Thoracostomy and fibrinolysis for the management of empyema

A little throw back to 2009 prompted by a discussion on management of parapneumonic effusion/empyema.

In the frequently quoted study out of The Center for Prospective Clinical Trials in Kansas City, the authors compared the effectiveness of VATS vs thoracostomy/fibrinolysis in 36 patients.  Empyema was defined based on imaging characteristics or WBC content and then managed with either VATS or thoracostomy (chest catheter drainage with a12 F tube) with fibrinolysis using 3 doses of 4 mg of Altase given over a 48 hour period.

No significant difference was found in the outcomes assessed, which were days of hospitalization (6.9 vs. 6.8 days), days of oxygen requirement (2.3 days), days until afebrile (3.1 vs. 3.8), or analgesic requirements. The difference in cost was $11.7K vs $7.6K between VATS and thoracostomy /fibrinolysis, respectively.

Although fibrinolysis was sufficient for most patients, 16.6% still needed VATS; an important point to mention to parents when discussing the procedure.

Another important point to stress here is that in many institutions, the most common chest catheters available are 8.5 Fr (and not 12 Fr), and one should make sure the appropriate catheter is used to optimize the chance for success.