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Surgical versus non‐surgical management of pleural empyema

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Abstract

Background

Pleural empyema is a collection of pus between the lungs and the chest wall. There is debate about treatment options with the advent of both fibrinolytic enzymes to facilitate tube drainage and less invasive video‐assisted thoracoscopic surgery (VATS).

Objectives

To determine which was more effective: surgical (using thoracoscopy or thoracotomy) or non‐surgical techniques (thoracocentesis, chest tube drainage); and to establish whether there was an optimum time for intervention.

Search methods

In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, issue 3) which contains the Acute Respiratory Infections Group's specialized register; MEDLINE (January 2002 to July Week 4, 2005); and EMBASE (January 2001 to 3rd Quarter 2005). Bibliographies, reference lists of identified studies and review articles were handsearched. Personal communication with authors is ongoing. There were no language restrictions.

Selection criteria

Randomised controlled trials (RCTs) of surgical techniques versus non‐surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.

Data collection and analysis

Trial quality was assessed using Jadad criteria (Jadad 1996). Authors were contacted for missing information. The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed the length of time chest tubes were required, pain, hospital stay and any complications.

Main results

Only one small randomised study was identified. Some methodological quality considerations cast doubt on the validity of the study with regard to patient selection, unclear allocation concealment and outcome assessor blinding and it scored 'B' overall (Jadad score 3). When compared with chest tube drainage combined with streptokinase, video‐assisted thoracoscopic surgery (VATS) had a significantly higher primary treatment success and patients spent less time in hospital. Each treatment group suffered one mortality. The latest search revealed no further published randomised studies but communication with authors revealed two ongoing studies comparing conventional chest tube drainage plus antibiotics with and without fibrinolytics with video‐assisted thorascopic surgery (VATS). A small unpublished study is awaiting assessment that compared chest tube drainage and antibiotics with thoracoscopy or thoracotomy plus antibiotics.

Authors' conclusions

It seems that for large, loculated pleural empyemas VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay. However, there are questions about validity in the one study which met the inclusion criteria and the study has too few participants to draw conclusions. There are risks of complications (associated with all treatments) which may not be apparent with small numbers. Larger studies are needed.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Plain language summary

Video‐assisted chest surgery may be more effective than chest tube drainage for the lung complication pleural empyema

Pleural empyema is a collection of pus between the lungs and the chest wall. Drainage is usually necessary unless antibiotics are started early enough. This review identified one trial comparing chest tube drainage combined with streptokinase (a drug that breaks down tube blockage and further aids drainage by breaking down fibrinous walls or loculations in the empyema) to video‐assisted chest surgery (VATS), which is performed under general anaesthetic. VATS was more effective. There were unpublished and ongoing studies yet to be assessed.