Treatment of Parapneumonic Effusion in Children.

To the Editors: We read the article by Lohuis et al1 regarding conservative treatment of parapneumonic effusion in children. In their article, the authors stated that the greater amount of children with parapneumonic effusion (PPE) could be treated conservatively with antibiotics only, especially in the absence of mediastinal shift, pleural septations/pockets, pleural thickening or extensive effusions. In a cohort of 136 patients, 117 patients (86%) were treated conservatively and 19 (14%) underwent pleural drainage. They found patients undergoing pleural drainage had mediastinal shift more frequently compared with conservatively treated patients (58% vs. 3%, difference 55%; 95% confidence interval: 32%–77%). In the study patients treated conservatively, median duration of hospitalization was 5 days (Interquartile range: 4–112) compared with 19 days (Interquartile range: 15–24) in the drainage group (P < 0.001), without significant difference in readmission rate (11% vs. 4%). Children with pneumonia can admit initially with an effusion that is in any one of the stages of evolution. The stage of evolution of the parapneumonic process and what therapy has already been provided is the key point for treatment. As in the study of Lohuis et al1 not all the patients were evaluated with ultrasonography, it is not possible to state how benign or complicated were PPE in the initial phase, since the cohort is not large enough to generalize to whole population and it is not easy to say PPE could be treated conservatively with antibiotics only, this statement might change due to geographic location, immunization schedules or surveillance data. For patients with parapneumonic effusions, clinicians can use ultrasound to quantify and characterize pleural fluid to determine whether diagnostic or therapeutic drainage is indicated, as well as to guide whether intrapleural fibrinolytics or surgical treatment is needed.2 In our center, 48 patients between 1 and 17 years of age from January 2011 to December 2016 were diagnosed with PPE, tube thoracostomy was performed in 43 of 48 (89.6%). Patients treated with fibrinolytic therapy was 22 (45.8%) and the mean dose was 5.18 ± 2.59 (1–9) in total. Fibrinolytic therapy was significantly higher in PE stage (II) than the other stages (P = 0.001). Intensive care need was 20.8% (n = 10), while total hospital stay was 23.58 ± 8.69 (3–47) days. Thoracotomy/decortication or Video assisted thoracoscopic surgery were required in 5 (10.4%) patients. There was no significant relationship between the operation and fibrinolytic treatment status of patients. The complication rate was 41.6% in total.3 Similarly, Lohuis et al1 also discussed that thoracic ultrasound could play a more important role in the decision making for the favorable treatment option with either conservative management or pleural drainage. Their study suggests that a Computed tomography scan does not play a major role in the diagnosis and treatment of PPE in children. These studies highlighting therapy of parapneumonic effusion in children are very helpful to guide clinicians and more randomized controlled trails are warranted.