Role of Thoracic Ultrasound in Assessing the Severity of Pleural Empyema in Infants and Children

Background/Objectives In children and infants, thoracic empyema commonly arises as a complication of parapneumonic effusions evolving into purulent collections. With an incidence of 0.6% among pneumonia cases, our study aimed to systematically characterize pediatric empyema by exploring the interplay between clinical, biochemical, and radiological parameters and their influence on patient outcomes. Materials and Methods: This is a retrospective single center study comprising patients diagnosed with parapneumonic pleural empyema, treated in the Pulmonology Department of “Grigore Alexandrescu” Emergency Hospital for Children, between January 2021-December 2024. We selected patients who were treated surgically, either with a simple pleural drain or Video-Assisted Thoracic Surgery (VATS). None of the patients received fibrinolytics, due to a lack of experience with their use in our department. Patients were stratified by initial treatment into chest-tube drainage-group or VATS-group. Clinical, laboratory, and radiographic data were extracted from hospital records. Results: This study included a final cohort of 33 patients. Median [IQR] age at inclusion was 4 years [3-8]. Median time until initial intervention for the entire cohort was 2 [1-5] days. Fourteen (42.4%) of children undergo VATS as initial intervention, p=0.384, after a median time of 4.5 [2-6.3] days. In 19 children, chest-tube drainage was implemented initially, after a median time of 1[0-3] days with a mean duration of 21.2 11.5 days. Median hospitalization length was 27 [21-38.5] days for the overall cohort. A linear regression model identified loculations and septations as significant predictors of hospitalization length. Drainage duration was significantly shorter in the initial VATS group (n=14, median 9.5 days [IQR 7.8–12.5]) compared to the chest tube group (n=19, 19 days [IQR 11–30]; p=0.011). Pleural fluid thickness, septations, and loculations on thoracic ultrasound were not significantly associated with the choice of primary intervention (VATS vs. chest tube drainage). Dyspnea was a strong predictor of intervention type, significantly increasing the likelihood of VATS over chest tube drainage (OR 18.00, 95% CI 1.86–174.21; p= 0.013). Patients were equally divided between early and late VATS intervention groups, each included 11 patients. Early VATS did not significantly reduce hospital stay (29 vs. 31 days; p=0.151), and VATS timing had minimal impact (R²=0.042; p=0.358). VATS overall did not reduce hospitalization length compared to chest tube drainage alone (24 vs. 28 days; p=0.665). CT was performed in 15 children (45.5%) and revealed complications including bronchopleural fistula (21.2%), empyema necessitans (12.1%), and pyopneumothorax (21.2%), with 15.2% presenting multiple complications. CT imaging was associated with longer hospitalization. Conclusions In this cohort, chest-tube drainage represented the primary treatment, with decision-making guided by a combination of clinical features, paraclinical data, and institutional protocols, rather than imaging findings alone. Thoracic ultrasound (TUS) played a key role in assessing effusion complexity and guiding management, yet demonstrated limited prognostic value, similar to biochemical markers. The absence of fibrinolytic use—due to limited institutional experience—resulted in nearly half of the patients requiring escalation to VATS, underscoring the need for standardized symptom-driven algorithms combined with biomarkers and imagistic findings to guide escalation of care