Coote Nicky, Kay Elspeth S
Paediatric Ambulatory Care Unit, Hammersmith and Queen Charlotte's Hospitals, Du Cane Road, London, UK, W12 0HS.
Cochrane Database Syst Rev. 2009 Oct 7;2009(4):CD001956. doi: 10.1002/14651858.CD001956.pub3.
Pleural empyema is a collection of pus between the lungs and the chest wall. There is debate about treatment options with the advent of both fibrinolytic enzymes to facilitate tube drainage and less invasive video-assisted thoracoscopic surgery (VATS).
To determine which was more effective: surgical (using thoracoscopy or thoracotomy) or non-surgical techniques (thoracocentesis, chest tube drainage); and to establish whether there was an optimum time for intervention.
In this updated review we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, issue 3) which contains the Acute Respiratory Infections Group's specialized register; MEDLINE (January 2002 to July Week 4, 2005); and EMBASE (January 2001 to 3rd Quarter 2005). Bibliographies, reference lists of identified studies and review articles were handsearched. Personal communication with authors is ongoing. There were no language restrictions.
Randomised controlled trials (RCTs) of surgical techniques versus non-surgical approaches for treatment of pus in the pleural cavity in children and adults but not neonates. Studies of empyema associated with tuberculosis or malignancy were excluded.
Trial quality was assessed using Jadad criteria (Jadad 1996). Authors were contacted for missing information. The primary outcomes were death or resolution of the empyema. Secondary outcomes addressed the length of time chest tubes were required, pain, hospital stay and any complications.
Only one small randomised study was identified. Some methodological quality considerations cast doubt on the validity of the study with regard to patient selection, unclear allocation concealment and outcome assessor blinding and it scored 'B' overall (Jadad score 3). When compared with chest tube drainage combined with streptokinase, video-assisted thoracoscopic surgery (VATS) had a significantly higher primary treatment success and patients spent less time in hospital. Each treatment group suffered one mortality. The latest search revealed no further published randomised studies but communication with authors revealed two ongoing studies comparing conventional chest tube drainage plus antibiotics with and without fibrinolytics with video-assisted thorascopic surgery (VATS). A small unpublished study is awaiting assessment that compared chest tube drainage and antibiotics with thoracoscopy or thoracotomy plus antibiotics.
AUTHORS' CONCLUSIONS: It seems that for large, loculated pleural empyemas VATS is superior to chest tube drainage in terms of duration of chest tubes in situ and length of hospital stay. However, there are questions about validity in the one study which met the inclusion criteria and the study has too few participants to draw conclusions. There are risks of complications (associated with all treatments) which may not be apparent with small numbers. Larger studies are needed.
胸膜腔积脓是指肺与胸壁之间的脓液积聚。随着促进胸腔引流的纤维蛋白溶解酶的出现以及侵入性较小的电视辅助胸腔镜手术（VATS）的开展，关于治疗方案存在争议。
确定哪种方法更有效：手术治疗（使用胸腔镜或开胸手术）还是非手术技术（胸腔穿刺术、胸腔闭式引流）；并确定是否存在最佳干预时机。
在本次更新的综述中，我们检索了Cochrane对照试验中心注册库（CENTRAL）（《Cochrane图书馆》2005年第3期），其中包含急性呼吸道感染组的专业注册库；MEDLINE（2002年1月至2005年7月第4周）；以及EMBASE（2001年1月至2005年第3季度）。对手检文献、已识别研究的参考文献列表和综述文章进行了手工检索。与作者的个人沟通正在进行中。没有语言限制。
针对儿童和成人（不包括新生儿）胸膜腔积脓的手术技术与非手术方法的随机对照试验（RCT）。排除与结核病或恶性肿瘤相关的脓胸研究。
采用Jadad标准（Jadad 1996）评估试验质量。联系作者获取缺失信息。主要结局为脓胸死亡或治愈。次要结局涉及胸腔闭式引流所需时间、疼痛、住院时间和任何并发症。
仅识别出一项小型随机研究。一些方法学质量方面的考虑对该研究在患者选择、分配隐藏不明确以及结局评估者盲法方面的有效性提出了质疑，总体评分为“B”（Jadad评分3分）。与胸腔闭式引流联合链激酶相比，电视辅助胸腔镜手术（VATS）的初始治疗成功率显著更高，患者住院时间更短。每个治疗组各有1例死亡。最新检索未发现进一步发表的随机研究，但与作者的沟通显示有两项正在进行的研究，比较传统胸腔闭式引流加抗生素与加或不加纤维蛋白溶解酶的情况，以及与电视辅助胸腔镜手术（VATS）的比较。一项未发表的小型研究正在等待评估，该研究比较了胸腔闭式引流和抗生素与胸腔镜或开胸手术加抗生素的情况。
对于大型、局限性胸膜腔积脓，就胸腔闭式引流的持续时间和住院时间而言，电视辅助胸腔镜手术（VATS）似乎优于胸腔闭式引流。然而，符合纳入标准的一项研究存在有效性问题，且该研究参与者过少，无法得出结论。（所有治疗均）存在并发症风险，小样本可能未显示出来。需要开展更大规模的研究。
