P3.J196: Predictors for Use of Primary Chest Tube Drainage vs. Video Assisted Thoracoscopic Surgery in Children with Parapneumonic Effusion/Empyema

Background:

Introduction:
Parapneumonic effusion and pleural empyema (PPE/PE) are the most common complications of community-acquired pneumonia (CAP), causing significant mortality and morbidity worldwide. The management of PPE/PE often involves using chest tube (CT) drainage or video-assisted thoracoscopic surgery (VATS). However, the decision-making process regarding which approach to use can be challenging, especially in pediatric patients.

Objective:
To conduct a comparative analysis of demographic, radiological, and laboratory predictors of performing any surgical procedure and using different procedures such as VATS and CT drainage for the management of complicated CAP (cCAP). Understanding these predictors could potentially help in stratifying patients based on their likelihood of benefiting from one intervention over the other.

Methods: A retrospective chart review was conducted on 156 children, aged 3 months to 18 years, admitted with community-acquired pneumonia complicated by parapneumonic effusion (cCAP) between December 1, 2010, and December 1, 2020. Patients without other co-morbidities were included. Clinical and laboratory characteristics of patients with PPE/PE were compared using univariate statistics. Multivariate Poisson regression analysis was utilized to model independent predictors of undergoing any surgical procedure, as well as individual surgical procedures such as VATS.

Results: Among the 2047 children admitted with community-acquired pneumonia (CAP), 156 (7.6%) were diagnosed with complicated CAP (cCAP). Among them, 71 (45.5%) were managed solely with antibiotics, while 85 (54.5%) underwent surgical intervention. Among those who underwent surgery, 54 (34.6%) received chest tube (CT) placement with or without fibrinolytic administration, and 31 (19.8%) underwent procedures including video-assisted thoracoscopic surgery (VATS). The presence of large PE on chest X-ray (RR 2.048; 95% CI 1.20, 3.49; p=0.008) and loculated PE on chest ultrasound ( RR 1.44; 95% CI 1.03, 2.01; p=0.03) were independently associated with undergoing any surgical procedure. However, the only independent predictor of undergoing a surgical procedure involving VATS was fever upon admission to the hospital (temperature > 100.4°F) (Risk Ratio 2.267; 95% CI 1.23, 4.18; p=0.009).See tables.

Conclusion: The decision on which approach to use for the treatment cCAP in pediatric patients may be based on multiple factors, including clinical, laboratory, and radiologic parameters. Our study indicates that the presence of severe PE and the presence of loculation in the pleura are the most significant factors associated with the use of surgical procedures. Additionally, fever upon admission emerges as the sole predictor in the choice of a procedure associated with VATS.