Published online before print August 23, 2006, 10.1148/radiol.2411050966
(Radiology 2006;241:223-227.)
© RSNA, 2006
Percutaneous Thoracic Drainage in Neonates: Catheter Drainage versus Treatment with Aspiration Alone1
Ryan Margau, MD,
Joao G. Amaral, MD,
Peter G. Chait, MD and
Justine Cohen, MSc
1 From the Department of Radiology, the Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8. From the 2004 RSNA Annual Meeting. Received June 8, 2005; revision requested August 3; revision received August 19; accepted September 15; final version accepted, November 23.
Address correspondence to R.M. (e-mail: ryan.margau{at}utoronto.ca).
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ABSTRACT
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Purpose: To retrospectively compare thoracic drainage in neonates by using catheter and aspiration techniques.
Materials and Methods: Approval was obtained from the institutional research ethics board; informed consent from parents was waived. Retrospective review of 21 neonates (19 boys, two girls; mean gestational age, 39.3 weeks) who underwent percutaneous thoracic drainage during a 9-year period was performed. Data such as indication for drainage, type of drainage, age and weight at birth, corrected age and weight at the time of drainage, use of mechanical ventilation at the time of drainage, and outcomes were collected. Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. Fisher exact test and two-tailed unpaired student t test with a confidence level of 95% (unequal variances assumed) were used to compare neonates treated with a catheter and those treated with aspiration.
Results: Image-guided therapy was used to treat pleural effusion (29%, n = 6), chylothorax (24%, n = 5), empyema (19%, n = 4), pneumothorax (14%, n = 3), mediastinal seroma (10%, n = 3), and congenital cystic adenomatoid malformation (5%, n = 1). Sixteen (76%) infants were treated with catheter placement, with a success rate of 81% (13 of 16). Five (24%) infants were treated with simple aspiration with no success. The difference in success rates was significant (P = .003). There was no significant difference between the catheter placement and aspiration groups in terms of average age, average weight, and percentage dependent on mechanical ventilation. One complication (cellulitis) was directly related to catheter drainage. In cases where treatment was successful, the mean length of the chest tube placement was 13.5 days, and there were no deaths at follow-up. In cases where treatment failed, the long-term mortality rate was 50% (four of eight).
Conclusion: Image-guided percutaneous thoracic drainage success rates are improved if drainage catheters are placed rather than if aspiration alone is performed.
© RSNA, 2006
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INTRODUCTION
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Advances in neonatal intensive care have improved the survival of premature infants with complex medical and surgical problems. Thoracic collections due to pneumothorax, pleural effusion, hemothorax, empyema, and lung abscess are a major source of morbidity and mortality in this population. Percutaneous drainage is a well-established treatment option in these situations (1–9).
Previous authors have reported the use of percutaneous thoracic drainage catheters in pediatric patients. Complication rates related to this procedure are known to be higher in smaller children. In one series (1) (n = 133), complications occurred more frequently in infants weighing less than 5 kg (36%) than in toddlers weighing 5–10 kg (9%) or in larger children (28%).
Percutaneous management of specific thoracic entities in children has also been examined. For empyema, surgical management has been compared with percutaneous drainage with (2–6) and without (7) intrapleural instillation of fibrinolytic agents. Findings have shown the success of percutaneous therapy for the treatment of pediatric pneumothorax (1), esophageal perforation (8), postinfectious necrotizing pneumonia and lung abscess (9), chylothorax (10), and mediastinal seroma (11). A single case report has demonstrated successful transthoracic drainage as a temporizing measure during the treatment of a congenital cystic adenomatoid malformation (CCAM) of the lung (12).
Few studies have dealt specifically with neonates, and, to our knowledge, no large studies have specifically focused on neonatal image-guided thoracic drainage. There are also no publications in the English-language literature in which drainage by means of catheter placement was compared with treatment with simple aspiration. Thus, the purpose of our study was to retrospectively compare thoracic drainage performed in neonates by using catheter and aspiration techniques.
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MATERIALS AND METHODS
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Patients
Twenty-one neonates (19 boys, two girls; mean corrected gestational age equivalent, 39.3 weeks) underwent percutaneous thoracic drainage during a 9-year period. Infants were classified as neonates if they were less than 1 month old (corrected gestational age, less than 44 weeks) at the time of the drainage procedure. Approval was obtained from our institutional research ethics board. Informed consent from parents was waived by the board for this retrospective study.
