Tratamiento de los derrames pleurales paraneumónicos

Asensio de la Cruz, O.; Blanco González, J.; Moreno Galdó, A.; Pérez Frías, J.; Salcedo Posadas, A.; Sanz Borrell, L.

doi:10.1016/S1695-4033(01)77526-1

Article information

Las neumonías son una de las causas más frecuentes de derrame pleural en los niños. El 0,6-2 % de las neumonías se complican con empiema y aproximadamente el 40% de las neumonías que precisan hospitalización en niños presentan derrame pleural. En los últimos años, Streptococcus pneumoniae es el germen aislado con mayor frecuencia.

El tratamiento se basa en el empleo adecuado y precoz de antibióticos, técnicas de imagen, toracocentesis, drenaje pleural, fibrinolíticos, toracoscopia y toracotomía.

La colocación de un drenaje pleural está indicada de forma precoz en las siguientes situaciones: presencia de pus en el espacio pleural, tinción de Gram positiva del líquido pleural, glucosa del líquido pleural inferior a 50 mg/dl, pH del líquido pleural inferior a 7, presencia de septos o tabiques en el líquido pleural en la ecografía.

La instilación local de fibrinolíticos puede disminuir la necesidad de tratamiento quirúrgico, con una eficacia entre el 38 y el 100 %, según lo avanzado del estadio del derrame. El desbridamiento por toracoscopia es útil en fase fibrinopurulenta con tabicaciones y adherencias, con resultados favorables según la precocidad de su realización, entre el 30-100 %

Palabras clave:

Neumonías

Derrame pleural paraneumónico

Empiema

Drenaje pleural

Fibrinolíticos

Toracoscopia

Niños

Pleural effusion in children is most often due to bacterialpneumonia. Between 0.6 and 2% of pneumonias are complicated by empyema and approximately 40 % of children hospitalized with pneumonia have a pleural effusion. In recent years Streptococcus pneumoniae is the most prevalent organism.

Treatment is based on the early and judicious use of antibiotics, imaging techniques, thoracocentesis, pleural drainage, fibrinolytics, thoracoscopy and thoracotomy. Indications for early pleural drainage are gross pus, positive Gram stain in pleural fluid, pleural glucose less than 50 mg/dL, pleural fluid pH of less than 7 and sonographic evidence of loculations. Local fibrinolytics may decrease the need for surgical treatment, with a success rate between 38 and 100 %, according to the effusion stage. Thoracoscopic debridement is useful in the fibrinopurulent stage with loculations, with favorable results in 30-100 % of patients, also depending on the effusion stage

Key words:

Pneumonia

Parapneumonic pleural effusion

Empyema

Pleural drainage

Fibrinolytics

Thoracoscopy

Children

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Bibliografía

[1.]

A. Segado, F. Rodríguez Panadero.

Fisiopatología de la pleura: manejo del derrame pleural.

Manual de Neumología y Cirugía Torácica, pp. 1671-1684

[2.]

A. DeLuca, G. Kurland.

Empyema in children: epidemiology, diagnosis and management.

Semin Pediatr Infect Dis, 9 (1998), pp. 205-211

[3.]

H. Hamm, R.W. Light.

Parapneumonic effusion and empyema.

Eur Respir J, 10 (1997), pp. 1150-1156

Medline

[4.]

S.A. Sahn.

The pleura.

Am Rev Respir Dis, 138 (1988), pp. 184-234

http://dx.doi.org/10.1164/ajrccm/138.1.184 | Medline

[5.]

R.W. Light.

Parapneumonic effusions and empyema.

Pleural diseases, 3.a, pp. 129-153

[6.]

S.A. Sahn.

Management of complicated parapneumonic effusions and empyema.

Am Rev Respir Dis, 148 (1993), pp. 813-817

http://dx.doi.org/10.1164/ajrccm/148.3.813 | Medline

[7.]

B. Freij, H. Kusmiesz, J.D. Nelson, G.H. McCracken.

Parapneumonic effussions and empyema in hospitalized children: a retrospective review of 277 cases.

