What is the best treatment option for empyema requiring drainage in children

A 4-year-old girl attends with a 3-day history of cough, breathlessness and fever. She is started on antibiotics but fails to improve over the subsequent 48 hours. A chest X-ray and ultrasound of the thorax reveals a large, loculated pleural effusion amenable to drainage. In managing children with a large empyema (patient), does a pleural drain with fibrinolytics or primary video-assisted thorascopic surgery (VATS) (intervention) result in better treatment outcome (outcome)? There are currently no applicable reviews in the Cochrane database. The PubMed Index was searched with the following strategy: ‘(paediatric OR pediatric OR child) AND empyema AND (VATS OR thorascopic) AND (drain OR thoracostomy) AND (urokinase OR fibrinolysis OR fibrinolytics)'. This revealed 36 articles. All abstracts were reviewed; four prospective randomised studies were identified. We did not consider studies that compared VATS with chest drain without fibrinolytics1 or national surveillance studies.2 All references in these papers were reviewed, and no further relevant papers were found. These papers are summarised in table 1. View this table: Table 1 Summary of papers The incidence of empyema in children in the developed world appears to be increasing.3 A simple parapneumonic effusion may progresses from the exudative stage with anechoic non-septated fluid (stage 1), through hyperechoic fluid with fibrinous septation (stage 2) to an organisational stage with hyperechoic loculations with or without thick pleural peel (stage 3). Many treatment options are available, from intravenous antibiotics alone, …