“It seems probable that this study covers the period of practical extinction of empyema as an important disease.” Lionakis B et al , J Pediatr 1958. 

### 1.1 Structure of the guideline

The format follows that used for the BTS guidelines on the management of pleural disease in adults.1 At the start there is a summary table of the abstracted bullet points from each section. Following that is an algorithm summarising the management of pleural infection in children (fig 1). Each section starts with bulleted points of key recommendations using the revised SIGN grading system (table 1) available on http://www.sign.ac.uk/guidelines/fulltext/50/section6.html. Beneath each set of bullet points is a short paragraph detailing the referenced literature and the rationale behind the recommendations. The primary source literature has been individually graded for its methodology and the grading is given alongside each reference using the revised SIGN levels of evidence (table 2).

View this table:

 Table 1 
 Revised SIGN grading system: grades of recommendation



View this table:

 Table 2 
 Revised SIGN grading system: levels of evidence





 Figure 1 
 Algorithm for the management of pleural infection in children.



### 1.2 Methodology for generation of the guidelines

The initial literature search was carried out by the Library of the National Heart Lung Institute, Imperial College London. Further searches were then carried out by members of the working group who concentrated on their own topics. Details of the search strategy are given in Appendix 1.

Each section of the guideline was researched and drafted by a subgroup of the Paediatric Pleural Diseases Subcommittee (itself a subcommittee of the BTS Standards of Care Committee). Publications were rated according to the SIGN criteria for the calibre of the methodology of the research to give levels of evidence (table 2). Tables of evidence were then produced before writing the guideline sections using the SIGN grades of recommendations (table 1). Once all parts were merged into one document, the whole group then met to discuss …

https://thorax.bmj.com/content/thoraxjnl/60/suppl_1/i1.full.pdf

BTS guidelines for the management of pleural infection in children

https://www.annalsthoracicsurgery.org/article/S0003-4975(09)01926-2/pdf

Outcomes of Video-Assisted Thoracoscopic Decortication

The use of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has been proposed since the early 1990s, but among surgeons, its use varies considerably, and the results are discordant. This report aims to provide a retrospective assessment of the authors’ experience and the literature on VATS in an effort to ascertain rational criteria for the use of this technique. Over a period of 12 years, a total of 120 cases of pleural empyema were recorded. The patients were assessed with chest x-ray, computed tomography, ultrasound, and thoracentesis. On the basis of clearly defined clinical and radiographic parameters, 38 patients underwent VATS immediately, whereas the remaining 82 were treated initially by means of tube thoracostomy. The latter was found to be sufficient for only 10 patients. Consequently, for the remaining 72 patients, it was decided to proceed also with VATS. The procedure was performed completely by VATS in 101 patients (91.8%), whereas in 9 patients (8.2%) it was necessary to convert to thoracotomy. The postoperative course was uneventful for 98 of the 110 patients (89%), whereas the remaining 12 patients experienced complications, including one case of persistent empyema (0.9%) treated by thoracotomy. The mean chest tube duration was 6 days (range, 3–25 days). The mean postoperative hospital stay was 7.1 days (range, 5–17 days). Of the 80 patients completing a 6-month follow-up evaluation, the results were considered good for 72, moderately good for 8, and less than satisfactory for 2 patients. In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.

Video-assisted thoracic surgery in the treatment of pleural empyema.

For expert pulmonologists, advanced procedures in medical thoracoscopy are the nonroutine and more complex applications of the method. The main current indications are the treatment of infected pleural space, forceps lung biopsy and sympathectomy. In parapneumonic effusions and empyema, medical thoracoscopy is as a drainage procedure, intermediate between tube thoracostomy and video-assisted thoracoscopic surgery (VATS), which is efficient, significantly lower in cost and avoids surgical thoracoscopy under general anaesthesia. It is essential that it is performed early in the course of the disease and is particularly advisable for frail patients at high surgical risk. The efficacy of forceps lung biopsy has been demonstrated in diffuse lung diseases, whereas results in localised lung diseases and chest-wall lesions have been less positive. However, VATS is currently the preferred approach for these indications. The technique still maintains its efficacy for visceral pleura and peripheral lung biopsy, in particular in the presence of pleural effusion and lung disorders. At the present time, thoracoscopic sympathectomy is minimally invasive and is an accepted intervention for patients with a variety of autonomous nervous system disturbances. Essential hyperhidrosis patients, and well-selected patients with other disorders, can be helped with this procedure, which can also be performed by interventional pulmonologists.

https://erj.ersjournals.com/content/erj/28/5/1051.full.pdf

Advanced techniques in medical thoracoscopy

Background Traditional and modern treatments are proposed for thoracic empyema. The efficacy of video-assisted thocoscopic surgery (VATS) has been studied when the method is applied either as primary treatment for thoracic empyema or after the failure of fibrinolytic therapy. Methods Thirty-eight patients treated with VATS for thoracic empyema have been reviewed. Of those, 20 patients (group 1) with empyema thoracis were referred to VATS after failure of the fibrinolytic treatment. Another 18 patients (group 2) with primary empyema thoracis were treated thoracoscopically immediately when empyema was diagnosed. Both groups were staged 5, 6, or 7 according to Light's criteria. Results The group 2 patients showed a higher empyema resolving rate (95% versus 85%), shorter hospital stay (4.5 versus 7.5 days), and significantly shorter duration of the procedure (70 ± 14 versus 62 ± 10 minutes) in comparison with the patients of group 1. Conclusions The VATS technique for thoracic empyema is a well-tolerated, minimally invasive technique, with excellent therapeutic results, mild postoperative complications, and reduced hospitalization. VATS should be considered as the treatment of choice for thoracic empyema, in the fibrinopurulent stage, as it is more effective when applied primarily than when applied after fibrinolytic therapy.

Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure?

Postpneumonic empyema complicates 5% of all pneumonia cases. The loculated fibrinopurulent stage cannot be resolved by drainage tube insertion alone; it requires a debriding limited thoracotomy. Recent reports of series seem to indicate that video-assisted thoracic surgery (VATS) can replace thoracotomy advantageously. Eighty-six cases of postpneumonic empyema were operated on in our institution during the last 12 years: 33 cases (group I) using limited thoracotomy (1985–1991) and 53 by VATS (1992–1996). Data were collected prospectively for group II and retrospectively for the first group. The two populations were comparable in age, gender, stage of disease, and co-morbid status. There were no significant differences between the groups. VATS debridement for loculated fibrinopurulent postpneumonic empyema offers better results than thoracotomy in terms of resolution of the disease and length of stay in hospital. It also seems to be more advantageous, resulting in fewer surgical sequelae, lower cost, less labor impediment, and better cosmesis.

Diego Angelillo-Mackinlay

Papers

Surgical treatment of postpneumonic empyema.