Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2017 Mar 17;3(3):CD010651.
doi: 10.1002/14651858.CD010651.pub2.

Surgical versus non-surgical management for pleural empyema

Mark D Redden  1 , Tze Yang Chin  2   3 , Mieke L van Driel  4
Affiliations
Meta-Analysis

Surgical versus non-surgical management for pleural empyema

Mark D Redden et al. Cochrane Database Syst Rev. .

Abstract

Background: Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment.

Objectives: To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016).

Selection criteria: Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach.

Main results: We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals.

Authors' conclusions: Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.

PubMed Disclaimer

Conflict of interest statement

Mark Redden: None known. Tze Yang Chin: None known. Mieke van Driel: None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 1 Mortality.
1.2
1.2. Analysis
Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 2 Length of hospital stay (days).
1.3
1.3. Analysis
Comparison 1 Open thoracotomy versus thoracostomy drainage, Outcome 3 Procedural complications.
2.1
2.1. Analysis
Comparison 2 VATS versus thoracostomy drainage, Outcome 1 Mortality.
2.2
2.2. Analysis
Comparison 2 VATS versus thoracostomy drainage, Outcome 2 Length of hospital stay (days).
2.3
2.3. Analysis
Comparison 2 VATS versus thoracostomy drainage, Outcome 3 Procedural complications.
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD010651

References

References to studies included in this review

Bilgin 2006 {published data only}
    1. Bilgin M, Akcali Y, Oguzkaya F. Benefits of early aggressive management of empyema thoracis. ANZ Journal of Surgery 2006;76(3):120‐2. - PubMed
Cobanoglu 2011 {published data only}
    1. Cobanoglu U, Sayir F, Bilici S, Melek M. Comparison of the methods of fibrinolysis by tube thoracostomy and thoracoscopic decortication in children with stage II and III empyema: a prospective randomized study. Pediatric Reports 2011;3(4):e29. - PMC - PubMed
Karaman 2004 {published data only}
    1. Karaman I, Erdogan D, Karaman A, Cakmak O. Comparison of closed‐tube thoracostomy and open thoracotomy procedures in the management of thoracic empyema in childhood. European Journal of Pediatric Surgery 2004;14(4):250‐4. - PubMed
Kurt 2006 {published data only}
    1. Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video‐assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006;118(3):e547‐53. - PubMed
Marhuenda 2014 {published data only}
    1. Marhuenda C, Barceló C, Fuentes I, Guillén G, Cano I, López M, et al. Urokinase vs VATS for treatment of empyema: A randomised multicenter clinical trial. Pediatrics 2014;134(5):e1300. - PubMed
Peter 2009 {published data only}
    1. Peter SD, Tsao K, Spilde TL, Keckler SJ, Harrison C, Jackson MA, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. Journal of Pediatric Surgery 2009;44(1):106‐11. - PMC - PubMed
Sonnappa 2006 {published data only}
    1. Sonnappa S, Cohen G, Owens CM, Doorn C, Cairns J, Stanojevic S, et al. Comparison of urokinase and video‐assisted thoracoscopic surgery for treatment of childhood empyema. American Journal of Respiratory & Critical Care Medicine 2006;174(2):221‐7. - PubMed
Wait 1997 {published data only}
    1. Wait MA, Sharma S, Hohn J, Dal Nogare A. A randomised trial of empyema therapy. Chest 1997;111(6):1548‐51. - PubMed

