Original Article

Empyema Thoracis in Children: A 5‑Year Experience in a Tertiary Care

Institute
Kartik Chandra Mandal, Gobinda Mandal1, Pankaj Halder, Dipanwita Mitra2, Bidyut Debnath, Mala Bhattacharya1

Departments of Pediatric Objective: Empyema thoracis (ET) in children is a disease of significant morbidity
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Abstract
Surgery, 1Pediatric Medicine
and 2Anesthesiology,
and mortality. In the event of failure to resolute following intercostal chest tube
Dr. B. C. Roy Post drainage (ICD), thoracotomy decortication (TDC) remains the treatment of choice.
Graduate Institute of We have reviewed the outcome of management of 96 cases of ET with the intent
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Pediatric Sciences, Kolkata, to establish the scope of ICD as primary form of the management.
West Bengal, India Materials and Methods: This is a retrospective study of 96 patients of ET
who were managed in pediatric surgery department over a period of 5 years
(April 2013 – March 2018). Ninety‑six patients at a single center met inclusion
criteria for having ET and underwent ICD. We excluded the cases where
video‑assisted thoracoscopic surgery was provided as primary treatment. The
patients were categorized into complicated and uncomplicated groups. Those with
pyopneumothorax, encysted empyema, multiloculated empyema, and bilateral ET
were assigned as complicated group. There were two treatment groups: (I) those
responded with ICD alone (II) those with ICD followed by TDC.
Results: All 96 cases received ICD as primary management. There were
54 uncomplicated cases and 42 complicated cases. Out of 42 complicated cases,
26 patients recovered with ICD alone and 16 patients needed TDC. A total of
80 (83.33%) patients (54 uncomplicated ± 26 complicated) recovered with ICD
alone. Significant complications were encountered in follow‑up of patients who
underwent delayed thoracotomy in the form of overriding of the ribs (n = 3) and
postoperative air leak (n = 4). There was no mortality in our series.
Conclusion: Early initiation of management of ET with intercostal tube drainage
is simple, safe, effective even in complicated cases, and has less complications.
Thoracotomy with decortication should be reserved for ICD failure cases.

Received: May, 2018.

Keywords: Children, decortication, empyema thoracis, failure, intercostal chest
Accepted: December, 2018. tube

Introduction antibiotics may fail to clear the pus in loculated ET,

E mpyema thoracis (ET) is known since Hippocrates’
time; nonetheless, incidence is still rising all
over the world.[1] The disease can produce significant
morbidity in children if inadequately treated. Treatment
ranges from intravenous antibiotics, intercostal chest
tube drainage (ICD), video‑assisted thoracoscopic
surgery (VATS) to thoracotomy decortication (TDC).
Early initiation of intravenous antibiotics and ICD
procedure promote smooth recovery and lung expansion
bilateral empyema, thickened pleura, and chronic ET
with lung trapping. Failed cases should be investigated
promptly for planning of surgical intervention. Thus,
close monitoring of the responses to ICD procedure is
essential in the management of ET. The current study
Address for correspondence: Dr. Pankaj Halder,
Saroda Pally, Sitko Road, Baruipur, Kolkata ‑ 700 144,
West Bengal, India.
E‑mail: pankaj.cnmc@gmail.com

in up to 86% of cases.[2] ICD with intravenous This is an open access journal, and articles are distributed under the terms of the Creative
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How to cite this article: Mandal KC, Mandal G, Halder P, Mitra D,

Debnath B, Bhattacharya M. Empyema thoracis in children: A 5‑year
DOI: 10.4103/jiaps.JIAPS_112_18 experience in a tertiary care institute. J Indian Assoc Pediatr Surg
2019;24:197-202.

© 2019 Journal of Indian Association of Pediatric Surgeons | Published by Wolters Kluwer - Medknow 197
 Mandal, et al.: Role of intercostal chest tube drainage in the management of empyema thoracis in children

evaluates the treatment and outcome of 96 patients with Table 1: Clinicopathological spectrum of empyema
ET highlighting the indications for TDC. thoracis in children (n=96)
Parameters Subparameters Number of
Materials and Methods cases (%)
We conducted a retrospective study of 96 children who Age <2 years 36 patients
received treatment for ET over a period of 5 years in the Male 24 (25)
department of pediatric medicine and pediatric surgery Female 12 (12.5)
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2-5 years 32 patients

in our institute. We included the patients who had
Male 30 (31.25)
clinicoradiological evidence of ET and received ICD as
Female 2 (2.08)
initial treatment procedure. In our study, indications for >5 years 28 patients
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ICD were persistent fever inspite of parenteral antibiotic Male 26 (27.09)

