CLINICAL PROFILE AND OUTCOME OF CHILDREN WITH EMPYEMA THORACIS IN TERTIARY HOSPITAL

Empyema thoracis (ET) is an accumula�on of pus in the pleural space. It is a common condi�on in childhood having signiﬁcant morbidity and mortality. The clinical manifesta�ons of empyema are high grade fever with chills and rigors, cough, breathlessness, chest pain. The present study analyses the epidemiological aspects of the disease, e�ological agents, clinical features and associated lesions in diagnosis of empyema and the outcome of early Video-assisted thoracoscopic surgery (VATS) on morbidity of disease in children.


Introduc on
Empyema thoracis (ET) is an accumula on of pus in the pleural space. It is a common condi on in childhood having significant morbidity and mortality. The clinical manifesta ons of empyema are high grade fever with chills and rigors, cough, breathlessness, chest pain. The present study analyses the epidemiological aspects of the disease, e ological agents, clinical features and associated lesions in diagnosis of empyema and the outcome of early Videoassisted thoracoscopic surgery (VATS) on morbidity of disease in children.

Objec ves
To study various demographic characteris c and to evaluate various management strategies and outcome in children with empyema thoracis.

Methodology
This is a prospec ve hospital based observa onal study, conducted at Nobel Medical College Teaching Hospital Biratnagar, from December 2021 to November 2022. All children in the age group of 1month to 16 years diagnosed pyogenic empyema by lights criteria during the study are included in the study. Children below 1 month of age and pleural effusion not mee ng the criteria for exuda ve pleural effusion by Light's criteria are excluded from the study.

Result
Majority of the study popula on are in the age group of >5 years. Males are more common than females. Most common clinical feature was fever followed by cough, chest pain and shortness of breath. Culture is posi ve in 68% out of which 32% is staphylococcus aureus, 20% is mycobacterium tuberculosis, 16% is streptococcus pneumonia. Dura on of illness is <1week in 48% of the children, 1-2weeks in 40% and >3 weeks in 12% of the children. In 80% of the children there is unilateral involvement in the x-ray chest. In the children who are uncomplicated all of them had intercoastal chest tube drain (ICD) usage,76.4% had urokinase therapy and 5.8% had undergone thoracotomy and none of them had need for surgery. In the children with complica on 87.5% had ICD usage and urokinase therapy,25% of them had undergone thoracotomy and 12.5% had need for surgery.

Conclusion
Empyema thoracis is more commonly seen in the males of the group>5 years with dura on of illness <1 week maned mostly by ICD usage, where there was mostly unilateral involvement in x ray chest.

INTRODUCTION
Empyema thoracis, the presence of pus in the pleural space develops as a complica on of bacterial pneumonia in 5-10% 1 of children. About 0.6% of childhood pneumonias' progress to pleural empyema and is a recognized common complica on of bacterial pneumonia.In most of the cases, it is of parapneumonic origin. It is usually caused by local spread of infec on from pneumonia, tuberculosis or lung abscess but may be caused by organism brought to pleural space via blood or lympha cs or abscess extending upward from below the diaphragm or as a consequence of infec on at other sites distant from lung. Less common causes include following surgical procedures, traumas and oesophageal perfora on, inhala on of a foreign body, immunodeficiency states such as hypogammaglobulinemia, and immuno suppression a er chemotherapy, cor costeroid treatment, or malnutri on but these are rare in children. Condi ons are more common in boys than girls and are more frequently encountered in infants and young children. They are also more common in winter and spring, presumably due to their 2 infec ve origin. Empyema thoracis (ET) is known since Hippocrates' me; nonetheless, incidence is s ll rising all 3 over the world. Possible reasons could be poverty, ignorance, malnutri on, misdiagnosis, delay in ini a ng treatment or inadequate/inappropriate treatment of bacterial pneumonia, non-evacua on of pleural space and delayed referral. The incidence of empyema is increasing despite the advent of potent an microbial agents resul ng .4,5 in significant childhood morbidity The pleural space usually contains a small amount of fluid (0.3ml/kg of body weight),which is absorbed and secreted in equilibrium via the lympha c drainage system. This circulatory system can cope with a substan al increase in fluid produc on; however, disrup on of this balance can lead to fluid accumula on and an associated pleural effusion, which may be further exacerbated if infec on is present. Infec on in the lung ac vates an immune response and s mulates pleural inflamma on. Pleural vasculature becomes more permeable and inflammatory cells and bacteria leak into the pleural space causing pleural fluid infec on and forma on of pus resul ng in the classical 2 rou nely employed in laboratories for clinical use. Empyema usually presents with persistent high-grade fever, cough, fast breathing or difficulty in breathing, irritability and some mes chest deformity. Cough may be absent in the earlypart of the pneumonic process caused by Streptococcus pneumoniae but develops asthe disease advances. Chest pain and diarrhoea may be a feature. Malnutri on is frequently associated. The pa ents may present with several previous consulta ons and treatment without complete resolu on of symptoms a er being administered various broad-spectrum an bio cs including empirical antuberculous treatment. Rarely the empyema may be bilateral. The disease can produce significant morbidity in 6,8 children if inadequately treated. Empyema usually advances in severity in a con guous fashion which can be divided into three stages namely: exuda ve, fibrinopurulent and organizing, commonly

