The study authors defined “complicated pneumonia” as a pneumonia with pleural effusion. This study compared 3 alternatives for treating complicated pneumonia: chest tube placement, video-assisted thoracoscopic surgery (VATS), and thoracotomy. The study authors noted that VATS has many of the benefits of thoracotomy (eg, opportunity to debride pleural space) but is less invasive. Previous efforts to compare the 3 approaches have been completed at single centers or with few patients.

This study used the Pediatric Health Information System, an administrative database that contained data from 42 freestanding US children’s hospitals. Twenty-seven of the hospitals reported resource use for any discharge, and the subjects for this study were drawn from these 27 hospitals. Subjects were 12 months to 18 years old. From 2001 to 2005 they were patients in the participating hospitals, and patients also had one of the 3 procedures performed within 48 hours of being admitted to the hospital. The study authors excluded children with chronic medical conditions that might have been associated with pneumonia or study utilization outcomes.

The primary outcome of interest was the length of stay (LOS), with a secondary outcome of interest being need for an additional procedure to drain fluid. The type of procedure was the predictor variable of interest, but the study authors also controlled for age, sex, race/ethnicity, seasonal variation, whether patients received empirical antibiotics, whether patients received steroids or fibrinolytics, and whether the subjects had asthma.

The study authors identified 2862 cases of complicated pneumonia, comprising 5.8% of all subjects in the dataset who had pneumonia. Of the 2862 subjects, 961 (33.6%) had one of the 3 procedures performed within 48 hours of admission and are the subjects of this study. The subjects were admitted at a median age of 4.0 years, and 14.5% of the subjects had asthma and received steroids. For all subjects, the median LOS was 10 days, and 31% of subjects required an additional drainage procedure. In bivariate analyses comparing LOS between procedure types, the median LOS was shortest for VATS at 7 days, compared with 10 days for chest tube placement and 10 days for thoracotomy.

In regression analyses controlling for asthma, steroid administration, and whether the patients received vancomycin initially, VATS was associated with a 24% shorter LOS compared with patients treated by chest tube placement. After adjustment in regression analyses, VATS was also associated with 84% reduction in need for a second pleural fluid drainage procedure. Use of steroids and empirical use of vancomycin were both associated with increased LOS. Asthma was not associated with LOS after controlling for steroid use. The analyses also adjusted for clustering within the hospitals.

The study authors concluded that VATS is associated with shorter LOS compared with chest tube placement.

Viewpoint

The study authors noted that this study may not be generalizable to all hospitals, given that the data were derived from referral children’s hospitals. As they noted, there are many reasons why a patient may or may not receive a given procedure, only some of which can be controlled with administrative data. The study findings do seem compelling enough to consider a randomized trial comparing VATS with chest tube placement for patients with complicated pneumonia, but such a study would need similarly capable surgeons at each institution, and that may be difficult to carry out. Although time series data are not presented in the study, the data provided also seem to offer justification for a gradual reduction in open thoracotomy, given that outcomes of interest in this study were similar. The administrative data couldn’t compare other outcomes of interest, including pain or other complications directly, but some of these might factor into LOS. Finally, the study authors noted that a prospective study would want to evaluate longer-term outcome measures, including function and pain.

 

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