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Is chest drain insertion and fibrinolysis therapy equivalent to video-assisted thoracoscopic surgery to treat children with parapneumonic effusions?
  1. Aaron Colin John Bell,
  2. Camilla Baker,
  3. Amedine Duret
  1. Department of Paediatric Infectious Diseases, St Mary's Hospital, Imperial College NHS Healthcare Trust, London, UK
  1. Correspondence to Dr Amedine Duret, Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, W2 1NY, UK; aduret{at}

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A 12-year-old boy, previously fit and well, presents to his local paediatric emergency department after 5 days of fever and a cough, and 2 days of increasing difficulty breathing. His oxygen saturation is 90% in air, and he requires 2 L of oxygen via nasal cannula. He is started on broad-spectrum antibiotics and further investigations are arranged.

A chest X-ray is performed and shows a large left-sided pleural effusion. An ultrasound demonstrates the effusion is complex and loculated, with underlying lung consolidation, in keeping with a stage II parapneumonic effusion.

The medical team wonders whether insertion of a chest drain and fibrinolysis (CDF) or video-assisted thoracoscopic surgery (VATS) would be the most appropriate next step.

Structured clinical question

Is CDF therapy equivalent to VATS to treat children with parapneumonic effusions?

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Search strategy

Search terms including keywords such as “empyema”, “parapneumonic effusion”, “thoracostomy”, “chest drain” and “video-assisted thoracic surgery” were used in different databases to identify relevant publications (online supplemental appendix 1). This yielded 692 search results, including 346 duplicates. Abstracts were screened for relevance by two independent reviewers. Overall, 20 studies were included for review of the full manuscript.

Supplemental material


A Cochrane review1 of surgical versus non-surgical management of pleural empyema reviewed the length of hospital stay in patients under 18 years of age in four randomised clinical trials (RCTs) published between 2006 and 2014.2–5 Furthermore, a systematic review published in 2019 by Pacilli and Nataraja6 reviewed the four RCTs considered in the Cochrane review, one additional RCT published in 20067 and five prospective cohort studies. Primary data published …

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  • Contributors AD—establishment of search terms, independent review of papers for inclusion/exclusion, independent review of data and drafting of the manuscript. ACJB—independent review of papers for inclusion/exclusion, independent review of data, cover letter, review, submission and updating of the manuscript. CB—independent review of papers for inclusion/exclusion and review of the manuscript.

  • Funding Dr Amedine Duret is supported by an NIHR Academic Clinical Fellowship and acknowledges infrastructure support for this research from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre (BRC).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.