Çocuklarda plevral ampiyem ve fibrinolitik tedavi: Tek merkez deneyimi

Öz

Amaç: Plevral ampiyem (PA) pnömoninin ciddi bir komplikasyonudur ve önemli bir problem olmaya devam etmektedir. Farklı tedavi yaklaşımları yayımlanmış birçok raporda dikkat çekicidir, ancak ideal tedavi için güçlü kanıt sağlamamaktadır. Bu çalışmada, PA tanısı alan hastalara yaklaşımımızı değerlendirmeyi ve daha önce yayınlanmış çalışmalarda tam oturmamış tedavi yaklaşımı gölgesinde merkezimizin deneyimini sunmayı amaçladık.

Gereç ve Yöntemler: Bu çalışma Ocak 2011-Aralık 2016 tarihleri arasında tek merkezde izlenen 1-17 yaşları arasındaki 48 hastanın değerlendirildiği retrospektif bir çalışmadır. Hastaların başvuru öncesi durumları,  riskleri ve tedavileri, başvuru sırasındaki klinik ve laboratuvar bulguları, seçilmiş tedavi yaklaşımları, özellikle fibrinolitik tedavi ve komplikasyonlar değerlendirilmiştir.

Bulgular: Tüp torakostomi 43/48 (% 89,6) hastaya uygulandı. Fibrinolitik tedavi ile tedavi edilen hastaların sayısı 22 (% 45.8) ve ortalama doz toplamda 5,18 ± 2,59 (1-9) idi. Fibrinolitik tedavi PA evre II'de diğer evrelere göre anlamlı derecede yüksekti (p = 0.001). Yoğun bakım ihtiyacı % 20,8 (n = 10) iken toplam hastanede kalış süresi 23,58 ± 8,69 (3-47) gündü. Beş hastada (% 10.4) cerrahi girişim gerekli oldu. Ameliyat ile hastaların fibrinolitik tedavi durumu arasında anlamlı ilişki bulunmadı. Komplikasyon oranı toplamda % 41.6 idi.

Sonuç: Çocuklarda PA'da tedavi yaklaşımı standardize edilmemiştir. Sonuç olarak, her merkez bizim merkezimizde olduğu gibi önceki deneyimleri ve sonuçları göz önünde bulundurarak kendi tedavi yaklaşımını uygulamayı tercih ediyor gibi görünmektedir.

Anahtar Kelimeler

• Plevral ampiyem; Çocuklar; Fibrinolitik tedavi

Pleural empyema and fibrinolytic therapy in children: A single center experience

Öz

Objective: Pleural empyema (PE) is a serious complication of pneumonia and continues to be an important problem. Different treatment approaches are remarkable in many reports, but do not provide strong evidence for ideal treatment. In this study, we aimed to evaluate our approach to the patients diagnosed as PE, and to demonstrate the experience of our center in the shadow of the not fully seated treatment approach in previously published studies.

Material and Methods: This is a retrospective study of 48 patients aged between 1-17 years from January 2011 to December 2016 in one center. Pre-admission status, risks and treatments of the patients, clinical and laboratory findings on admission, selected treatment approaches, especially the fibrinolytic therapy, and complications were evaluated.

Results: Tube thoracostomy was performed in 43/48 (89.6%). Patients treated with fibrinolytic therapy was 22 (45.8%) and the mean dose was 5,18±2,59 (1-9) in total. Fibrinolytic therapy was significantly higher in PE stage (II) than the other stages (p = 0.001). Intensive care need was 20.8% (n = 10) while total hospital stay was 23.58 ± 8.69 (3-47) days.  Thoracotomy/decortication or VATS were required in five (10.4%) patients. There was no significant relationship between the operation and fibrinolytic treatment status of patients. The complication rate was 41.6% in total.

Conclussion: The therapeutic approach to PE in children is not standardized. As a result, each center seems to prefer to apply its own treatment approach, considering previous experiences and results, like in our center.

Anahtar Kelimeler

• Pleural empyema; Children; Fibrinolytic therapy

Kaynakça

1. 1. Sahn SA. Diagnosis and management of parapneumoniceffusions and empyema. Clin Infect Dis 2007;45:1480–1486.
2. 2. Roxburgh CS, Youngson GG, Townend JA, Turner SW. Trends in pneumonia and empyema in Scottish children in the past 25 years. Arch Dis Child 2008; 93: 316–318.
3. 3. Brims FJ, Lansley SM, Waterer GW, Lee YC. Empyema thoracis: new insights into an old disease. Eur Respir Rev 2010;19(117):220-8.
4. 4. Gupta R, Crowley S. Increasing paediatric empyema admissions. Thorax 2006;61:179.
5. 5. Satish B, Bunker M, Seddon P. Management of thoracic empyema in childhood: does the pleural thickening matter? Arch Dis Child 2003;88(10):918-21.
6. 6. Rahman NM, Davies RJO. Effusions from infections: parapneumonic effusion and empyema. In Light RW, Lee YCG (eds). Textbook of Pleural Disease. London: Hodder Arnold, 2008:341–366.
7. 7. Wells RG, Havens PL. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children. Radiology 2003;228(2):370-78.
8. 8. Wurnig PN, Wittmer V, Pridun NS, Hollaus PH. Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg 2006; 81:309–13.