Data Collection
Clinical data including underlying medical diagnosis, weight and age at birth, weight and corrected age at the time of the drainage procedure, need for mechanical ventilation at the time of the percutaneous treatment, and whether there had been prior attempts at non–image-guided thoracic drainage were recorded (R.M., J.C.). The indication for drainage, method of guidance, size of catheter (French) or aspiration needle (gauge), duration of catheter placement, use of intrapleural fibrinolysis, complications, and long-term outcomes were also noted.
Drainage was considered successful if the collection was treated without additional surgical or radiologic intervention. For analysis purposes, each neonate was counted once. If multiple drainages were performed at the initial procedure and one was not successful, the procedure was considered a failure. For procedures in which two or more drainage catheters were placed simultaneously, the size of the larger drainage catheter and the length of the longest drainage duration were recorded.
Neonates were divided into two groups: those treated with simple aspiration and those treated with catheter placement. The type of percutaneous treatment (drainage catheter placement or simple aspiration) was determined by the attending interventional radiologist (P.G.C.) in consultation with a neonatologist at the time of treatment.
Statistical Analysis
Statistical analysis was used to compare the aspiration and catheter placement groups. The Fisher exact test was performed to compare success rates between the two groups and to compare the need for mechanical ventilation at the time of the procedure. A two-tailed unpaired Student t test with a confidence level of 95% (unequal variances assumed) was used to compare the groups with respect to the average weight and age at birth and with respect to the average weight and corrected age at the time of treatment. A P value of less than .05 indicated a significant difference. Descriptive statistical analysis was also performed. All statistical analyses were conducted with SPSS software (version 12.0; SPSS, Chicago, Ill).
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RESULTS
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At initial presentation, 90% (19 of 21) of the infants had already undergone failed attempts at blind percutaneous thoracic drainage or surgical chest tube placement. Seventy-six percent (16 of 21) of the neonates required mechanical ventilation at the time of the image-guided drainage procedure. Image-guided therapy was requested to treat pleural effusions (n = 6, 29%), chylothorax (n = 5, 24%), empyema (n = 4, 19%; Fig 1), pneumothorax (n = 3, 14%), mediastinal seroma (n = 2, 10%), and CCAM (n = 1, 5%; Fig 2). For all 21 neonates in this study, the overall treatment success rate was 62% (n = 13). The results are summarized in Figure 3.
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Figure 1a: Anteroposterior views from single-contrast upper gastrointestinal series in a male neonate (gestational age, 34 weeks) with recent repair of tracheoesophageal fistula. (a) View shows right pleural collection (empyema) communicating with the esophagus (black arrowhead). An 8-F All-Purpose drainage catheter (white arrow) was inserted with sonographic and fluoroscopic guidance. Surgically placed chest tube (white arrowhead) and internal jugular central venous catheter (black arrow) are present. (b) Follow-up view shows resolution of the esophageal leak.
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Figure 1b: Anteroposterior views from single-contrast upper gastrointestinal series in a male neonate (gestational age, 34 weeks) with recent repair of tracheoesophageal fistula. (a) View shows right pleural collection (empyema) communicating with the esophagus (black arrowhead). An 8-F All-Purpose drainage catheter (white arrow) was inserted with sonographic and fluoroscopic guidance. Surgically placed chest tube (white arrowhead) and internal jugular central venous catheter (black arrow) are present. (b) Follow-up view shows resolution of the esophageal leak.
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Figure 2a: Unenhanced transverse computed tomographic (CT) scans in male neonate (gestational age, 40 weeks) with CCAM of right lung. (a) Complex cystic lesion in right hemithorax with collapse of the right lung. (b) Resolution of pneumothorax and reexpansion of right lung after treatment with fluoroscopically placed 8-F All-Purpose drainage catheter.
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Figure 2b: Unenhanced transverse computed tomographic (CT) scans in male neonate (gestational age, 40 weeks) with CCAM of right lung. (a) Complex cystic lesion in right hemithorax with collapse of the right lung. (b) Resolution of pneumothorax and reexpansion of right lung after treatment with fluoroscopically placed 8-F All-Purpose drainage catheter.
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Figure 3a: Bar graphs show results of treatment with (a) catheter placement (n = 16) and (b) simple aspiration (n = 5). Black bar = successful treatment, gray bar = failed treatment.
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Figure 3b: Bar graphs show results of treatment with (a) catheter placement (n = 16) and (b) simple aspiration (n = 5). Black bar = successful treatment, gray bar = failed treatment.
