Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score.

PURPOSE: Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS: In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS: Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION: Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial.

BACKGROUND: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown. METHODS/DESIGN: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality. DISCUSSION: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.

Retrospective comparison of costs between medical and surgical treatment of canine pyothorax.

This study compared costs of treating dogs with pyothorax medically versus surgically. Medical records from the University of Wisconsin School of Veterinary Medicine were searched for cases of pyothorax that underwent either medical or surgical treatment. Patients undergoing surgery were subdivided into early (ES; < 48 h) and late (LS; > 48 h) surgery groups. Costs and length of stay were compared between treatment groups. Treatment costs were adjusted for inflation. Nineteen dogs were included in analysis; 7 in the medical group (MG), 5 in the ES group, and 7 in the LS group. Total costs were significantly lower in the MG than in the LS group. Total costs were less for the MG than the ES group, and for ES than LS, but the differences did not achieve significance. Preoperative costs were higher in the LS than the ES group. We conclude that surgery for canine pyothorax is less costly if pursued earlier than later.

Comparaison rétrospective des coûts entre le traitement médical et chirurgical d'un pyothorax canin. Cette étude a comparé les coûts de traiter les chiens souffrant d'un pyothorax par voie médicale par opposition à une voie chirurgicale. Une recherche a été effectuée dans les dossiers médicaux du College of Veterinary Medicine, University of Wisconsin pour trouver des cas de pyothorax où les animaux avaient subi soit un traitement médical ou chirurgical. Les patients subissant une chirurgie ont été subdivisés en des groupes de chirurgie précoce (ES; < 48 h) et tardive (LS; > 48 h). Les coûts et la durée du séjour ont été comparés entre les groupes de traitement. Les coûts de traitement ont été ajustés pour l'inflation. Dix-neuf chiens étaient inclus dans l'analyse; sept dans le groupe médical (MG), cinq dans le groupe ES et sept dans le groupe LS. Les coûts totaux étaient significativement inférieurs dans le MG par rapport au groupe LS. Les coûts totaux étaient inférieurs pour le groupe MG par rapport au groupe ES et pour le groupe ES par rapport au groupe LS, mais les différences n'étaient pas significatives. Les coûts préopératoires étaient supérieurs dans le groupe LS par rapport au groupe ES. Nous tirons la conclusion que le coût de la chirurgie pour le pyothorax canin est inférieur si la chirurgie est réalisée tôt.(Traduit par Isabelle Vallières).

[Medical-and-economic substantiation of rational antibacterial therapy for patients with pleural empyema in the conditions of military medical institutions].

We have performed a post-hoc analysis of the results of using antibacterial therapy in patients with pleural empyema. The cost-effectiveness analysis of rational and empiric antibacterial therapies was performed. The cost-effectiveness ratio for rational antibacterial therapy was lower than for empiric one (2889 and 4480 rubles for 1 treated patient correspondingly). The use of the rules of rational antibacterial therapy in practice leads to proved saving of economic costs.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Is video-assisted thoracoscopic surgery the best treatment for paediatric pleural empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether video-assisted thoracic surgery (VATS) is the best treatment for paediatric pleural empyema. Altogether 274 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that early VATS (or thoracotomy if VATS not possible) leads to shorter hospitalisation. The duration of chest tube placement and antibiotic use is variable and does not correlate with treatment method. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs. 3.3%), re-intervention rate (2.5% vs. 23.5%), length of stay (10.8 days vs. 20.0 days), duration of tube thoracostomy (4.4 days vs. 10.6 days), and duration of antibiotic therapy (12.8 days vs. 21.3 days), compared with patients who underwent non-operative therapy. Similar complication rates were observed for the two groups (5% vs. 5.6%). Moreover, median hospital charges for VATS were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiological imaging charges were $5884 (IQR, $3142-$11,357) and $2875 (IQR, $1703-$4950), respectively, for VATS and tube drainage. Adjusting for propensity score matching, costs for primary VATS were equivalent to primary chest tube placement. Only one article found discordant results. Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and eight chest tube followed by VATS/thoracotomy); only four received fibrinolytics. Mean (standard deviation) length of stay was significantly shorter in the antibiotics alone group, 7.0 (3.5) days vs. 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>1/2 thorax filled).

Costs of treating children with complicated pneumonia: a comparison of primary video-assisted thoracoscopic surgery and chest tube placement.