treatment more than 48 h or respiratory distress due to Female 2 (2.08)
ET. We excluded the cases where primary VATS was Symptoms Fever 54 (56.25)
done for the management of ET. Respiratory distress 26 (27.08)
Chest pain + respiratory 16 (16.67)
The age range of cohort was 0–12 years, youngest
distress
patient being –2 months and the oldest being 11 years Site of involvement Unilateral
[Table 1]. Thirty‑six patients (37.5%) were below 2 years Left 46 (47.91)
of age, 32 (33.3%) were between 3 and 5 years, and Right 48 (50)
28 (29.16) were above 5 years of age. In this study, male Bilateral 2 (2.09)
and female distribution was 58 and 38, respectively. Duration of ICD <7 56 (58.33)
Forty‑eight (50%) patients had right‑sided disease (days) >7 40 (41.67)
while forty‑six patients (47.91%) had left‑sided disease; Pleural fluid color Clear 5 (5.2)
two (2.08%) patients were suffering from bilateral Reddish 20 (20.83)
disease. In sixty‑five (67.7%) patients, fever was the Straw 25 (26.04)
predominant symptom while 31 (32.29%) patients had Purulent 46 (47.92)
respiratory distress in addition to fever and chest pain. Pleural fluid growth No growth 91 (94.8)
Growth 5 (5.2)
After confirmation of ET by chest X‑ray (CXR) and Acinetobacter baumannii
ultrasonography (USG), all patients underwent ICD Staphylococcus aureus
placement under local anesthesia with needle aspiration
Staphylococcus
beforehand. Depending on the pathology (loculated haemolyticus
empyema in the same side or bilateral empyema), one Sphingomonas
or two ICDs were inserted. Immediately after the ICD paucimobilis
placement, a CXR was performed to see the position of Gram‑negative bacilli
the ICD. After 24 h, clinical assessment of empyema Complications of ICD Accidental came out 1 (1.04)
resolution is done by resolution of fever, respiratory (14 patients) Displacement 2 (2.08)
distress, and general wellbeing of the patients. In Blockage 8 (8.34)
addition to that, a series of follow‑up CXR were taken Kinking 2 (2.08)
at 3, 5, and 7 days, according to need. Pneumothorax 1 (1.04)
Failure ICD (post‑ICD needed 16 (16.66)
Results decortication)
Decortication None
All 54 uncomplicated empyema patients responded to
ICD: Intercostal chest drainage
ICD alone while 26 patients with complicated empyema
resolved with ICD alone. Complicated empyema
pleural fluid was positive for Gm/acid‑fast bacilli stain
category comprised patients with pyopneumothorax,
in 4 patients (4.16%).
encysted empyema, multiloculated empyema, and
bilateral ET. The mean age of the patient at ICD Complications of ICD were seen in 14 patients (14.54%)
placement was 46.47 months and range 2–122 months. in the form of pneumothorax 1 patient, displacement and/
The average time of keeping the ICD was 8.66 days, or kinking of the tube in 9 patients, and tube blockade due
range 3–19 days and the mean duration of keeping the to thick pus in 4 patients. The mean duration of hospital
ICD after thoracotomy was 10 days, range 5–14 days. stay was 5 days for ICD and 8 days for decortication.
There was no difficulty in placing or inadvertent removal Redo ICD was needed in two cases. Out of 42 complicated
of ICD in any patient. The culture of the aspirated cases, 16 patients did not improve satisfactorily with

198 Journal of Indian Association of Pediatric Surgeons / Volume 24 / Issue 3 / July-September 2019
 Mandal, et al.: Role of intercostal chest tube drainage in the management of empyema thoracis in children

ICD procedure. They (7 patients with pyopneumothorax,
4 patients with encysted empyema, 4 patients with
multiloculated empyema, and one patient with thickened
pleura with trapped lung) underwent further investigation
in the form of computed tomography (CT) followed by
TDC [Table 2]. Out of these 16 patients of decortication,
4 patients had severe fibrosis where we encountered
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ventilation electively for the first 48 h in the postoperative
period. Out of the decorticated group, three patients had
overriding of the ribs and four patients had minimal air
leak which resolved with time. All patients resumed full
oral feeds by 3rd postoperative day. There were no major
complications related to TDC or death in this series.