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Percutaneous Drainage Catheter Placement
Sixteen (76%) neonates were treated by means of percutaneous catheter placement, with a success rate of 81% (n = 13). In this group, the average gestational age at birth was 37.3 weeks, and the average corrected gestational age at the time of drainage was 40.1 weeks. The average weight at birth was 3033 g, and the average weight at the time of drainage was 3226 g. Twelve (75%) of the 16 neonates required mechanical ventilation at the time of treatment. Drainage catheters were placed to treat chylothorax (n = 5), pneumothorax (n = 3), empyema (n = 3; Fig 1), pleural effusion (n = 2), mediastinal seroma (n = 2), and untreated CCAM (n = 1; Fig 2). Infants had an underlying diagnosis of complex congenital heart disease (n = 4), congenital diaphragmatic hernia (n = 4), CCAM (n = 3, two had undergone recent surgical resection), tracheoesophageal fistula (n = 2; Fig 1), trisomy 21 (n = 1), asphyxia (n = 1), and meconium aspiration syndrome (n = 1).
The majority of the catheters were 8 F in size (69%, 11 of 16). The 8-F catheters used were either an All-Purpose drainage catheter (Boston Scientific, Spencer, Ind) or a Dawson-Mueller drainage catheter (Cook, Bloomington, Ind). A few catheters were larger in size (10 F, n = 3; 12 F, n = 1; 14 F, n = 1). The 10- and 14-F catheters were All-Purpose drainage catheters (Boston Scientific), and the 14-F catheter was a Thalquick (Cook) drainage catheter.
Most drainage catheters (56%, nine of 16) were placed with sonographic guidance. In six cases, additional fluoroscopic (n = 5) or CT guidance (n = 1) was used. In four neonates, two drainage catheters were placed simultaneously. In one case of complex empyema, intrapleural fibrinolysis was performed at the time of the drainage by using a 2-mg single dose of intrapleural Altiplase (Activase; Genetech, San Francisco, Calif).
Three (19%) of 16 patients underwent failed catheter drainage. One neonate with an underlying diagnosis of chylothorax and congenital heart disease died (not related to the drainage procedure). The other two patients with failed catheter drainage, one with an underlying diagnosis of pneumothorax after surgical resection of a CCAM and the other with a chylothorax after surgery for congenital heart disease, were successfully treated with repeated drainage catheters placed with image guidance.
Simple Aspiration
The remaining five (24%) of 21 neonates were treated with simple aspiration, with no success. In this group, the average gestational age at birth was 33.8 weeks, and the average corrected gestational age at the time of treatment was 36.7 weeks. The average weight at birth was 2451 g, and the average weight at the time of treatment was 2864 g. Eighty percent (four of five) of the infants required mechanical ventilation at the time of drainage.
Image-guided percutaneous aspiration was used to treat four cases of pleural effusion and one case of empyema. In the empyema case, a drainage catheter could not be safely placed because the collection was too close to the heart. These neonates had an underlying diagnosis of pneumonia (n = 1), tracheoesophageal fistula (n = 1), complex congenital heart disease (n = 1), congenital diaphragmatic hernia (n = 1), and necrotizing enterocolitis (n = 1).
All procedures were performed with sonographic guidance. Four (80%) of five aspirations were accomplished by using a 16-gauge needle (BD Insyte; Becton Dickinson Infusion Therapy Systems, Sandy, Utah). In one case, a smaller 20-gauge needle (Angiocath; Becton Dickinson Infusion Therapy Systems) was used.
After failed aspiration, the thoracic collections were untreated (n = 2, both infants subsequently died) or were treated with antibiotics alone (n = 1), imaged-guided drainage catheter placement (n = 1), or surgical chest tube placement (n = 1, the infant subsequently died).
Comparison between Treatment Strategies
The difference in success rates between the group treated with catheter placement (81%, 13 of 16) and that treated with aspiration (0%, zero of five) was significant (P = .003). There was no significant difference in the average corrected age (P = .30), average weight (P = .69), or dependence on mechanical ventilation at the time of treatment between the two groups (P > .99). There was also no significant difference between the two groups in terms of average age (P = .32) or weight (P = .42) at birth. Although there was no statistically significant difference between the two groups in terms of age and weight, at birth the aspiration group was on average 3.5 weeks younger and weighed 582 g less than did the catheter drainage group. Similarly, at the time of treatment, the aspiration group was, on average, 3.4 weeks younger and weighed 362 g less than the catheter drainage group.
