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Long-term Outcomes in Children With Pleural Empyema

Long-term Outcomes in Children With Pleural Empyema For most acute infectious diseases, studies exploring short-term outcomes, such as hospitalization rate, length of hospital stay, time to resolution of symptoms, and trends in laboratory markers of infection, are ubiquitous. These immediate outcomes are important to consider when examining the comparative effectiveness of existing therapies or the development of novel therapeutics. However, there is a paucity of data regarding the longer-term outcomes of acute infections. In this issue of the Archives of Pediatrics & Adolescent Medicine, Cohen et al1 present a prospective observational study of children with pleural empyema, a condition in which pus accumulates in the pleural space, with the goal of examining longer-term outcomes including health-related quality of life (HR-QOL). While some of the longer-term outcomes of infections such as meningitis and otitis media have been explored, to our knowledge, this study is one of the few to describe such outcomes of pediatric empyema. Community-acquired pneumonia accounts for more than 3 million outpatient visits and more than 150 000 hospitalizations each year in the United States.2,3 Pleural empyema complicates the course of up to 15% of children hospitalized with community-acquired pneumonia.4,5 While pediatric pneumonia hospitalizations among younger children have declined since the introduction of routine childhood pneumococcal vaccination,6 hospitalizations for pneumonia-associated complications, such as pleural empyema, have increased.3,7 The change in the epidemiology of pleural empyema is important because affected children often require intensive care unit admission, multiple surgical procedures, and prolonged hospitalization at a cost of approximately $20 000 per episode.5 Determining appropriate therapy to improve outcomes is challenging for the individual physician as a result of inconsistent and insufficient evidence, wide variation in treatment practices, and lack of data on long-term outcomes. To minimize unnecessary variation, the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society published guidelines for the management of community-acquired pneumonia in children.8 The recommendations for the care of children with empyema in these guidelines highlight some of the controversy surrounding initial procedural management of children hospitalized for empyema. The Infectious Diseases Society of America/Pediatric Infectious Diseases Society guidelines conclude that both video-assisted thorascopic surgery (VATS) and chest tube placement with instillation of fibrinolytic agents are effective, and the choice of procedure should rely on local expertise. Current data suggest that there may be a tradeoff in the short term between the increased risk of additional drainage procedures with initial chest tube placement compared with the risks of general anesthesia and other perils of surgical intervention with VATS.5 When such tradeoffs exist, parental and child preference become even more important in clinical decision making.9 Such shared decision making requires knowledge of the potential short-term and long-term outcomes of any treatment choice. For pediatric empyema, there is a gap in our understanding of the meaning of the procedure choice in the longer term. Knowledge of these long-term outcomes could better inform clinician and parental decision making. In the study by Cohen et al,1 approximately two-thirds of the patients were treated with parenteral antibiotics and chest drainage, with more than 75% of those undergoing drainage receiving instillation of fibrinolytic agents. No patients underwent VATS on initial presentation, and one-third received parenteral antibiotics without pleural drainage. Patients had scheduled evaluations 1, 6, and 12 months following hospital discharge. Outcomes included persistence of symptoms, chest radiograph findings at 1 month after hospital discharge, spirometry, and HR-QOL. Abnormalities, including continued fever and cough, abnormal breath sounds, restrictive or obstructive lung disease, and abnormal chest radiographs, were present in more than 25% of the cohort 1 month after hospital discharge. Radiograph abnormalities at this time included pleural effusions and pneumatoceles in 27% and 4% of children, respectively. Although abnormalities were common during the first month, they had largely resolved during the 12 months following hospital discharge; fewer than 6% of children demonstrated spirometric or radiographic abnormalities at the end of the study period. It was not possible to determine whether the persistence of short-term abnormalities at 1 month was associated with worse longer-term outcomes because of the relatively small sample size and the generally favorable outcomes. A particularly novel aspect of this study was the use of the Pediatric Quality of Life Inventory, a validated 23-item questionnaire that captures parent and child perceptions of HR-QOL in multiple domains, including physical, emotional, social, and school functioning. The authors compared the findings of children with pleural empyema with normative data for the Pediatric Quality of Life Inventory for healthy children, as well as for children with asthma, a common chronic respiratory disease. In the short term, most children missed school during the first month after hospital discharge, and approximately one-quarter of parents missed work. These findings suggest a societal cost well beyond the aforementioned $20 000 per hospitalization for each child with