References to studies excluded from this review

Angelillo 1996 {published data only}
    1. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, Piedras MA, Angaramo G, Emery J. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Annals of Thoracic Surgery 1996;61(6):1626‐30. - PubMed
Bagheri 2013 {published data only}
    1. Bagheri R, Tavassoli A, Haghi SZ, Attaran D, Sadrizadeh A, Asnaashari A, et al. The role of thoracoscopic debridement in the treatment of parapneumonic empyema. Asian Cardiovascular & Thoracic Annals Aug 2013;21(4):443‐6. - PubMed
Bouros 1997 {published data only}
    1. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Panagou P, Siafakas NM. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: a prospective, double‐blind study. American Journal of Respiratory & Critical Care Medicine 1997;155(1):291‐5. - PubMed
Bouros 1999 {published data only}
    1. Bouros D, Schiza S, Tzanakis N, Chalkiadakis G, Drositis J, Siafakas N. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double‐blind study. American Journal of Respiratory & Critical Care Medicine 1999;159(1):37‐42. - PubMed
Chin 1997 {published data only}
    1. Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111(2):275‐9. - PubMed
Cho 2000 {published data only}
    1. Cho CH, Kwak SM, Park CS, Bae IY, Moon TH, Cho JH, et al. The effects of urokinase instillation therapy via percutaneous transthoracic catheter drainage in loculated pleural effusion: a randomised prospective study. European Respiratory Journal 2000;16(31):579.
Davies 1997 {published data only}
    1. Davies RJ, Traill ZC, Gleeson FV. Randomised controlled trial of intrapleural streptokinase in community acquired pleural infection. Thorax 1997;52(5):416‐21. - PMC - PubMed
Diacon 2004 {published data only}
    1. Diacon AH, Theron J, Schuumans MM, Wal BW, Bolliger CT. Intrapleural streptokinase for empyema and complicated parapneumonic effusions. American Journal of Respiratory & Critical Care Medicine 2004;170(1):49‐53. - PubMed
Hewidy 2014 {published data only}
    1. Hewidy A, Elshafey M. Medical thoracoscopy versus intrapleural fibrinolytic therapy in complicated parapneumonic effusion and empyema. Egyptian Journal of Chest Diseases and Tuberculosis 2014;63(4):896‐9.
Lin 2011 {published data only}
    1. Lin JC, Zhang CR, Xu WM, Li M, Cui WL. Effectiveness and safety of intrapleural tissue plasminogen activator in the prevention of pleural thickening and loculated effusions by infective pleurisy. International Journal of Infectious Diseases 2011;15(Suppl):104‐5.
Maskell 2005 {published data only}
    1. Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R, et al. UK controlled trial of intrapleural streptokinase for pleural infection. New England Journal of Medicine 2005;352(9):865‐74. - PubMed
Mathew 2015 {published data only}
    1. Mathew JL, Lodha R, Sharma S. VATS or urokinase for treatment of empyema?. Indian Pediatrics 2015;52(1):57‐60. - PubMed
Minchev 2004 {published data only}
    1. Minchev TS, Dzhambazov V, Petrov D, Stanoev V, Aleksov S, Petkov R. Video‐assisted thoracoscopic surgery (VATS) for treatment of pleural empyema [Video‐asistirana torakoskopska khirurgiia (VATS) za lechenie na plevralniia empiem]. Khirurgiia 2004;60(2):15‐7. - PubMed
Misthos 2005 {published data only}
    1. Misthos P, Sepsas E, Konstantinou M, Athanassiadi K, Skottis L, Lioulias A. Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. European Journal of Cardio‐Thoracic Surgery 2005;28(4):599‐603. - PubMed
Nandeesh 2013 {published data only}
    1. Nandeesh M, Sharathchandra BJ, Thrishuli PB. ICD versus VATS as primary treatment in fibrinopurulent stage of empyema thoracis. Journal of Clinical and Diagnostic Research 2013;7(12):2855‐8. - PMC - PubMed
Rahman 2009 {published data only}
    1. Rahman NM, Maskell N, Davies CW, West A, Teoh R, Arnold A, et al. Primary result of the Second Multicentre Intrapleural Sepsis (MIST2) trial; randomised trial of intrapleural TPA and DNase in pleural infection. Thorax 2009;64:A1.
Rahman 2011 {published data only}
    1. Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. New England Journal of Medicine 2011;365(6):518‐26. - PubMed
Sahn 1998 {published data only}
    1. Sahn SA. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax 1998;53(Suppl):65‐72. - PMC - PubMed
Shah 2006 {published data only}
    1. Shah NN, Bachh AA, Bhargava R, Ahmad Z, Panday DK, Shameem M. Role of intrapleural streptokinase in management of multiloculated thoracic empyemas. JK Practitioner 2006;13(2):91‐4.
Singh 2004 {published data only}
    1. Singh M, Mathew JL, Chandra S, Katariya S, Kumar L. Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children. Acta Paediatrica 2004;93(11):1443‐5. - PubMed
Talib 2003 {published data only}
    1. Talib SH, Verma GR, Arshad M, Tayade BO, Rafeeque A. Utility of intrapleural streptokinase in management of chronic empyemas. Journal of the Association of Physicians of India 2003;51:464‐8. - PubMed
Thommi 2012 {published data only}
    1. Thommi G, Shehan JC, Robison KL, Christensen M, Backmeyer LA, McLeay MT. A double blind randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions. Respiratory Medicine 2012;106(5):716‐23. - PubMed
Thomson 2002 {published data only}
    1. Thomson AH, Hull J, Kumar MR, Wallis C, Balfour Lynn IM. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57(4):343‐7. - PMC - PubMed