One complication (cellulitis) was directly related to a drainage catheter and was treated with antibiotics. No complications were identified in the aspiration group. There were no deaths directly attributable to either catheter placement or aspiration. In cases in which treatment was successful, the mean length of chest tube placement was 13.5 days; there were no deaths at follow-up. In cases in which treatment failed (catheter placement group, n = 3; aspiration group, n = 5), the long-term mortality rate was 50% (four of eight).
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DISCUSSION
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To our knowledge, our study constitutes the first large-scale review of percutaneous thoracic drainage procedures performed in neonates by an interventional radiology department. The neonates referred to our department were a complicated cohort, the majority (90%) having previously undergone failed non–image-guided percutaneous drainage or surgical chest tube placement. This is an expected observation since thoracic drainage in very young infants is known to have a high complication rate and to be less successful for nonserous or nonchylous collections (1). The neonates in our series were likely representative of the type of infants referred to an interventional radiologist for thoracic drainage; in general, they are poor surgical candidates owing to the presence of comorbidities.
In this series, the overall success rate was 62% (13 of 21). To our knowledge, there is no equivalent cohort in the literature to which comparison can be made. When subgroup analysis was performed, the results clearly demonstrated improved outcomes in neonates treated with catheter placement compared with those treated with simple aspiration. The success rate after aspiration was 0%, much lower that the 81% success rate observed in the drainage catheter group (P = .003). There was no difference in the number of complications between the two groups, which suggests that both treatment options are equally safe; however, the small cohort size and low complication rate limit this comparison.
The neonates in this study had different underlying diagnoses and comorbid conditions, which made the subgroup analysis somewhat difficult. By using weight and age at birth, weight and corrected age at the time of drainage, and dependence on mechanical ventilation as surrogate markers for overall health, there was no significant difference between infants treated with simple aspiration and those in whom a catheter was left in situ. On average, the neonates treated with simple aspiration were younger and weighed less at birth and at the time of treatment; although these differences were not statistically significant, even small changes in age and weight may affect clinical well-being and outcome in this patient population.
The mode of treatment was related to the observed complexity of the thoracic collection. Aspiration was used when the interventional radiologist encountered simple pleural fluid; neonates in the aspiration group were primarily treated for uncomplicated pleural effusion (80%, four of five). The poor outcome after aspiration is even more notable, since other authors (1) have shown simple pleural fluid collections to be highly amenable to percutaneous treatment in the pediatric population.
Three of the neonates in this series had an underlying diagnosis of CCAM, and two of these infants were treated for postoperative complications after surgical resection of the malformation. One infant with type I CCAM underwent catheter placement for treatment of a large air-containing cyst prior to surgical resection of the underlying abnormal lung. In this infant, catheter drainage was successful and the parents chose to forego subsequent surgical resection of the CCAM. There have been no complications after 6 years of follow-up. There is one reported case of percutaneous drainage of a CCAM as a temporizing measure prior to surgical resection (12). To our knowledge, there are no published cases where percutaneous drainage was used as definitive treatment for this disease. Nonsurgical management of CCAM is controversial. Some authors (13) have suggested that asymptomatic lesions can be followed by citing evidence that prenatally diagnosed malformations can spontaneously resolve without consequence. However, many authors (14,15) stress the need for resection in all cases of CCAM, emphasizing the risk of infection and possible malignant transformation.
In our series, there was a single case in which an empyema was successfully treated with thoracostomy tube placement combined with intrapleural fibrinolysis. Two other neonates with empyema were successfully treated with a drainage catheter alone, and one infant with empyema underwent failed treatment with simple aspiration. Successful treatment of complex pleural fluid in children by using thoracostomy tube placement and intrapleural fibrinolysis has been well demonstrated (16,17). To our knowledge, the case in our series constitutes the first reported use of intrapleural fibrinolysis in a neonate. The use of intrapleural fibrinolysis remains controversial. In the pediatric population, there have been small retrospective studies comparing surgical management of empyema with percutaneous drainage and intrapleural fibrinolysis; some authors have favored percutaneous therapy (2,3), while others have argued for early surgical intervention (4–6). In a recent large randomized trial in adults (18), the addition of intrapleural fibrinolysis to percutaneous therapy for pleural infection had no effect on mortality, the rate of surgery, or the length of hospital stay.
This study was limited by its observational and retrospective nature. In addition, despite being a large series for neonates, the overall size of the study population was small. Despite these limitations, the results suggest that if image-guided drainage is requested for a neonate, strong consideration should be given to the placement of a drainage catheter rather than to aspiration alone, because the former technique appears to be equally safe but more effective.