empyema. However, by the end of the study period, parental and child perceptions of HR-QOL were similar to healthy children and better than children with asthma. These findings provide some reassurance that, despite the short-term morbidity of empyema, the longer-term sequelae may be mild. Data on outcomes of these children as they transition to adulthood will further improve our understanding of the long-term consequences of empyema. Although outcomes were favorable regardless of whether a child with pleural empyema received pleural drainage, the authors did not intend to compare one treatment method with another. Thus, meaningful conclusions regarding the comparative effectiveness of initial procedural management for empyema cannot be drawn from this study. Furthermore, no children received VATS, making the results of this study difficult to generalize to the many centers that use early VATS as the preferred treatment for pleural empyema. The results of the study by Cohen et al highlight the need to better understand the risks, benefits, and costs of an invasive initial management strategy compared with more conservative treatment. To date, there have been only 3 randomized trials exploring the issue of VATS compared with chest tube drainage with fibrinolysis.10-12 These single-center studies included too few patients to examine outcomes other than length of hospital stay. A large, multicenter, retrospective cohort study found that while the length of stay was similar among different drainage strategies, chest tube placement alone was the least expensive option and both chest tube alone and chest tube with fibrinolysis were associated with a higher frequency of additional drainage procedures compared with VATS.5 None of these studies explored patient-reported outcomes or HR-QOL. The limitations of these studies accentuate the need for further research exploring the comparative effectiveness of these interventions. If the longer-term outcomes of empyema are generally favorable, as the study by Cohen et al suggests, we believe that future research should focus on prospective studies of sufficient size to rigorously examine short-term risks, as well as cost, quality of life, and patient-reported outcomes. Given this study's conclusion and the short-term tradeoff of empyema drainage procedures, the question of what role shared decision making between health care providers and families plays in treatment choices becomes paramount. Should a more invasive procedure be performed as a result of a parent's preference to minimize short-term discomfort? The definitive answer to this question remains unknown; however, this study opens the door to further examination of the role of treatment choice in long-term outcomes for children with pleural empyema. Moreover, if long-term outcomes of empyema are favorable, future research should focus on the shorter-term risks and benefits of invasive procedures for empyema compared with more conservative approaches. If the clinical outcomes, such as length of stay or time to resolution of symptoms, are in fact similar regardless of initial management, data regarding quality of life and patient-reported outcomes become even more paramount in understanding the differences between these treatment strategies. Back to top Article Information Correspondence: Dr Shah, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 9016, Cincinnati, OH 45229 (samir.shah@cchmc.org). Published Online: September 3, 2012. doi:10.1001/archpediatrics.2012.1713 Financial Disclosure: None reported. References 1. Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study [published online September 3, 2012]. Arch Pediatr Adolesc Med. 2012;166(11):999-1004Google ScholarCrossref 2. Kronman MP, Hersh AL, Feng R, Huang YS, Lee GE, Shah SS. Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics. 2011;127(3):411-41821321038PubMedGoogle ScholarCrossref 3. Lee GE, Lorch SA, Sheffler-Collins S, Kronman MP, Shah SS. National hospitalization trends for pediatric pneumonia and associated complications. Pediatrics. 2010;126(2):204-21320643717PubMedGoogle ScholarCrossref 4. Shah SS, DiCristina CM, Bell LM, Ten Have T, Metlay JP. Primary early thoracoscopy and reduction in length of hospital stay and additional procedures among children with complicated pneumonia: results of a multicenter retrospective cohort study. Arch Pediatr Adolesc Med. 2008;162(7):675-68118606939PubMedGoogle ScholarCrossref 5. Shah SS, Hall M, Newland JG, et al. Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood. J Hosp Med. 2011;6(5):256-26321374798PubMedGoogle ScholarCrossref 6. Grijalva CG, Nuorti JP, Arbogast PG, Martin SW, Edwards KM, Griffin MR. Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in the USA: a time-series analysis. Lancet. 2007;369(9568):1179-118617416262PubMedGoogle ScholarCrossref 7. Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. 2010;125(1):26-3319948570PubMedGoogle ScholarCrossref 8. Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e7621880587PubMedGoogle ScholarCrossref 9. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-6929032835PubMedGoogle ScholarCrossref 10. Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics. 2006;118(3):e547-e55316908618PubMedGoogle ScholarCrossref 11. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med. 2006;174(2):221-22716675783PubMedGoogle ScholarCrossref 12. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial [published correction appears in J Pediatr Surg. 2009;44(9):1865]. J Pediatr Surg. 2009;44(1):106-111, discussion 11119159726PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Long-term Outcomes in Children With Pleural Empyema

