Eric D. Zee Bay Area Pediatric Pulmonary California Pacific Medical Center Children’s Hospital & Research Center Oakland 12 November 2010

 Complicated versus uncomplicated pneumonias  Controversies ◦ Imaging ◦ Approaches and management  Role of Vaccines  Necrotizing pneumonias and post infectious pneumatoceles  Case study

 Infective pleural effusions  Lung abscess  Necrotizing pneumonia

 Excess liquid caused by disequilibrium of filtration (formation) and absorption (removal) ◦ Increased filtration with normal or impaired absorption ◦ Normal filtration with impaired absorption ◦ Addition of exogenous fluid (intravenous fluid or peritoneal fluid)

 Infection and inflammation damages vascular endothelium and promotes capillary leak  Inflammation also promotes increased local blood flow  Net liquid and protein transudation

 Fluid in the pleural space secondary to pneumonia ◦ Parapneumonic effusion  Exudative: high LDH, high protein, low glucose, low pH ◦ Empyema

 Staphylococcus aureus in infants less than 2 years  Streptococcus pneumoniae most common community acquired  Haemophilus influenzae less since vaccine  Pseudomonas aeruginosa less commom  Anaerobes (Fusobacterium and Bacteroides) rare

 S pneumo consistent through the years  Since 2000, increased incidence of MSSA, MRSA, Fusobacterium, Pseudomonas and S milleri

 Three phases: ◦ Exudative stage: low wbc counts ◦ Fibrinopurulent stage: more wbc, fibrin, start of loculations ◦ Organizational stage : fibrous pleural peel

 Differing definitions: ◦ Uncomplicated:  No pleural fluid or necrotic lung versus  Exudative stage ◦ Complicated:  Presence of pleural fluid versus  Fibrinopurluent and organizational stages

 Imaging modalities?  No consensus on appropriate treatment ◦ Surgery way ◦ Pediatric way  No “trapped lung syndrome” in children unlike adults ◦ No restrictive or obstructive lung sequelae

 Plain films (roentgenogram) ◦ Upright and decubitus films ◦ Easy, readily available, infiltrate and fluid easy to see ◦ Intrapleural pathology and parenchymal disease drawbacks  Ultrasound ◦ Estimate size of effusion ◦ Loculations and pleural thickening easy to see

 Computed tomography ◦ Able to estimate size pleural fluid ◦ Detailed information on anatomy and location of disease (parenchymal versus pleural)  MRI ◦ Detect loculations ◦ Differentiates between inflammatory and non inflammatory changes ◦ Logistical and availability disadvantages in pediatrics

 CT radiation risk is real  Ultrasound superior in resolution pleural fluid and loculations  CT chest is useful in determining parenchymal disease, necrosis, pneumatocele, abscess  CT no additional clinical information not already seen on ultrasound

 More emphasis on staging effusions  Purulence and fibrin may inhibit simple drainage, small caliber chest tubes  Avoid complications and salvage procedures  Meta-analysis: operative versus non- operative therapy ◦ Non-operative: antibiotics and simple chest tube ◦ Operative: VATS, thoracotomy, fibrinolysis

 Non-operative therapy: 20 days  Fibrinolysis: 10 days  VATS: 10 days  Failure rate non- operative therapy: 23.6%

 Although primary operative therapy decreases LOS and failure rate, >76% resolve without surgery.  Step-wise approach possible but many favor initial surgery to decrease LOS and morbidity.  VATS cost-effective in centers where chest tubes placed in OR.

 Better than thoracotomy  Not superior than fibrinolysis  Consider if clinical symptoms for compressive effects

 Seattle Children’s Hospital: conservative management Half treated with antibiotics alone  Retrospective study: ◦ Small effusions: <10mm or <¼ thorax ◦ Large effusions:>10mm or >1/4 thorax Larger effusions required pleural drainage

 Pleural interventions ◦ Chest tube ◦ Chest tube with fibrinolytics ◦ VATS  No consensus VATS versus fibrinolytics is more efficacious  Pleural intervention if clinically ill or CXR shows mediastinal shift

 28% children with initial simple chest tube required VATS ◦ Seattle advocates initial VATS intervention ◦ Seattle less experience with fibrinolytics  Antibiotics: IV Ceftriaxone and Clindamycin ◦ Vancomycin IV if child critically ill  Less emphasis on staging effusions

 Mortality and long-term morbidity very low  Pleural intervention directed at decreasing short-term morbidity and LOS  Surgery papers advocate early intervention ◦ LOS with antibiotics alone comparable at 7 days  Chest tubes alone may increase LOS ◦ Those with chest tubes may take longer time to eventual VATS

 Children usually do well with antibiotics alone  Unusual to require intervention  Drainage possible via airways  Invasive intervention (needle aspiration, bronchoscopy, wedge resection or lobectomy) ◦ Clinical deterioration ◦ Mediastinal shift ◦ Airway compression

 Increasing incidence since 2000 ◦ Increasing detection? ◦ Computed tomography readily available  Antibiotics able to sterilize pleural fluid  Resulting inflammatory reaction  Some advocate surgical resection but controversy remains

 Query increase in S pneumo complicated pneumonias with PCV 7  Studies from Salt Lake City, Alberta and US National database: increased incidence empyema  Query serotype replacement: non-vaccine serotypes 5 and 19A more prevalent  Query increased MRSA