excessive bleeding while peeling the visceral pleura off. Discussion

These patients required blood transfusion postoperatively. ET is defined as “pus in the chest” or presence
All patients of TDC were put under pressure support of microorganism in the pleural fluid. Overall,
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Table 2: Clinicoradiological profile of children underwent thoracic decortication (n=16)

n Age Sex Duration of ICD before CT findings Indications Complications
decortication (days)
1 2 years Male 10 (R) pyopneumothorax Nonfunctioning ICD persistent Overriding of the ribs
with collapse of lung collection lung collapse
2 3 years Male 5 (R) multiloculated ET, Loculated ET not responding to Nil
pleural thickening with ICD poor lung expansion
lung collapse
3 7 years Female 21 (R) encysted ET upper Nonfunctioning ICD encysted Nil
zone with adjacent lung effusion poor lung expansion
atelectasis
4 1 month Male 7 (L) pyopneumothorax Referred from rural health Air leak in PO period
15 days with collapse and center due to poorly resolved resolved with ICD
consolidation of lung postpneumonic ET lung collapse
5 2 months Female 14 (L) pyopneumothorax Partially expanded lung encysted Nil
with encysted collection collection
6 10 months Male 5 Thickened pleura Persistent respiratory distress Overriding of ribs
with (L) trapped lung nonfunctioning ICD poor lung
expansion
7 4 years 6 Male 11 (R) multiloculated Persistent fever due to lung Bleeding and air leak
months thick‑walled cystic SOL abscess nonfunctioning ICD in PO period resolved
in the lung within 5 days
8 6 months Male 5 (L) pyopneumothorax, Nonfunctioning ICD poor lung Nil
lung collapse, and expansion lung collapse and
contralateral mediastinal mediastinal shift
shifting
9 4 years Male 10 Large multiloculated Persistent fever nonfunctional Air leak on PO period
thick‑walled cystic area ICD multiloculated ET resolved with ICD
in the (R) lung
10 2 years Male 6 Collapse (R) lung with Nonfunctioning ICD poor lung Nil
encysted collection expansion poor air entry
11 11 months Male 5 Thickened pleura with Persistent respiratory distress Nil
encysted collection in nonfunctional ICD poor lung
the (R) lung expansion
12 3 years Male 6 (R) multiloculated ET Nonfunctioning ICD poor lung Air leak in PO period
expansion loculated collection overriding of ribs
13 2 months Male 10 Pyopneumothorax (L) Persistent fever and respiratory Bleeding and air leak
lung distress nonfunctional ICD
14 7 months Male (L) pyopneumothorax, Nonfunctioning ICD poor lung Nil
lung collapse, and expansion lung collapse and
mediastinal shifting mediastinal shift
15 6 years Female 18 (R) encysted pleural Nonfunctioning ICD poor lung Nil
effusion with lung expansion encysted collection
atelectasis
16 4 months Female 12 (L) pyopneumothorax
Persistent fever nonfunctioning Nil
ICD partially expanded lung
ICD: Intercostal drainage, ET: Empyema thoracis, CT: Computed tomographic, PO: Post-Operative, SOL: Space occupying lesion

