title: Medical management of parapneumonic pleural disease.
abstract: Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.
authors.affiliation: Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
authors.forename: N P
authors.initials: NP
authors.lastname: Barnes
authors.forename: J
authors.initials: J
authors.lastname: Hull
authors.forename: A H
authors.initials: AH
authors.lastname: Thomson
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D002444:Cefuroxime / Q000008:administration & dosage; D015505:Chest Tubes; D002648:Child; D002675:Child, Preschool; D004311:Double-Blind Method; D004322:Drainage / Q000295:instrumentation*; D016724:Empyema, Pleural / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D045604:Extracellular Fluid / Q000382:microbiology; D005260:Female; D005500:Follow-Up Studies; D006094:Gram-Positive Bacteria / Q000302:isolation & purification; D016908:Gram-Positive Bacterial Infections / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy; D006801:Humans; D007223:Infant; D007275:Injections, Intravenous; D007322:Instillation, Drug; D007902:Length of Stay; D008297:Male; D010960:Plasminogen Activators / Q000008:administration & dosage*; D035422:Pleural Cavity / Q000000981:diagnostic imaging; D010996:Pleural Effusion / Q000175:diagnosis / Q000382:microbiology / Q000628:therapy; D018410:Pneumonia, Bacterial / Q000150:complications* / Q000000981:diagnostic imaging; D013902:Radiography, Thoracic; D012189:Retrospective Studies; D013908:Thoracotomy; D016896:Treatment Outcome; D014463:Ultrasonography; D014568:Urokinase-Type Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D000900:Anti-Bacterial Agents; D010960:Plasminogen Activators; D014568:Urokinase-Type Plasminogen Activator; D002444:Cefuroxime