OBJECTIVES: To describe charges associated with primary video-assisted thoracoscopic surgery (VATS) and primary chest tube placement in a multicenter cohort of children with empyema and to determine whether pleural fluid drainage by primary VATS was associated with cost-savings compared with primary chest tube placement. STUDY DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Administrative database containing inpatient resource utilization data from 27 tertiary care children's hospitals. Patients between 12 months and 18 years of age diagnosed with complicated pneumonia were eligible if they were discharged between 2001 and 2005 and underwent early (within 2 days of index hospitalization) pleural fluid drainage. MAIN EXPOSURE: Method of pleural fluid drainage, categorized as VATS or chest tube placement. RESULTS: Pleural drainage in the 764 patients was performed by VATS (n = 50) or chest tube placement (n = 714). There were 521 (54%) males. Median hospital charges were $36,320 [interquartile range (IQR), $24,814-$62,269]. The median pharmacy and radiologic imaging charges were $5,884 (IQR, $3,142-$11,357) and $2,875 (IQR, $1,703-$4,950), respectively. Adjusting for propensity score matching, patients undergoing primary VATS did not have higher charges than patients undergoing primary chest tube placement. CONCLUSIONS: In this multicenter study, we found that the charges incurred in caring for children with empyema were substantial. However, primary VATS was not associated with higher total or pharmacy charges than primary chest tube placement, suggesting that the additional costs of performing VATS are offset by reductions in length of stay (LOS) and requirement for additional procedures.

[Economic efficacy of thoracoscopic treatment for pleural empyema in children].

Results of treatment carried out during 1989-2000 years were analyzed in 164 children with pleural empyema. Economic analysis proves that videothoracoscopic pleural cavity sanation is more beneficial in acute period in 1.7 times and in long-term period--in 1.9 times, compared with traditional method (puncture and drainage). "Cost-efficacy" analysis shows that videothoracoscopic pleural cavity sanation allows increasing of clinical efficacy in 3.6 times in comparison with traditional treatment mode. "Cost-value" analysis shows improvement of life quality in 1.2 times after application of videothoracoscopic pleural cavity sanation compared with traditional method. Cost effectiveness of videothoracoscopic pleural cavity sanation for better life quality achievement is higher in 2.3 times compared with traditional method.

Cost-effectiveness of competing strategies for the treatment of pediatric empyema.

BACKGROUND: The optimal management of pediatric empyema is controversial. The purpose of this decision analysis was to assess the relative merits in terms of costs and clinical outcomes associated with competing treatment strategies. METHODS: A cost-effectiveness analysis was conducted using a Bayesian tree approach. Probability and outcome estimates were derived from the published literature, with preference given to data derived from randomized trials. Costing was based on published estimates from Great Ormond Street Hospital (London, United Kingdom), supplemented by American and Canadian data. Five strategies were evaluated: (1) nonoperative; (2) chest tube insertion; (3) repeated thoracentesis; (4) chest tube insertion with instillation of fibrinolytics; or (5) video-assisted thorascopic surgery. The model was used to project overall costs, survival in life-years, and incremental cost-effectiveness ratios for competing strategies. RESULTS: In the base-case analysis, chest tube with instillation of fibrinolytics was the least expensive therapy, at $7787 per episode. This strategy was projected to cost less but provide equivalent health benefit when compared with all of the competing strategies except repeated thoracentesis, which had an incremental cost-effectiveness ratio of approximately $6,422,699 per life-year gained relative to chest tube with instillation of fibrinolytics. In univariable and multivariable sensitivity analyses, thorascopic surgery was preferred only when the length of stay associated with chest tube with instillation of fibrinolytics exceeded 10.3 days or when the probability of dying as a result of this strategy exceeded 0.2%, assuming a threshold willingness to pay of $75,000 per life-year gained. Chest tube with instillation of fibrinolytics was preferred in >58% of Monte Carlo simulations. CONCLUSIONS: On the basis of the best available data, chest tube with instillation of fibrinolytics is the most cost-effective strategy for treating pediatric empyema. Video-assisted thorascopic surgery would be preferred to chest tube with instillation of fibrinolytics if the differential in length of stay between these 2 strategies were proven to be greater than that suggested by currently available data.

Primary operative management for pediatric empyema: decreases in hospital length of stay and charges in a national sample.