Journal of Indian Association of Pediatric Surgeons / Volume 24 / Issue 3 / July-September 2019 199
 Mandal, et al.: Role of intercostal chest tube drainage in the management of empyema thoracis in children
0.6% of childhood pneumonias are complicated by
parapneumonic effusion which may progress to ET. It
predominantly involves in the right lung and 7.1% are
bilateral.[3] In developing countries, more than one‑fourth
of hospital‑admitted patients with pneumonia eventually
develop parapneumonic effusion or empyema because
of delayed initiation of adequate treatment. Traumatic
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hemopneumothorax may progress to ET following
an infection with antibiotic‑resistant organisms or
associated with comorbid conditions (malnutrition,
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immunocompromised).[4]
The course of parapneumonic effusion has been
described in three stages; exudative, fibropurulent, and
organized. This classification is for better understanding
of pathophysiological progression of the disease. Specific
management strategies according to the stages are not
described clearly in English literature.[5] In exudative
stage (Stage I), the effusion sprawl in the pleural space.
In fibropurulent stage (Stage II), the effusion becomes
stickier and pleural surfaces become thickened due
to fibrin deposition. At times, the pleural surfaces
adhere to each other by fibrous septae culminating into
loculated effusion. Usually, loculated effusion develops
within 7–10 days from the onset of the parapneumonic
effusion. This fibropurulent stage may last several weeks
after which there is fibrosis in the pleural surfaces,
resulting in an inelastic covering of the lung, the
stage of organization (Stage III).[6] There is restriction
of movement of the chest wall and diaphragm with
crowding of the ribs.
The prime aim of treating ET is to restore the lung
function. Several studies concluded that Stage I and
II disease can safely be managed by antibiotics and
ICD with or without fibrinolysis therapy/antiseptic
lavage‑irrigation of the chest tube[7,8] while Stage III
and IV disease require surgical intervention.[9] Frank
purulent or turbid pleural fluid on needle aspiration
signifies early stage (I/II) of the disease which required
prompt ICD. Other criteria of ICD procedure are
pH <7.2 in pleural aspirate, isolation of organisms in
the pleural aspirate by Gram stain and/or culture, huge
nonpurulent pleural collection (for symptomatic relief),
and loculated collection.[10] Satish et al. conducted a
study with ICD procedure in the treatment of ET in
children in a secondary‑level care center and showed
clinicoradiological improvement in all (100%) cases.
The average duration of keeping ICD was 8 days with
a median hospital stay of 14 days (maximum stay
28 days).[11] Stephen et al., Magnate et al., and Chan
et al. showed the success rate as 45%, 93.22%, and
82%, respectively.[12,13] In our study, ICD procedure
was successful in 83.33% cases (56.96% uncomplicated
200 Journal of Indian Association of Pediatric Surgeons / Volume 24 / Issue 3 / July-September 2019
group and 26.36% complicated group) with average
duration of keeping the ICD – 8.66 days, range
3–19 days which is comparable to contemporary
studies [Figure 1]. Theoretically, the outcome of ICD
procedure depends on the initial demographic profile
of the patients. A new scoring system, depending on
the clinical features, laboratory findings, and initial
radiographic pictures, has been evolved to predict the
outcome of conservative management of ET[14] However,
a few mechanical factors such as wrong position of tube,
inappropriate size of tube, underutilization of vacuum
suction, and unproductive breathing exercise may be the
hidden causes of treatment failure with ICD.[15] In our
study, 50% of ICD failure cases had loculated collection
with pleural thickening. In developing countries, majority
of the patients come in advanced stage with loculations
where initial needle aspiration is dry. USG‑guided
aspiration/ICD with administration of streptokinase may
be helpful in such situation.[16,17] Fibrinolytic therapy
is not recommended universally as the exact timing of
administration for breaking septae and definite role in
controlling of pleural sepsis are not clear.[18] CT chest
should be done to get detailed information regarding
the pleural thickening, trapped lung, endobronchial
obstruction, and mediastinal pathology.[19,20] However,
we observed that CT chest is not obligatory in all
cases. It was done in failure cases with ICD procedure
for planning of further intervention. Nowadays, many
centers have adopted thoracoscopic intervention instead
of ICD ± fibrinolytic therapy for the treatment of
Stage I and II empyema. A combination of thoracoscopy
and fibrinolytic therapy reduces the requirements
of open decortication.[21] However, thoracoscopic
intervention is not appropriate in many of the chronic
empyema (Stage III/IV) or in ICD failure cases.[22,23] A
a
b
Figure 1: (a) X‑rays of a patient with (r) empyema thoracis (before and
72 h of intercostal drainage). (b) X‑rays (before and 72 h of intercostal
chest tube drainage procedure) in a patient with loculated (r) empyema
thoracis where two drains were placed in the same side
 Mandal, et al.: Role of intercostal chest tube drainage in the management of empyema thoracis in children
few surgeons prefer thoracoscopic decortication over
open decortication. Open decortication has plenty of
perioperative complications such as persistent air leaks,
excessive bleeding, and sepsis. These are directly related
to the chronicity of the disease. Thus, early decision
of TDC definitely reduces the major perioperative
complications as well as morbidity and mortality.[24]
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Rib crowding occurs early in the course of empyema.
Resection of one or two ribs provides a wide window
for proper pleural toileting under supervision, easy
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collection of pleural tissue for biopsy and proper
placement of adequately sized chest tube. In our series,
rib resection was done in one case because of thick pus
[Figure 2]. Although our study had a limited number of
cases (n = 96), we infer TDC as the answer in chronic
empyema/ICD failure cases. Open decortication still
remains the best method. Moreover, decision for the
TDC should be taken early considering the etiology
of empyema (i.e., primary versus secondary), general
condition of the patient, and stage of disease.[25]
Conclusion
As far as our small series is concerned, ICD procedure
is the most important therapeutic procedure in the
management of ET cases. It is also successful in majority
of the complicated ET cases. Proper timing, correct
techniques, and positioning of the ICD ensure a very
good functional outcome with high patient satisfaction.
CT chest is warranted where needle aspiration is dry
or in the ICD failure cases for planning of TDC.
Considering our result and recent literatures, we vouch
that specific approaches based on institutional practice
and available resources always have a positive impact in
the management of ET.
Acknowledgment
We would like to thank Prof. Dilip Pal (MD), MSVP,
Department of Pediatric Medicine, Dr. B. C. Roy Post
Graduate Institute of Pediatric Sciences, Kolkata, India
and Prof. Sanat Kumar Ghosh (MD), Head of the
Figure 2: Pictures of computed tomography of chest and intra-operative
photographs showing loculated empyema, thoracotomy incision with
pathology, lung after decortication, specimen of thick pus, and excised
rib in one of the intercostal chest tube drainage failure patients
Journal of Indian Association of Pediatric Surgeons / Volume 24 / Issue 3 / July-September 2019
Department, Pediatric Medicine, Dr. B. C. Roy Post
Graduate Institute of Pediatric Sciences, Kolkata, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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