DISCUSSION
Our results show a remarkable difference in the use of pleural drainage
in two comparable hospitals caring for similar pediatric populations
with PPE/PE. Unexpectedly, LOS was longer in the center that performed
pleural drainage more frequently. Differences in both the use of pleural
drainage and LOS appeared to be independent of disease severity. In
fact, LOS was also different in patients with PPE/PE−, none of whom
required pleural drainage.
The only initial difference was that HA patients with PPE/PE+ were
admitted earlier and transferred more frequently from peripheral
hospitals, while HB patients spent more time with fever and oral
antibiotics before hospital admission, and admissions originated more
frequently from its own emergency department. These differences are
possibly due to social and geographical factors, and we do not believe
that they had a significant impact on the main outcome measures, given
that the duration of fever and antibiotic treatment prior to admission
to the tertiary hospital were similar between centers. The similar needs
for oxygen therapy, mechanical ventilation, surgery, and the presence of
pneumothorax also suggests that disease severity was comparable in the
two centers. Pleural drainage was placed and managed in the PICU in HB,
but not necessarily in HA, which explains the differences observed in
the proportion of patients admitted to the PICU. The duration of
antibiotic treatment was longer in HB, which probably contributed to the
longer hospital stay.
The shorter duration of fever during hospitalization in HB patients
might suggest that pleural drainage accelerates healing. However, fever
was often intermittent and particularly difficult to account for
retrospectively. Data on fever could have been recorded differently in
the two hospitals, as suggested by the fact that its median duration was
shorter in HB, including in the PPE/PE− patients who did not require
drainage. On the other hand, when quantifying the total duration of
fever from the onset of disease, before hospitalization, differences
were only observed in PPE/PE+2 patients, who may have benefited most
from pleural drainage. Therefore, differences in the duration of fever
between the two centers should be interpreted with caution. Prolonged
fever is common in patients with PPE/PE. Although it is often
interpreted as a sign of treatment failure, it may also be due to
underlying inflammation, prompting the addition of corticosteroids to
the treatment 9-10.
In conclusion, this study adds weight to others 6-8,11suggesting that restricting the use of pleural drainage is safe and does
not prolong LOS, which may be more conditioned by the routines at each
center. Controlled studies are needed to identify patients who may
benefit from the use of pleural drainage procedures, as many treatment
decisions are heavily based on subjective interpretation of data and
local habits.