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpediatrics.2012.1713
Publisher site
See Article on Publisher Site

Abstract

For most acute infectious diseases, studies exploring short-term outcomes, such as hospitalization rate, length of hospital stay, time to resolution of symptoms, and trends in laboratory markers of infection, are ubiquitous. These immediate outcomes are important to consider when examining the comparative effectiveness of existing therapies or the development of novel therapeutics. However, there is a paucity of data regarding the longer-term outcomes of acute infections. In this issue of the Archives of Pediatrics & Adolescent Medicine, Cohen et al1 present a prospective observational study of children with pleural empyema, a condition in which pus accumulates in the pleural space, with the goal of examining longer-term outcomes including health-related quality of life (HR-QOL). While some of the longer-term outcomes of infections such as meningitis and otitis media have been explored, to our knowledge, this study is one of the few to describe such outcomes of pediatric empyema. Community-acquired pneumonia accounts for more than 3 million outpatient visits and more than 150 000 hospitalizations each year in the United States.2,3 Pleural empyema complicates the course of up to 15% of children hospitalized with community-acquired pneumonia.4,5 While pediatric pneumonia hospitalizations among younger children have declined since the introduction of routine childhood pneumococcal vaccination,6 hospitalizations for pneumonia-associated complications, such as pleural empyema, have increased.3,7 The change in the epidemiology of pleural empyema is important because affected children often require intensive care unit admission, multiple surgical procedures, and prolonged hospitalization at a cost of approximately $20 000 per episode.5 Determining appropriate therapy to improve outcomes is challenging for the individual physician as a result of inconsistent and insufficient evidence, wide variation in treatment practices, and lack of data on long-term outcomes. To minimize unnecessary variation, the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society published guidelines for the management of community-acquired pneumonia in children.8 The recommendations for the care of children with empyema in these guidelines highlight some of the controversy surrounding initial procedural management of children hospitalized for empyema. The Infectious Diseases Society of America/Pediatric Infectious Diseases Society guidelines conclude that both video-assisted thorascopic surgery (VATS) and chest tube placement with instillation of fibrinolytic agents are effective, and the choice of procedure should rely on local expertise. Current data suggest that there may be a tradeoff in the short term between the increased risk of additional drainage procedures with initial chest tube placement compared with the risks of general anesthesia and other perils of surgical intervention with VATS.5 When such tradeoffs exist, parental and child preference become even more important in clinical decision making.9 Such shared decision making requires knowledge of the potential short-term and long-term outcomes of any treatment choice. For pediatric empyema, there is a gap in our understanding of the meaning of the procedure choice in the longer term. Knowledge of these long-term outcomes could better inform clinician and parental decision making. In the study by Cohen et al,1 approximately two-thirds of the patients were treated with parenteral antibiotics and chest drainage, with more than 75% of those undergoing drainage receiving instillation of fibrinolytic agents. No patients underwent VATS on initial presentation, and one-third received parenteral antibiotics without pleural drainage. Patients had scheduled evaluations 1, 6, and 12 months following hospital discharge. Outcomes included persistence of symptoms, chest radiograph findings at 1 month after hospital discharge, spirometry, and HR-QOL. Abnormalities, including continued fever and cough, abnormal breath sounds, restrictive or obstructive lung disease, and abnormal chest radiographs, were present in more than 25% of the cohort 1 month after hospital discharge. Radiograph abnormalities at this time included pleural effusions and pneumatoceles in 27% and 4% of children, respectively. Although abnormalities were common during the first month, they had largely resolved during the 12 months following hospital discharge; fewer than 6% of children demonstrated spirometric or radiographic abnormalities at the end of the study period. It was not possible to determine whether the persistence of short-term abnormalities at 1 month was associated with worse longer-term outcomes because of the relatively small sample size and the generally favorable outcomes. A particularly novel aspect of this study was the use of the Pediatric Quality of Life Inventory, a validated 23-item questionnaire that captures parent and child perceptions of HR-QOL in multiple domains, including physical, emotional, social, and school functioning. The authors compared the findings of children with pleural empyema with normative data for the Pediatric Quality of Life Inventory for healthy children, as well as for children with asthma, a common chronic respiratory disease. In the short term, most children missed school during the first month after hospital discharge, and approximately one-quarter of parents missed work. These findings suggest a societal cost well beyond the aforementioned $20 000 per hospitalization for each child with empyema. However, by the end of the study period, parental and child perceptions of HR-QOL were similar to healthy children and better than children