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ADVANCE IN KNOWLEDGE
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- In neonates with thoracic collections, percutaneous treatment with catheter drainage was more successful than treatment with simple aspiration.
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FOOTNOTES
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Abbreviations: CCAM = congenital cystic adenomatoid malformation
Authors stated no financial relationship to disclose.
Author contributions: Guarantors of integrity of entire study, R.M., J.G.A., P.G.C.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, all authors; clinical studies, R.M., J.G.A., P.G.C.; statistical analysis, all authors; and manuscript editing, all authors
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References
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- Roberts JS, Bratton SL, Brogan TV. Efficacy and complications of percutaneous pigtail catheters for thoracostomy in pediatric patients. Chest 1998;114(4):1116–1121.[Abstract/Free Full Text]
- Kilic N, Celebi S, Gurpinar A, et al. Management of thoracic empyema in children. Pediatr Surg Int 2002;18(1):21–23.[CrossRef][Medline]
- Cochran JB, Tecklenburg FW, Turner RB. Intrapleural instillation of fibrinolytic agents for treatment of pleural empyema. Pediatr Crit Care Med 2003;4(1):39–43.[CrossRef][Medline]
- Balci AE, Eren S, Ulku R, Eren MN. Management of multiloculated empyema in children: thoracotomy versus fibrinolytic treatment. Eur J Cardiothorac Surg 2002;22(4):595–598.[Abstract/Free Full Text]
- Hilliard TN, Henderson AJ, Langston Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child 2003;88(10):915–917.[Abstract/Free Full Text]
- Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic collections in infants and children. J Pediatr Surg 2000;35(2):265–268.[CrossRef][Medline]
- Furuya-Meguro ME, Mejia-Arangure JM, Martinez-Martinez BE, Villalpando-Canchola R, Fuentes-Arellano SA. Pneumonia complicated with empyema in children, to operate or not? risk factors for surgery and review of the literature [in Spanish]. Gac Med Mex 2000;136(5):449–454.[Medline]
- Martinez L, Rivas S, Hernandez F, et al. Aggressive conservative treatment of esophageal perforations in children. J Pediatr Surg 2003;38(5):685–689.[CrossRef][Medline]
- Hoffer FA, Bloom DA, Colin AA, Fishman SJ. Lung abscess versus necrotizing pneumonia: implications for interventional therapy. Pediatr Radiol 1999;29(2):87–91.[CrossRef][Medline]
- Kavvadia V, Greenough A, Davenport M, Karani J, Nicolaides KH. Chylothorax after repair of congenital diaphragmatic hernia: risk factors and morbidity. J Pediatr Surg 1998;33(3):500–502.[CrossRef][Medline]
- Connolly BL, Temple MJ, Chait PG, Restrepo R, Adatia I. Early mediastinal seroma secondary to modified Blalock-Taussig shunts: successful management by percutaneous drainage. Pediatr Radiol 2003;33(7):495–498.[CrossRef][Medline]
- Allegaert K, Proesmans M, Naulaers G, Moerman P, Lerut T, Devlieger H. Neonatal transthoracic puncture in a case of congenital cystic adenomatoid malformation of the lung. J Pediatr Surg 2002;37(10):1495–1497.[CrossRef][Medline]
- Bagolan P, Nahom A, Giorlandino C, et al. Cystic adenomatoid malformation of the lung: clinical evolution and management. Eur J Pediatr 1999;158:879–882.[CrossRef][Medline]
- Keidar S, Ben-Sira L, Weinberg M, Jaffa AJ, Silbiger A, Vinograd I. The postnatal management of congenital cystic adenomatoid malformation. Isr Med Assoc J 2001;3(4):258–261.[Medline]
- Roggin KK, Breuer CK, Carr SR, Hansen K, Kurkchubasche AG. The unpredictable character of congenital cystic lung lesions. J Pediatr Surg 2000;35(5):801–805.[CrossRef][Medline]
- Wells RG, Havens PL. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children. Radiology 2003;228(2):370–378.[Abstract/Free Full Text]
- Weinstein M, Restrepo R, Chait PG, Connolly B, Temple M, Macarthur C. Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions. Pediatrics 2004;113(3 pt 1):e182–e185. http://pediatrics.aappublications.org/cgi/content/full/113/3/e182. Accessed April 2005.[Abstract/Free Full Text]
- Maskell NA, Davies CW, Nunn AJ, et al. U.K. controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352(9):865–874. [Published correction appears in N Engl J Med 2005;352(20):2146.][Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
