Chase Williams 3/17/2011

 4 YO M admitted with 5 day h/o Fever (104.7), cough, and chest pain  PMH: reflux with oral eversion; G-Tube dependent  WBC 11.7 with 13% bands on admission  CXR: RUL consolidation  Dx: community aquired pneumonia

 Admitted to the Pediatric service  IV Ceftriaxone started  Continued fevers to 39.5, Clindamycin added  WBC increased to 19.0  Increased oxygen requirement to 2L NC  General surgery consulted  Repeat CXR with development of effusion  Now 8 days after onset of symptoms  US chest: moderate sized loculated fluid collection

 R VATS on HD 7 (12 days after onset of symptoms)  2 5mm ports used  500ml of pus drained  Multiple loculations taken down  Decortication or thick fibropurulent rind  Lung able to fully expand at end of case  20 Fr chest tube left in place to suction  Chest tube removed POD 3, DC POD 6 on oral antibiotics

 Incidence of pneumonia in children ranges from 1.0 to 4.5 cases per 100 children per year  Approximately 0.6% of childhood pneumonias progress to empyema  The prevalence of parapneumonic empyema has been increasing over the past decade despite the introduction of strep pneumovaccine in 2001  2001: 8.5/100,000 children  2007: 12.5/100,000 children ( p=0.006)  Ninety-eight percent were due to nonvaccine serotypes Byington, et al, 2010

 Parenchymal disease evokes pleural inflammation  Immune cellular-mediated cytokine release  Increased vascular permeability  Increased pleural fluid production  Increased procoagulant activity  Decreased fibrinolysis  Decreased pleural resorption  Clinical sequelae  Parapneumonic effusion  Dyspnea  Fever  Pleuritic pain

 Stage 1: Exudative Stage  Collection of thin reactive fluid with few cells  Usually <7days after parenchymal disease  Stage 2: Fibrinopurulent Stage  Complicated parapneumonic effusion  7-14 days following parenchymal disease  WBC and Fibrin deposition on pleural surfaces  Loculations with potential colonization (empyema)  Stage 3: Organizational Stage  >10 days following parenchymal disease  Dense fibrin deposition on pleural surfaces  Fibrosis  Potential lung entrapment

Goals 1. Break the proinflammatory cycle 2. Reestablish the pleural circulation 3. Reexpand the pulmonary parenchyma 4. Optimize parenchymal circulation Modalities  Antibiotics  Thoracentesis  Chest tube or pigtail catheter  Chest tube or pigtail catheter with fibrinolytic instillation  Thoracoscopy (VATS = Video-assisted Thoracic Surgery)  Thoracotomy/ Mini Thoracotomy

 Surgical drainage vs nonoperative treatment  Who can get by with antibiotics alone  Early vs Late VATS  VATS vs Chest tube and fibrinolytics

Avansino, Goldman, Sawin. Primary Operative Versus Nonoperative Therapy for Pediatric Empyema: A Meta-analysis. Pediatrics  67 studies mostly retrospective series comparing:  Operative management (VATS or Thoracotomy)  Nonoperative management (Abx, Thorocentesis, chest tube drainage)  10 Fold reduction in failure rates ( 2.5% vs 23.6%)  Decreased LOS (10.8 vs 20.0 days)  Decreased duration of chest tube (4.4 vs 10.6 days)  Shorter duration of antibiotics (12.8 vs 21.3)

Carter, Waldhausen, et al. Management of Children with Empyema: Plerual Drainage is Not Always Necessary. Pediatric Pulmonology  Retrospective study of 182 Pts with pneumonia and pleural effusion or empyema  Small pleural effusions were excluded  87 (48%) underwent drainage procedures based on the Empyema Management Protocol  No clinical improvement after 48-72hrs of IV Abx  21 chest tubes, 66 surgical interventions  92 (52%) were successfully treated with Abx alone

 Characteristics of patients who failed Abx management alone: 1. Large Effusions (>1/2 thorax filled)  71% in drainage group vs 34% abx group. p < ICU stay  30% in drainage group vs 4% in abx group p< Mediastinal shift  42% in drainage group vs 12% in abx group p<0.001  Loculated pleural fluid was not significantly significant  75% patient requiring drainage had procedure within 72hrs of admission Conclusions  Approximately half of patients with moderate-large pleural effusions can be treated successfully with antibiotics alone  Not everybody with a parapneumonic effusion should be treated with drainage procedures  Patients less likely to do well on antibiotics alone can be seen in the above data

Schultz et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics  Retrospective study comparing timing of VATS in empyema in children  Early VATS (49 patients)  <48hrs from admission  Late VATS (78 patients)  >48hrs from time of admission  LOS significantly lower for early VATS  11.5 days vs 15.1; p-value 0.008

Sonnappa, et al. Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema. American Journal of Respiratory & Critical Care Medicine  Prospective randomized control trial with 30 patients in each arm  Percutaneous chest drain placement with lytic treatment using urokinase  Urokinase administered Q12hrs for 3 days  VATS with decortication  Primary outcome: Number of hospital days following intervention  Secondary outcomes: chest drain days, total hospital stay, failure rate, radiologic outcome at 6 months, and total treatment costs

UK (30)VATS (30)p-Value Hospital days6 (4-25)6 (3-16)0.31 after intervention Chest drain days-1 d0.55 Inpatient days 7 (4-25)8 (4-17)0.64 Failure rates 5 (16%)5 (16%) Abnormal CXR 18/2021/ Cost 9,12711,379 <0.001 Conclusion: Fibrinolytic treatment is a better economic choice and should be the treatment of choice for pediatric empyema Limitations: Poor definition of VATS failure rate

1. There are many differing opinions regarding management of complicated parapneumonic effusions 2. There is little reliable data to base these opinions 3. Most patients get better regardless of which modality is chosen 4. Everybody should get a trial of antibiotics alone with close clinical monitoring and a low threshold for invasive intervention (VATS or drainage with thrombolytics) if patient fails to improve 5. The decision for invasive intervention should be made within 3 days of starting IV antibiotics 6. Percutaneous drainage with thrombolytics has the potential to be an effective and cost effective treatment