OBJECTIVE: To determine whether primary operative management (decortication within the first 2 days of hospitalization) decreases hospital length of stay (LOS) and total charges in children with empyema. DESIGN: Retrospective cohort study. SETTING: Nationally representative Kids' Inpatient Database for 2003. PARTICIPANTS: Children and adolescents aged 0 to 18 years (hereinafter referred to as children) with empyema. MAIN OUTCOME MEASURES: Hospital LOS and total charges. RESULTS: A total of 1173 children with empyema were identified. Compared with children treated with primary nonoperative management, children treated with primary operative management had a shorter hospital LOS by 4.3 (95% confidence interval [CI], 2.3-6.4) days and lower total hospital charges by $21,179.80 (95% CI, -$34,111.12 to -$8248.48) and were less likely to be transferred to another short-term hospital (0% vs 13.3%). In addition, children with primary operative management were less likely to have therapeutic failure (odds ratio, 0.08 [95% CI, 0.04-0.15]). There was no difference in complications between the 2 groups (odds ratio, 1.01 [95% CI, 0.59-1.74]). CONCLUSION: Primary operative management is associated with decreased LOS, hospital charges, and likelihood of transfer to another short-term hospital, compared with nonoperative management.

Air leaks after lobectomy increase the risk of empyema but not of cardiopulmonary complications: a case-matched analysis.

PURPOSE: To assess whether the presence and duration of air leaks after lobectomy are associated with an increased incidence of cardiopulmonary complications. METHODS: Propensity score analysis was used on 726 patients undergoing pulmonary lobectomy from 1995 through 2004 to form three well-matched pairs of patients: patients with prolonged air leak (PAL) [> 7 days] and without air leak; patients with short air leak (SAL) [< or = 7 days] and without air leak; and patients with SAL and PAL. These matched groups were then compared to assess postoperative hospital stay and early outcome. RESULTS: Patients with SAL had a longer postoperative hospital stay compared to patients without air leak (8.6 days vs 7.8 days, respectively; p < 0.0001) but had similar morbidity and mortality. Patients with PAL had a longer postoperative hospital stay compared to patients without air leak (16.2 days vs 8.3 days, respectively; p < 0.0001) and with SAL (16.9 days vs 9 days, respectively; p < 0.0001), but similar cardiopulmonary complications were noted between the groups. Patients with PAL had a higher rate of empyema compared to patients without air leak and with SAL (8.2% vs 0%, p = 0.01 and 10.4% vs.1.1%, p = 0.01, respectively). CONCLUSIONS: The presence of air leak was not associated with an increased incidence of cardiopulmonary morbidity but was associated with an increased risk of empyema. Future prospective studies are needed to confirm safety of fast track in patients with air leak.

Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema.

BACKGROUND: Despite increasing incidence and morbidity, little evidence exists to inform the best management approach in childhood empyema. AIM: To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema. METHODS: Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days after intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiologic outcome at 6 mo, and total treatment costs. RESULTS: Sixty children were recruited. The two groups were well matched for demographics; baseline characteristics; and hematologic, biochemical, and bacteriologic parameters. No significant difference was found in length of hospital stay after intervention between the two groups: VATS (median [range], 6 [3-16] d) versus urokinase (6 [4-25] d) (p = 0.311; 95% confidence interval, -2 to 1). No difference was demonstrated in total hospital stay: VATS versus urokinase (8 [4-17] d and 7 [4-25] d) (p = 0.645); failure rate: 5 (16.6%); and radiologic outcome at 6 mo after intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm US dollars 9,127 (US dollars 6,914) were significantly lower than those for the VATS arm US dollars 11,379 (US dollars 10,146) (p < 0.001). CONCLUSIONS: There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared with VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.

Use of urokinase in childhood pleural empyema.

Urokinase is an enzyme with a fibrinolytic effect that facilitates pleural empyema drainage through a chest tube. The aim of this study was to assess the risk of pneumothorax, the need for pleural debridement surgery, the persistence of fever, and the number of days in hospital in a group of children with parapneumonic pleural empyema treated with urokinase. This was an uncontrolled retrospective study on children suffering from parapneumonic empyema. Data collected on 17 children treated with urokinase were compared with 11 children treated prior to the advent of urokinase (the "historic" group). The urokinase was instilled in the pleural cavity over a period ranging from 2-8 days, amounting to a median total dose per kilogram of body weight of 18,556 IU (range, 7,105-40,299). Surgical treatment of the empyema involved drainage tube placement and/or debridement of the pleural cavity. Three children developed pneumothorax during their hospital stay, and one more case occurred 6 months after the child had recovered from his empyema; there were 3 cases of pneumothorax during the acute phase in the "historic" group (P = 0.54). Five children in the urokinase group were debrided and 12 were only drained, as opposed to 9 and 2, respectively, in the "historic" group (P = 0.02). The overall hospital stay was 17 days for the urokinase group, and 24 for the "historic" group (P = 0.02). No bleeding or other major complications were reported in the group treated with urokinase. In conclusion, urokinase treatment does not carry a risk of pneumothorax, while it does reduce hospital stay and the need for pleural debridement.