References to studies awaiting assessment

Ahmed 2016 {published data only}
    1. Ahmed S, Azam H, Basheer I. Is open decortication superior to fibrinolytic therapy as a first line treatment in the management of pleural empyema?. Pakistan Journal of Medical Sciences 2016;32(2):329‐32. - PMC - PubMed
Hasimoto 2015 {published data only (unpublished sought but not used)}
    1. Hasimoto EN, Hasimoto FN, Cataneo DC, Cataneo AJM. Pleural empyema treatment in children: Simple pleural drainage or videothoracoscopy? A controlled clinical trial. Interactive Cardiovascular and Thoracic Surgery 2015;21(Suppl 1):59‐510.
NCT00234208 {published and unpublished data}
    1. NCT00234208. Early medical thoracoscopy versus simple chest tube drainage in complicated parapneumonic effusion and pleural empyema. clinicaltrials.gov/ct2/show/NCT00234208?term=empyema&rank=1 (first received 5 October 2005).
Zhang 2011 {published data only}
    1. Zhang J, Liu J, Li Y, Huang SH, Chen HG, Wang CP, et al. Video‐assisted thoracic surgery (VATS) is superior to chest tube drainage in fibropurulent empyema. International Journal of Infectious Diseases 2011;15(Suppl 1):51‐2.

