Published ahead of print on May 4, 2006, doi:10.1164/rccm.200601-027OC
Am. J. Respir. Crit. Care Med., Volume 174, Number 2, July 2006, 221-227
A more recent version of this article appeared on July 15, 2006
Submitted on January 6, 2006
Accepted on April 28, 2006
Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema
Samatha Sonnappa1*, Gordon Cohen2, Catherine M Owens3, Carin van Doorn2, John Cairns4, Sanja Stanojevic5, Martin J Elliott2, and Adam Jaffe1
1 Department of Respiratory Medicine, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom; Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health, London, United Kingdom,
2 Department of Cardio-Thoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom,
3 Department of Radiology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom,
4 Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom,
5 Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health, London, United Kingdom
* To whom correspondence should be addressed. E-mail: s.sonnappa{at}ich.ucl.ac.uk.
Background: Despite increasing incidence and morbidity little evidence exists to inform the best management approach in childhood empyema. Aim: To compare chest drain with intrapleural urokinase and primary video-assisted thoracoscopic surgery (VATS) for the treatment of childhood empyema. Methods: Children were prospectively randomized to receive either percutaneous chest drain with intrapleural urokinase or primary VATS. The primary outcome was the number of hospital days post-intervention. Secondary end points were number of chest drain days, total hospital stay, failure rate, radiological outcome at 6 months and total treatment costs. Results: Sixty children were recruited. The 2 groups were well matched for
demographics, baseline characteristics, hematological, biochemical and bacteriological parameters. No significant difference was found in length of hospital stay post-intervention between the two groups: VATS [median (range) 6 (3-16) days] v. urokinase 6 (4-25) days) p=0.311, 95% CI -2 to 1 ]. No difference was demonstrated in total hospital stay: VATS v. urokinase [median (range) 8(4-17) days and 7(4-25) days p=0.645)], failure rate: 5 (16.6%) and radiological outcome at 6 months post-intervention in both groups. The mean (median) treatment costs of patients in the urokinase arm $9,127 ($6,914) were significantly lower than those for the VATS arm $11,379 ($10,146) (p< 0.001). Conclusions: There is no difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema. Urokinase is a more economic treatment option compared to VATS and should be the primary treatment of choice. This study provides an evidence base to guide the management of childhood empyema.
www.clinicaltrials.gov ID: NCT00144950
Key words: prospective randomized trial, intrapleural urokinase, primary videoassisted thoracoscopic surgery (VATS)
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