Profile and outcome of patients referred for thoracic empyema in Bloemfontein, South Africa.

OBJECTIVE: To establish the profile and outcome of patients referred to the Department of Cardiothoracic Surgery at Pelonomi Hospital, Bloemfontein for management of thoracic empyema. This was considered important in view of the proposed restructuring of health services in the Free State. METHODS: Files of 77 consecutive patients referred to the Department of Cardiothoracic Surgery at Pelonomi Hospital were reviewed. The effect of condition of the ipsilateral lung on the outcome was statistically analysed. This series was compared with a similar size series from Crawford Hospital in Atlanta, Georgia, USA. RESULTS: The male-to-female ratio was 6:1. Eighty-three per cent of patients were referred from a hospital. The aetiology included a wide variety of causes, but trauma (56%), destroyed lung (10%) and pneumonia (9%) were the most common causes. Active tuberculosis was diagnosed in 6 patients, and the prevalence of HIV was 16%. Mismanagement had probably occurred in 21 cases (27%), usually involving an intercostal drain left in for too long. Surgery was eventually necessary in 52 cases (68%). The final outcome was good in 64 of the 77 patients (83%). CONCLUSIONS: The high prevalence of surgery requires timely referral to a specialised cardiothoracic surgeon, and facilities should be available. Empyema associated with a diseased lung, especially a destroyed lung, is a therapeutic challenge and the outcome is often unsatisfactory.

Pleural space disease in pediatric patients: a retrospective analysis.

Pleural space disease, pleural effusions, and parapneumonic empyema present a therapeutic dilemma regarding the most appropriate medical and surgical management (i.e., performing a thoracentesis on admission versus delayed, placing a pigtail catheter versus a regular chest tube, and performing early versus late thoracoscopy). Other questions remain about early surgical intervention to decrease morbidity, shorten hospital stay, and produce cost-effective results. To define a clinical approach for a prospective study, the charts of all patients who were discharged with ICD-9 codes 511.8, 511.9, and 510.9, between June 5, 1991, and May 7, 1995, were reviewed. Thirty-one patients were identified. A database was developed and the results were analyzed. This paper presents a clinical pathway suggested by this retrospective study with cost analysis.

Evaluation of treatment modalities for thoracic empyema: a cost-effectiveness analysis.

BACKGROUND: Empyema thoracis is treated with a multitude of therapeutic options. Optimal therapy and cost-containment requires selection of the most appropriate initial intervention. METHODS: A retrospective review of treatment modalities was performed on 77 patients diagnosed with empyema thoracis from 1990 to 1997 at one institution. Mean age was 59 years (range, 21 to 90 years); 52 were men and 25 were women. RESULTS: Sixty-five percent (50/77) were parapneumonic and 68% (52/77) were multiloculated. Treatment modalities were as follows: group 1, antibiotics only (n = 4); group 2, primary intervention: image-directed catheter (n = 20) or tube thoracostomy (n = 24); and group 3, secondary intervention: decortication (n = 17), rib resection or muscle interposition (n = 12). Thirty-four percent (9/20 image-directed catheter and 8/24 tube thoracostomy) had failure of initial intervention. Patients undergoing decortication more often had multiloculated empyema thoracis (16 of 17) compared with those undergoing image-directed catheters (8 of 20) or tube thoracotomy (16 of 24). Length of stay was reduced for decortication patients (17 days) compared with those having image-directed catheters (21.8 days), failed image-directed catheters (29.7 days), or tube thoracostomies (19.6 days). Hospital charges per patient between decortication and image-directed catheter ($34,770.79 versus $37,869.41) were comparable, but charges were significantly decreased in decortication patients as compared with failed image-directed catheters ($55,609.32; p < 0.05). CONCLUSIONS: Our series revealed that early decortication has charges similar to those of primary intervention (image-directed catheter or tube thoracostomy) but is more cost-effective than failed image-directed catheter. We advocate the use of early surgical intervention as the most optimal and cost-effective initial modality for the treatment of empyema thoracis.