title: Establishing Equipoise: National Survey of the Treatment of Pediatric Para-Pneumonic Effusion and Empyema.
abstract: BACKGROUND
  Despite six randomized trials of various treatments for pediatric para-pneumonic effusion (PPE), management approaches differ. The purpose of this study was to gain insight into opinions on PPE treatment with the goal of designing a definitive trial to generate consensus intervention guidelines.
  
  
  METHODS
  To evaluate physician opinions regarding PPE management, we developed a survey based on input from a nationwide, multi-disciplinary advisory group that established content validity. The survey was disseminated broadly to six pediatric medicine and interventional radiology groups. Descriptive and χ2statistics were calculated.
  
  
  RESULTS
  There were 741 respondents (response rate 13.1%), of whom 52.2% were surgeons, 15.2% hospitalists, 14.2% pulmonologists, 12.4% intensivists, and 6.0% interventional radiologists. Nearly all respondents (97.3%) reported caring primarily for pediatric patients. Eighty percent reported no written institutional treatment guidelines. Nearly all (90.3%) agreed that patients require antibiotics, but there was disagreement regarding their duration. Respondents also were split as to how often PPE required drainage. There were multiple absolute indications for drainage, including mediastinal shift on chest radiograph (67.2%) and loculations on imaging (47.7%). There were substantial differences in the preferred first-line methods of drainage based on the treating physician's specialty, with surgeons preferring tube thoracostomy and a fibrinolytic agent (42.0%) or video-assisted thoracoscopic surgery (41.6%), whereas interventional radiologists preferred either a tube thoracostomy (46.4%) or a tube thoracostomy with a fibrinolytic agent (39.3%) (p < 0.001). A large majority (75.3%) believed that the published evidence does not identify the optimal intervention.
  
  
  CONCLUSIONS
  There is a lack of consensus regarding the optimal treatment of PPE. Respondents believed the published evidence is inconclusive and were willing to participate in a prospective trial. These findings will help inform the design of a randomized, pragmatic clinical trial to optimize PPE management.
authors.affiliation: 1 Department of Surgery, University of Washington , Seattle, Washington.
authors.forename: Morgan K
authors.initials: MK
authors.lastname: Richards
authors.affiliation: 1 Department of Surgery, University of Washington , Seattle, Washington.
authors.forename: Jarod P
authors.initials: JP
authors.lastname: Mcateer
authors.affiliation: 2 Department of Health Services, University of Washington , Seattle, Washington.
authors.forename: Todd C
authors.initials: TC
authors.lastname: Edwards
authors.affiliation: 3 Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children's Hospital , Seattle.
authors.forename: Lucas R
authors.initials: LR
authors.lastname: Hoffman
authors.affiliation: 4 Department of Pediatrics, Division of Infectious Disease, Seattle Children's Hospital , Seattle.
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Kronman
authors.affiliation: 5 Department of Radiology, Seattle Children's Hospital .
authors.forename: Dennis W
authors.initials: DW
authors.lastname: Shaw
authors.affiliation: 6 Department of Thoracic and General Surgery, Seattle Children's Hospital .
authors.forename: Adam B
authors.initials: AB
authors.lastname: Goldin
mesh_terms: D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D016724:Empyema, Pleural / Q000601:surgery*; D006801:Humans; D010820:Physicians / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000601:surgery*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D019616:Thoracic Surgical Procedures
keywords: chest surgery; empyema; pneumonia