Pediatr Infect Dis J, 3 (1984), pp. 578-592

[8.]

F. Brémont, C. Baunin, A. Juchet, F. Rance, C. Puget, M. Juricic.

Evolution clinique et traitement d lâ™empyème pleural chez lâ™enfant.

Arch Pediatr, 3 (1996), pp. 335-341

Medline

[9.]

H. Sarihan, A. Cahy, M. Aynaci, R. Akyazici, A. Baki.

Empyema in children.

J Thorac Cardiovasc Surg, 39 (1998), pp. 113-116

[10.]

W.D. Hardie, N.E. Roberts, S.F. Reising, C.D.C. Cristie.

Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae.

Pediatrics, 101 (1998), pp. 388-392

Medline

[11.]

T.Q. Tan, E.O. Mason, W.J. Barson, E.R. Wald, G.E. Schutze, J.S. Bradley.

Clinical characteristics and outcome of children with pneumonia attributable to penicillin-susceptible and penicillin- nonsusceptible Streptococcus pneumoniae.

Pediatrics, 102 (1998), pp. 1369-1375

Medline

[12.]

R.E. Bryant, C.J. Salmon.

Pleural empyema.

Clin Infect Dis, 22 (1996), pp. 747-764

Medline

[13.]

R.W. Light, W.M. Girard, S.G. Jenkinson, R.B. George.

Parapneumonic effusions.

Am J Med, 69 (1980), pp. 507-511

Medline

[14.]

D.A. Taryle, D.E. Potts, S.A. Sahn.

The incidence and clinical correlates of parapneumonic effusions in pneumococcal pneunonia.

Chest, 74 (1978), pp. 170-173

Medline

[15.]

W.H. Hendren III, R.J. Haggerty.

Staphylococic pneumonia in infancy and childhood.

JAMA, 168 (1958), pp. 6-16

[16.]

C.M. Ginsburg, J.B. Howard, J.D. Nelson.

Report of 65 cases of Haemophilus influenzae type b pneumonia.

Pediatrics, 64 (1979), pp. 283-286

Medline

[17.]

J.K. Mansel, E.C. Rosenow III, T.F. Smith, J.W. Martin.

Mycoplasma pneumoniae pneumonia.

Chest, 95 (1989), pp. 639-646

Medline

[18.]

H.B. Panitch, C. Papastamelos, D.V. Schidlow.

Abnormalities of the pleural space.

Pediatric Respiratory Medicine, pp. 1178-1196

[19.]

T.C. McLoud, C.D. Flower.

Imaging the pleura: sonography, CT and MR imaging.

AJR Am J Roentgenol, 156 (1991), pp. 1145-1153

http://dx.doi.org/10.2214/ajr.156.6.2028857 | Medline

[20.]

P.C. Yang, K.T. Luh, D.B. Chang, H.D. Wu, C.J. Yu, S.H. Kuo.

Value of sonography in determining the nature of pleural effusions: analysis of 320 cases.

AJR Am J Roentgenol, 159 (1992), pp. 29-33

http://dx.doi.org/10.2214/ajr.159.1.1609716 | Medline

[21.]

R.R. Ramnath, R.M. Heller, T. Ben-Ami, M.A. Miller, P. Campbell, W.W. Neblett.

Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia.

Pediatrics, 101 (1998), pp. 68-71

Medline

[22.]

H. Grewal, R.J. Jackson, C.W. Wagner, S.D. Smith.

Early video âassisted thoracic surgery in the management of empyema.

Pediatrics, 103 (1999), pp. 63

[23.]

L.F. Donnelly, L.A. Klosterman.

CT appearance of parapneumonic effusions in children: findings are not specific for empyema.

AJR Am J Roentgenol, 169 (1997), pp. 179-182

http://dx.doi.org/10.2214/ajr.169.1.9207521 | Medline

[24.]

C.S. Park, W.M. Chung, M.K. Lim, C.H. Cho, C.H. Suh, W.K. Chung.

Transcatheter instillation of urokinase into loculated pleural effusion: analysis of treatment effect.