with asthma. These findings provide some reassurance that, despite the short-term morbidity of empyema, the longer-term sequelae may be mild. Data on outcomes of these children as they transition to adulthood will further improve our understanding of the long-term consequences of empyema. Although outcomes were favorable regardless of whether a child with pleural empyema received pleural drainage, the authors did not intend to compare one treatment method with another. Thus, meaningful conclusions regarding the comparative effectiveness of initial procedural management for empyema cannot be drawn from this study. Furthermore, no children received VATS, making the results of this study difficult to generalize to the many centers that use early VATS as the preferred treatment for pleural empyema. The results of the study by Cohen et al highlight the need to better understand the risks, benefits, and costs of an invasive initial management strategy compared with more conservative treatment. To date, there have been only 3 randomized trials exploring the issue of VATS compared with chest tube drainage with fibrinolysis.10-12 These single-center studies included too few patients to examine outcomes other than length of hospital stay. A large, multicenter, retrospective cohort study found that while the length of stay was similar among different drainage strategies, chest tube placement alone was the least expensive option and both chest tube alone and chest tube with fibrinolysis were associated with a higher frequency of additional drainage procedures compared with VATS.5 None of these studies explored patient-reported outcomes or HR-QOL. The limitations of these studies accentuate the need for further research exploring the comparative effectiveness of these interventions. If the longer-term outcomes of empyema are generally favorable, as the study by Cohen et al suggests, we believe that future research should focus on prospective studies of sufficient size to rigorously examine short-term risks, as well as cost, quality of life, and patient-reported outcomes. Given this study's conclusion and the short-term tradeoff of empyema drainage procedures, the question of what role shared decision making between health care providers and families plays in treatment choices becomes paramount. Should a more invasive procedure be performed as a result of a parent's preference to minimize short-term discomfort? The definitive answer to this question remains unknown; however, this study opens the door to further examination of the role of treatment choice in long-term outcomes for children with pleural empyema. Moreover, if long-term outcomes of empyema are favorable, future research should focus on the shorter-term risks and benefits of invasive procedures for empyema compared with more conservative approaches. If the clinical outcomes, such as length of stay or time to resolution of symptoms, are in fact similar regardless of initial management, data regarding quality of life and patient-reported outcomes become even more paramount in understanding the differences between these treatment strategies. Back to top Article Information Correspondence: Dr Shah, Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, ML 9016, Cincinnati, OH 45229 (samir.shah@cchmc.org). Published Online: September 3, 2012. doi:10.1001/archpediatrics.2012.1713 Financial Disclosure: None reported. References 1. Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study [published online September 3, 2012]. Arch Pediatr Adolesc Med. 2012;166(11):999-1004Google ScholarCrossref 2. Kronman MP, Hersh AL, Feng R, Huang YS, Lee GE, Shah SS. Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994-2007. Pediatrics. 2011;127(3):411-41821321038PubMedGoogle ScholarCrossref 3. Lee GE, Lorch SA, Sheffler-Collins S, Kronman MP, Shah SS. National hospitalization trends for pediatric pneumonia and associated complications. Pediatrics. 2010;126(2):204-21320643717PubMedGoogle ScholarCrossref 4. Shah SS, DiCristina CM, Bell LM, Ten Have T, Metlay JP. Primary early thoracoscopy and reduction in length of hospital stay and additional procedures among children with complicated pneumonia: results of a multicenter retrospective cohort study. Arch Pediatr Adolesc Med. 2008;162(7):675-68118606939PubMedGoogle ScholarCrossref 5. Shah SS, Hall M, Newland JG, et al. Comparative effectiveness of pleural drainage procedures for the treatment of complicated pneumonia in childhood. J Hosp Med. 2011;6(5):256-26321374798PubMedGoogle ScholarCrossref 6. Grijalva CG, Nuorti JP, Arbogast PG, Martin SW, Edwards KM, Griffin MR. Decline in pneumonia admissions after routine childhood immunisation with pneumococcal conjugate vaccine in the USA: a time-series analysis. Lancet. 2007;369(9568):1179-118617416262PubMedGoogle ScholarCrossref 7. Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. 2010;125(1):26-3319948570PubMedGoogle ScholarCrossref 8. Bradley JS, Byington CL, Shah SS, et al; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e7621880587PubMedGoogle ScholarCrossref 9. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean? (or it takes at least two to tango). Soc Sci Med. 1997;44(5):681-6929032835PubMedGoogle ScholarCrossref 10. Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics. 2006;118(3):e547-e55316908618PubMedGoogle ScholarCrossref 11. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med. 2006;174(2):221-22716675783PubMedGoogle ScholarCrossref 12. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial [published correction appears in J Pediatr Surg. 2009;44(9):1865]. J Pediatr Surg. 2009;44(1):106-111, discussion 11119159726PubMedGoogle ScholarCrossref

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Nov 1, 2012

Keywords: child,pleural empyema

References