the exposure of children to unnecessary radiation and reduce costs. Trial registration number: The trial is fully registered with clinicaltrials.gov (ID: NCT00144950).Although relatively uncommon, the incidence of empyema in children is increasing in many countries.

Characterization of a New Mouse Model of Empyema and the Mechanisms of Pleural Invasion by Streptococcus pneumoniae

“…Another relevant observation is that aspiration of bacteria into the lungs resulted in bacterial translocation into the pleural space before histological evidence of pneumonia develops. This could explain why a surprisingly high proportion of cases of empyema have no radiological evidence of pneumonia (25).…”

Parapneumonic Effusion in Children

“…5,21 The initial treatment of all pleural effusion should be the use of antibiotics. For children with small effusions (<10 mm on lateral decubitus chest radiograph or opacification of less than one-fourth of the hemithorax), the choice of broad-spectrum antibiotics, chest radiographs, and good clinical exam should suffice on an outpatient basis.…”

“…5 part of it attributed to the debut of the conjugate pneumococcal vaccine. 6 However, rates of parapneumonic effusion (PPE) were noticed to increase 5,[7][8][9] In children younger than 2 years, the PPE rate significantly raised in North America from 3.5 cases per 100 000 children in 1996-1998 to 7.0 cases per 100 000 children in [2005][2006][2007]. 8 During the same periods, the PPE rate increased from 3.7 to 10.3 cases per 100 000 children between the age 2 and 4 years.…”

Should Empyema with or without Necrotizing Pneumonia in Children Be Managed Differently?

“…Paediatric studies showed contradictory conclusion regarding the surgery (including chest tube, VATS and thoracotomy): one study suggested that surgery was not better than thoracocentesis alone [12], and another supported early VATS as a valuable option to avoid prolonged recovery and late thoracotomy compared to conservative treatment [18]. retrospective study specifically reported that empyema associated with NP required a longer hospitalisation than empyema without NP [18], when the sole prospective study showed no difference in hospital length of stay [17], in line with our data. We could not complete the functional follow-up due to the small number of patients, but we found no difference in radiological follow-up between both groups.…”