AJR Am J Roentgenol, 167 (1996), pp. 649-652

http://dx.doi.org/10.2214/ajr.167.3.8751672 | Medline

[25.]

M.R. Palin, G.K. Griffin.

J Comput Assist Tomogr, 9 (1985), pp. 1079-1083

Medline

[26.]

R.E. Wood.

Diagnostic and therapeutic procedures in pediatric pulmonary patients.

Pediatric Respiratory Medicine, pp. 244-262

[27.]

S.R. Leonard, H. Nikaidoh, W.R. Thompson.

Thoracocentesis and chest tube insertion.

Essentials of Pediatric Intensive Care, 2.a, pp. 1519-1526

[28.]

S. Mahfood, W.R. Hix, B.L. Aaron, P. Blaes, W.C. Watson.

Reexpansion pulmonary edema.

Ann Thorac Surg, 45 (1988), pp. 340-345

Medline

[29.]

D.S. Cheng, R.M. Rodríguez, J. Rogers, M. Wagster, D.L. Starnes, R.W. Light.

Comparison of pleural fluid pH values obtained using blood gas machine, Ph meter, and pH indicator strip.

Chest, 114 (1998), pp. 1368-1372

Medline

[30.]

Heffner JE, Brown LK, Barbieri C, DeLeo JM. Pleural fluid chemical analysis in parapneumonic effusions. A meta-analysis. Am J Respir Crit Care Med 1995; 1700-1708

[31.]

J.E. Heffner.

Indications for draining a parapneumonic effusion: an evidence-based approach.

Semin Resp Infect, 14 (1999), pp. 48-58

[32.]

Light RW. Disorders of the pleura, mediastinum and diaphragm. Harrison's on line, Chapter 262. http://www.harrisonsonline.com

[33.]

R.W. Light.

A new classification of parapneumonic effusions and empyema.

Chest, 108 (1995), pp. 299-301

Medline

[34.]

J. Mensa, J.M. Gatell, M.T. Jiménez de Anta, G. Prats.

Masson, (2000),

[35.]

H. Rosen, V. Nadkarni, M. Theroux, R. Padman, J. Klein.

Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients.

Chest, 103 (1993), pp. 1190-1193

Medline

[36.]

S. Krishnan, N. Amin, A.J. Dozor, G. Stringel.

Urokinase in the management of complicated parapneumonic effusions in children.

Chest, 112 (1997), pp. 1579-1583

Medline

[37.]

A. Korneck, Y. Sivan.

Treatment of loculated pleural effusion with intrapleural urokinase in children.

J Pediatr Surg, 32 (1997), pp. 1473-1475

Medline

[38.]

D. Bouros, S. Schiza, G. Patsourakis, G. Chaldiakis, P. Paragou, N.M. Siafakas.

Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effussions: a prospective, double-blind study.

Am J Resp Crit Care Med, 155 (1997), pp. 191-195

[39.]

D. Bouros, S. Schiza, N. Siafakas.

Utility of fibrinolitic agents for draining intrapleural infections.

Semin Resp Infect, 14 (1999), pp. 39-47

[40.]

C.W. Davies, S. Lok, R.J. Davies.

The systemic fibrinolytic activity of intrapleural streptokinase.

Am J Crit Care Med, 17 (1998), pp. 328-330

[41.]

H.A. Steinbrecher, A.S. Najmaldin.

Thoracoscopy for empyema in children.

J Pediatr Surg, 33 (1998), pp. 708-710

Medline

[42.]

J.W. Klena, B.H. Cameron, J.C. Langer, A.L. Winthrop, C.R. Pérez.

Timing of video-assisted thoracoscopic debridement for pediatric empyema.

J Am Coll Surg, 187 (1998), pp. 404-408

Medline

[43.]

C.M. Merry, A.J. Bufo, R.S. Shah, K.P. Scropp, T.E. Lobe.

Early definitive intervention by thoracoscopy in pediatric empyema.

J Pediatr Surg, 34 (1999), pp. 178-180

Medline

[44.]