Additional references

Atkins 2004
    1. Atkins D, Best D, Briss PA, Eccles M, Falck‐Ytter Y, Flottorp S, et al. GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490. - PMC - PubMed
Aye 1991
    1. Aye RW, Froese DP, Hill LD. Use of purified streptokinase in empyema and hemothorax. American Journal of Surgery 1991;161(5):560‐2. - PubMed
Balfour‐Lynn 2005
    1. Balfour‐Lynn IM, Abrahamson E, Cohen G, Hartley J, King S, Parikh D, et al. British Thoracic Society: Guidelines for the management of pleural infection in children. Thorax 2005;60(Suppl 1):1‐21. - PMC - PubMed
Cameron 2008
    1. Cameron R, Davies HR. Intra‐pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database of Systematic Reviews 2008, Issue 2. [DOI: 10.1002/14651858.CD002312.pub3] - DOI - PubMed
Chapman 2004
    1. Chapman SJ, Davies RJ. The management of pleural space infections. Respirology 2004;9(1):4‐11. - PubMed
Davies 2010
    1. Davies HE, Davies RJO, Davies CWH. Management of pleural infection in adults: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:45‐53. - PubMed
Ferguson 1996
    1. Ferguson AD, Prescott RJ, Selkon JB, Watson D, Swinburn CR. The clinical course and management of thoracic empyema. Quarterly Journal of Medicine 1996;89:285‐9. - PubMed
GRADEpro GDT 2015 [Computer program]
    1. GRADEpro GDT. GRADEpro Guideline Development Tool [www.guidelinedevelopment.org]. Hamilton: McMaster University (developed by Evidence Prime, Inc.), 2015.
Higgins 2011
    1. Higgins JPT, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from www.handbook.cochrane.org.
Jaffé 2003
    1. Jaffé A, Cohen G. Thoracic empyema. Archives of Disease in Childhood 2003;88:839‐41. - PMC - PubMed
Jones 2003
    1. Jones PW, Moyers JP, Rogers JT, Rodriguez RM, Lee YCG, Light RW. Ultrasound‐guided thoracentesis. Is it a safer method?. Chest 2003;123(2):418‐23. - PubMed
Kaifi 2012
    1. Kaifi JT, Toth JW, Gusani NJ, Kimchi ET, Staveley‐O'Carroll KF, Belani CP, et al. Multidisciplinary management of malignant pleural effusion. Journal of Surgical Oncology 2012;105(7):731‐8. - PubMed
Krenke 2010
    1. Krenke K, Peradzynska J, Lange J, Ruszczynski M, Kulus M, Szajewska H. Local treatment of empyema in children: a systematic review of randomized controlled trials. Acta Paediatrica 2010;99(10):1449‐53. - PubMed
Kundu 2010
    1. Kundu S, Mitra S, Mukherjee S, Das S. Adult thoracic empyema: a comparative analysis of tuberculous and nontuberculous etiology in 75 patients. Lung India 2010;27(4):196‐201. - PMC - PubMed
Lardinois 2005
    1. Lardinois D, Gock M, Pezzetta E, Buchli C, Rousson V, Furrer M, et al. Delayed referral and gram‐negative organisms increase the conversion thoracotomy rate in patients undergoing video‐assisted thoracoscopic surgery for empyema. Annals of Thoracic Surgery 2005;79(6):1851‐6. - PubMed
Lefebvre 2011
    1. Lefebvre C, Manheimer E, Glanville J. Chapter 6: Searching for studies. In: Higgins JP, Green S, editor(s). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011). The Cochrane Collaboration, 2011. Available from handbook.cochrane.org.
Light 1985
    1. Light RW. Parapneumonic effusions and empyema.. Clinical Chest Medicine 1985;6(1):55‐62. - PubMed
Light 2006
    1. Light RW. Parapneumonic effusions and empyema. Proceedings of the American Thoracic Society 2006;3:75‐80. - PubMed
Marshall 2009
    1. Marshal JC, Naqbi AA. Principles of Source Control in the Management of Sepsis. Critical Care Clinics 2009;35(4):753‐68. - PubMed
Miller 1987
    1. Miller KS, Sahn SA. Chest tubes. Indications, technique, management and complications. Chest 1987;91:258‐64. - PubMed
Oddel 1994
    1. Oddel J. Management of empyema thoracis. Journal of the Royal Society of Medicine 1994;87:466‐71. - PMC - PubMed
RevMan 2014 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.3. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
Sahn 2007
    1. Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clinical Infectious Diseases 2007;45(11):1480‐6. - PubMed
Temes 1996
    1. Temes RT, Follis F, Kessler RM, Pett SB Jr, Wernly JA. Intrapleural fibrinolytics in management of empyema thoracis. Chest 1996;110(1):102‐6. - PubMed
Tillett 1951
    1. Tillett WS, Sherry S, Read CT. The use of streptokinase‐streptodornase in the treatment of chronic empyema; with an interpretive discussion of enzymatic actions in the field of intrathoracic diseases. Journal of Thoracic Surgery 1951;21(4):325‐41. - PubMed
Yim 1996
    1. Yim A, Liu H. Complications and failures of video‐assisted thoracic surgery: experience from two centers in Asia. Annals of Thoracic Surgery 1996;61:538‐41. - PubMed

References to other published versions of this review

Chin 2013
    1. Chin TY, Redden MD, Hsu CCT, Driel ML. Surgical versus non‐surgical management for pleural empyema. Cochrane Database of Systematic Reviews 2013, Issue 7. [DOI: 10.1002/14651858.CD010651] - DOI - PMC - PubMed
Coote 2005
    1. Coote N, Kay E. Surgical versus non‐surgical management of pleural empyema. Cochrane Database of Systematic Reviews 2005, Issue 4. [DOI: 10.1002/14651858.CD001956.pub3] - DOI - PubMed

LinkOut - more resources