Parapneumonic Effusion/Empyema Pleural effusion w/suspected pneumonia Chest Ultrasound Antibiotics & Observe Yes No Drainage of fluid by Chest tube or VATS by the Surgical team (VATS preferred) or Pleural catheter with fibrinolytics by IR Note: Preferred option is VATS Yes VATS by the Surgical team (preferred) or Pleural catheter with fibrinolytics by IR Small Effusion? (< 10 mm on decubitus, or < ¼ thorax filled on PA CXR?) Loculated fluid? Clinical severity high? ( ↑ RR, retractions, splinting, supp O 2 req.) Yes No Antibiotics & Observe Joint pulm/surg consult within the first 24 hrs of hospital admission Appropriate IV abx ≥ 48 hrs? No Yes If VATs was not done, and the pt does not improve within 3 days of pleural catheter placement, then consider VATS All Patients: Initial Labs: CBC w/diff, BC, CRP, CXR: PA, Lateral, & Decubitus Initial antibiotics: IV ceftriaxone and clindamycin If suspect MRSA or resistant pneumococcus or if pt is critically ill, then add vancomycin Is the patient’s condition critical? Large effusion with mediastinal shift with respiratory distress and hypoxemia; or The patient requires ICU admission; or > 40% FIO2 needed to keep SaO2 > 90%; or Toxic appearing and/or impending respiratory failure Yes No Cont. antibiotics, and observe for 48 hours. If no improvement, then consider chest US and pleural drainage The Seattle Children’s Hospital Empyema Algorithm (For previously healthy children > 12 months-old) Empyema algorithm – page 1 Go to page 2 Chest tubes: Remove when drainage falls to < 2cc/kg/shift. Try to remove within hrs. No need to go to water seal or clamping before removing

Empyema algorithm – page 2 The Seattle Children’s Hospital Empyema Algorithm (For previously healthy children > 12 months-old) Ongoing and Follow-up Management The decision has been made to treat the patient with VATS, chest tube/fibrinolytics, or IV antibiotics alone Continue to treat with IV antibiotics For 5-14 days Has the pt been afebrile off of antipyretics for 48 hrs and received at least 5 days of appropriate IV abx or after days of IV abx, fever and CRP are decreasing, and the patient is clinically near baseline, e.g., good activity and appetite, T max < 39, and CRP < 5? Note: avoid around-the-clock antipyretics after the first 72 hrs of appropriate abx therapy Yes No Change to PO antibiotics If doing well with PO then D/C home to complete a 10-day course of PO abx (high-dose amoxicillin, Augmentin, a cephalosporin, or clindamycin) Follow-up F/U with PCP within 1 week F/U with surgery or pulmonary services on a case-by-case basis Send pt home with a copy of the last CXR/CT scan Repeat CXR in 2 months or sooner if the patient has respiratory symptoms Consider Chest CT scan if CXR has not returned to normal 6 months after initial infection (excluding pleural thickening). Continue treatment Consider further imaging, including a Chest CT scan, and interventions per surgery and pulmonary service recommendations Note on fever in patients with parapneumonic effusions: Fever spikes to 39-40°C for up to 7 days are typical. After 3-5 days of appropriate IV antibiotics, the frequency and height of the fever should begin to decrease. Most patients will have fever for 5-10 days. During the second week of appropriate antibiotic therapy, the fever usually decreases in both frequency and magnitude. While defervesence suggests a good response to therapy, the patient’s overall clinical condition is a better indicator of improvement than is fever response. Avoid around-the-clock antipyretics after the first 72 hrs of appropriate abx., as this may mask fevers and give a false sense of fever resolution.

 CM is a 3 year old male initially presented with abdominal pain and fever for several days  No significant past medical history  Physical exam, grunting child, in moderate distress, diminished left lung base  ED: CT Abdomen: No abdominal pathology but LLL infiltrate, lingular abscess and effusion  Admitted

 Avensino JR, Goldman B, Savin RS et al. Primary Operative Versus Nonoperative Therapy for Pediatric Empyema: A Meta-analysis. Pediatrics :  Aziz A, Healey JM, Qureshi, F et al. Comparative anatoluysis of Chest Tube Thoracostomy and Video-Assisted Thoracoscopic Surgery in Empyema and Parapneumonic Effusion Associated with Pneumonia in Children. Surg infections :  Carter E, Waldhausen J, Zhang W et al. Management of Children With Empyema: Pleural Drainiage Is Not Always Necessary. Pediatric Pulmonology :  Chernick V, Boat TF, Wilmott RW, Bush A Editors. Kendig’s Disorders of the Respiratory Tract in Children. Saunders Eslevier, Philadelphia, 2006, pp  Chibuk TK, Robinson JL, Hartfield DS Pediatric complicated pneumonia and pneumococcal serotype replacement: trends in hospitalized children pre and post introduction of routine vaccination with Pneumococcal Conjugate Vaccine (PCV 7). E J Pediatr :  Kokoska ER, Chen MK. Position paper on video-assisted thoracoscopic surgery as treatment of pediatric empyema. J Pediatr Surgery ,  Kurian J, Levin TL, Han BK. Comparison of Ultyrasound and CT in the Evaluation of Pneumonia Complicated by Parapneumonic Effusion in Children. AJR :  Proesmans, M, De Boeck, K. Clinical practice: treatment of childhood empyema. Eur J Pediatr :  St. Peter SD, Tsao K, Harrison C et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective randomized trial. J Pediatr Surgery ,