R.M. Patton, M.S. Abrams, M.W. Gauderer.

Is thoracoscopically aided pleural debridement advantegous in children?.

Am Surg, 65 (1999), pp. 69-72

Medline

[45.]

O.N. Gofrit, D. Engelhard, K. Abu-Dalu.

Post-pneumonic thoracic empyema in children: a continued surgical challenge.

Eur J Pediatr Surg, 9 (1999), pp. 4-7

http://dx.doi.org/10.1055/s-2008-1072203 | Medline

[46.]

J.A. Carey, J.R. Hamilton, D.A. Spencer, K. Gould, A. Hasan.

Empyema thoracis: a role for open thoracotomy and decortication.

Arch Dis Child, 79 (1998), pp. 510-513

Medline

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Miembros del grupo de trabajo: D. Álvarez Gil (Hospital Infanta Margarita, Cabra, Córdoba); V. Alzina de Aguilar (Clínica Universitaria de Navarra, Pamplona); A. Andrés Martín (Hospital Universitario de Valme, Sevilla); C. Antelo Landeira (Hospital Universitario La Paz, Madrid); O. Asensio de la Cruz (Corporació Sanitària Parc Taulí, Sabadell, Barcelona); I. Barrio Gómez de Agüero (Hospital Universitario La Paz, Madrid); J. Blanco González (Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid); M. Bermejo Pastor (Hospital Materno-Infantil de Badajoz); A. Bonillo Perales (Hospital Torrecárdenas, Almería); M. Bosque García (Corporació Sanitària Parc Taulí, Sabadell, Barcelona); G. Cabrera Roca (Hospital Universitario Materno-Infantil, Las Palmas de Gran Canaria); M. Carrasco Zalvide (Hospital Juan Ramón Jiménez, Huelva); I. Cortell Aznar (Hospital Universitario La Fe, Valencia); J. Elorz Lambarri (Hospital de Cruces, Baracaldo, Vizcaya); A. Escribano Montaner (Hospital Clínico Universitario, Valencia); J. Figuerola (Hospital de Manacor, Baleares); M.D. Frías Morales (Madrid); D. Gómez-Pastrana Durán (Hospital de Jerez, Jerez de la Frontera, Cádiz); C. Landaluce Ugarte (Hospital Txagorritxu, Vitoria); S. Liñán Cortés (Hospital Materno-Infantil Vall d'Hebron, Barcelona); M. Machuca Contreras (Hospital Virgen del Rocío, Sevilla); C. Martínez (Hospital Universitario La Paz, Madrid); A. Moreno Galdó (Hospital Materno-Infantil Vall d'Hebron, Barcelona); C. Oliva Hernández (Hospital Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Canarias); M.T. Pascual Sánchez (Hospital de Sant Joan, Reus, Tarragona); L. Pardos Rocamora (CAP Balaguer, Lleida); J. Pérez Frías (Hospital Materno-Infantil Carlos Haya, Málaga); G. Pérez Pérez (Hospital Universitario Virgen de la Macarena, Sevilla); E. Pérez Ruiz (Hospital Materno-Infantil Carlos Haya, Málaga); C. Reverté Bover (CAP Amposta, Tarragona); A. Salcedo Posadas (Hospital Infantil Universitario Niño Jesús, Madrid); J. Sánchez Jiménez (Hospital de Sant Jaume, Calella, Barcelona); E. Sánchez Sánchez (CAP Premià de Mar, Barcelona); L. Sanz Borrell (Hospital de Sant Joan, Reus, Tarragona); A. Sequeiros González (Hospital Infantil Universitario Niño Jesús, Madrid); J. Sirvent Gómez (Complejo Hospitalario Juan Canalejo, La Coruña); J.M. Tabarés Lezcano (Hospital Cristal-Piñor, Orense); J.M. Torres Simón (Hospital de Palamós, Girona); M.I. Ubeda Sansano (CAP Godella, Valencia); J.R. Villa Asensi (Hospital Infantil Universitario Niño Jesús, Madrid).

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