METHODOLOGY
This is a prospec ve hospital based observa onal study, conducted at Nobel Medical College Teaching Hospital Biratnagar, from December 2021 to November 2022. 2 2 Sample size was calculated by using the formula ( n= Z pq/d ) where Z equals to 1.96, p equals to 3% and d equals to 0.05. All children in the age group of 1month to 16 years diagnosed pyogenic empyema by lights criteria during the study are included in the study. Children below 1 month of age and pleural effusion not mee ng the criteria for exuda ve pleural effusion by Light's criteria are excluded from the study. Ins tu onal ethics commi ee was also sought for conduc ng the study from the ins tu onal review commi ee of Nobel medical college and teaching hospital. They are divided according to mode of presenta on, dura on of illness and side involved in Xray chest. The basic inves ga on like chest Xray and blood culture were done in all the cases. A er collec ng, the data were verified and coded accordingly and entered in Microso excel 2007 and converted into sta s cal package for social science (SPSS v.20) for sta s cal analysis. For the descrip ve presenta on, frequency and percentage (%) were calculated, and also tabular presenta on was made.

RESULTS
During the study period 25 children were admi ed with empyema thoracis. Out of which 52% were male and 48% were female. 68% of the children were in the age group of more than 5years, 24% were in the age of 2-5 years and 8% were in age of less than 2 years.    Most common clinical feature was fever followed by cough, chest pain and shortness of breath. Dura on of illness was<1week in 48% of the children, 1-2weeks in 40% and >3weeks in 12% of the children. In 80% of the children there was unilateral involvement in the x-ray chest.
Culture was posi ve in 68% out of which 32% was staphylococcus aureus, 20% was Mycobacterium TB,16% was Streptococcus pneumoniae.
In the children who were uncomplicated, all of them had ICD usage,76.4% had urokinase therapy and 5.8% had undergone thoracotomy and none of them had need for surgery. In the children with complica on 87.5% had ICD usage and urokinase therapy,25% of them had undergone thoracotomy and 12.5% had need for surgery.
Sah VK et al

DISCUSSION
In empyema thoracis, clinical signs and symptoms in isola on are non-specific, and mimic pulmonary infec on of any compartment, with fever and increased white cell count being common findings. In developing countries, more than one-fourth of hospital-admi ed pa ents with pneumonia eventually develop parapneumonic effusion or empyema because of delayed ini a on of adequate treatment. The mortality and morbidity due to empyema thoracis may be due to underlying comorbidi es or delay in ini a on of 6,8 defini ve treatment. We have described a clinical presenta on and demographics of the children presen ng with empyema thoracis at the Department of paediatrics and Neonatology, Nobel Medical College Teaching Hospital, Biratnagar. In our study males were admi ed more commonly than females and most of them were in the age group of more than 5 years which is comparable to a study conducted by 12 2.
Bha a NK et al and Thakkar PK et al And Neha Agarwal et 6 al.
In most of the studies, male gender was iden fied as a risk factor of loculated effusion among children. However, un l now, the biologically plausible mechanism of gender distribu on among pa ents with pleural disease remains 2,8,12 unknown. In our study fever, cough, chest pain shortness of breath were the symptoms seen out of which fever was the most common mode of presenta on which was similar to the study conducted by Thakkar PKwhereas in a study conducted by Yuan-Ming Tsai et al most common presenta on was cough followed by chest pain. This difference may be due to the small sample size of our study and wide varia on in symptoms according to the ming of 2,13 presenta on and causa ve organisms. In our study dura on of illness was less than 1 week in 48% of the children,1-2weeks in 40% and more than 3weeks in

CONCLUSIONS
Empyema thoracis is the disease commonly seen in the young children. Most of the children were in the age group of >5 years and majority were males. Fever was the most common mode of presenta on followed by cough. Dura on of the illness was less than 1 week in most of the children with unilateral involvement was more common in the chest X-ray. Most commonly cultured organism was Staphylococcus aureus and the most of the children were managed with ICD usage in our study.

LIMITATION OF THE STUDY
The sample size was limited to draw conclusions and CT scan of the chest was not done due to financial constraints.