9. 9. Hope WW, Bolton WD, Stephenson JE. The utility and timing of surgical intervention for parapneumonic empyema in the era of video-assisted thoracoscopy. Am Surg 2005; 71:512–4.
10. 10. Coote N, Kay E, Coote N. Surgical versus non-surgical management of pleural empyema. Cochrane Database Syst Rev 2005:CD001956.
11. 11. Gates RL, Hogan M, Weinstein S, Arca MJ. Drainage, fibrinolytics, or surgery: a comparison of treatment options in pediatric empyema. J Pediatr Surg 2004;39:1638–42.
12. 12. Misthos P, Sepsas E, Konstantinou M, Athanassiadi K, Skottis I, Lioulias A. Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. Eur J Cardiothorac Surg 2005; 28:599–603.
13. 13. Ekingen G, Guvenc BH, Sozubir S, Tuzlaci A, Senel U. Fibrinolytic treatment of complicated pediatric thoracic empyemas with intrapleural streptokinase. Eur J Cardiothorac Surg 2004; 26:503–7.
14. 14. Light RW, MacGregor MI, Luchsinger PC, Ball WC. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13.
15. 15. Davies HE, Davies RJ, Davies CW. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010;65:ii41–53.
16. 16. Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir J 1997;10:1150-6.
17. 17. Hawkins JA, Scaife ES, Hillman ND, Feola GP. Current treatment of pediatric empyema. Semin Thorac Cardiovasc Surg 2004;16:196–200.
18. 18. Sonnappa S, Cohen G, Owens CM, van Doorn C, Cairns J, Stanojevic S, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006;174:221–7.
19. 19. Yao CT, Wu JM, Liu CC, Wu MH, Chuang HY, Wang JN. Treatment of complicated parapneumonic pleural effusion with intrapleural streptokinase in children. Chest 2004;125:566-71.
20. 20. Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol 2009;39:527–537.
21. 21. Kearney SE, Davies CW, Davies RJ, Gleeson FV. Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol 2000;55:542–547.
22. 22. Fletcher MA, Schmitt HJ, Syrochkina M, Sylvester G. Pneumococcal empyema and complicated pneumonias: global trends in incidence, prevalence, and serotype epidemiology. Eur J Clin Microbiol Infect Dis 2014;33(6):879-910.
23. 23. Langley JM, Kellner JD, Solomon N, Robinson JL, Le Saux N, McDonald J, et al. Empyema associated with community-acquired pneumonia: a Pediatric Investigator'sCollaborative Network on Infections in Canada (PICNIC) study. BMC Infect Dis 2008;8:129.
24. 24. Mitri RK, Brown SD, Zurakowski D, Chung KY, Konez O, Burrows PE, et al. Outcomes of primary image guided drainage of parapneumonic effusions in children. Pediatrics 2002;110:e37.
25. 25. Horsley A, Jones L, White J, Henry M. Efficacy and complications of small-bore, wire-guided chest drains. Chest 2006;130:1857–1863.
26. 26. Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R, et al. UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865–874.
27. 27. Lin CH, Lin WC, Chang JS. Comparison of pigtail catheter with chesttube for drainage of parapneumonic effusion in children. PediatrNeonatol 2011;52:337-41.
28. 28. Rahman NM, Maskell NA, Davies CW, Hedley EL, Nunn AJ, Gleeson FV, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010;137(3):536–43.
29. 29. Islam S, Calkins CM, Goldin AB, Chen C, Downard CD, Huang EY, et al: APSA Outcomes and Clinical Trials Committee,2011-2012. The diagnosis and management of empyema in children:a comprehensive review from the APSA Outcomes and Clinical Trials Committee.J Pediatr Surg 2012;47(11):2101-10.
30. 30. Scarci M, Zahid I, Billé A, Routledge T. Is video-assisted thoracoscopic surgery the best treatment for paediatric pleural empyema?Interact Cardiovasc Thorac Surg 2011;13(1):70-6.
31. 31. St Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009;44(1):106-11; discussion 111.
32. 32. Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, et al; Pediatric Infectious Diseases Society andthe Infectious Diseases Society of America.Executive summary:the management of communityacquired pneumonia in infants and childrenolder than 3 months of age: clinical practice guidelines by the Pediatric Infectious DiseasesSociety and the Infectious Diseases Society of America. Clin Infect Dis.2011;53(7):617-30.
33. 33. Balfour-Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, et al: BTS guidelines for the management of pleural infection in children. Thorax 2005;60(Suppl 1):i1-21.