1. Parapneumonic Effusion Meghan Flanagan, MD UW General Surgery R3 October 18, 2012

2. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Epidemiology Clin Infect Dis. 2002 Feb 15;34(4):434-40. Lancet. 1997 Feb 8;349(9049):402. Pediatrics. 2010;125(1):26. Pneumonia is the most common cause of hospitalization for children Parapneumonic effusions occur in 20-57% Empyema is associated with 3% of all pneumonia hospitalizations and 30% of S. pneumoniae hospitalizations Empyema – Likely to have undergone abx treatment prior to admission – equal male-female – bimodal distribution winter/spring – Fever >7d – Age >3yo

3. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Epidemiology Pediatrics. 2010;125(1):26. Increasing incidence of parapneumonic empyema? – Kids’ Inpatient Database (1997 v 2006) Goal to determine whether empyema rates decreased after introduction of PCV7 in 2000 Annual empyema associated hospitalization rates increased 70% from 1997-2006 Pneumococcal pneumonia incidence decreased 45% BUT empyema rates doubled Serotype 1 responsible for 4-10% of pneumonias, but 24-50% of empyemas Staph pneumonia incidence unchanged BUT empyema incidence increased

4. Thursday, October 18, 2012Meghan Flanagan, MD 0.1-0.2 cc/kg pleural fluid – Circulates in and out of pleural space via lymphatic channels + parietal pleura – Pleural Effusion = Increased production v Decreased resorption – Normal ph = 7.6 Exudative vs Transudative – Transudative Intrinsically normal pleura – Exudative Abnormal pleura (inflammation/infiltration) Parapneumonic Effusion = exudative pleural effusion resulting from bacterial or viral pneumonia, bronchiectasis or lung abscess – Uncomplicated = uninfected, will resolve with treatment of underlying process – Complicated = infected, will require drainage or surgery in 10-20% – Empyema = frank pus within pleural space Parapneumonic Effusion Pathophysiology

5. Thursday, October 18, 2012Meghan Flanagan, MD Phases of Infection 1. Exudative Stage (uncomplicated pleural effusion) Accumulation of excess fluid in pleural space 2/2 cytokine-mediated capillary permeability Normal gram stain and cultures, glucose >60, LDH <3x upper limit of normal, pH normal Free flowing effusion 2. Fibrinopurulent Stage (complicated pleural effusion) Infection of the parapneumonic fluid (decreased opsonins, complement) Gram stain and cultures + Glucose 3x upper limit of normal (cell death) Decreased fibrinolysis 2/2 bacteria  clot and adhesion formation (loculations) **Key is to successfully treat at this stage** 3. Organizational Stage (complicated pelural effusion vs empyema) Fibroblasts enter the pleural space and cause a restrictive rind to form on the pleural surfaces Prevents lung expansion and results in poor gas exchange Parapneumonic Effusion Pathophysiology

6. Thursday, October 18, 2012Meghan Flanagan, MD Upright lateral Parapneumonic Effusion Imaging - CXR Lateral decubitous AP radiology.emory.edu Clinics Chest Med 1999;20:607-622 67% sensitivity 70% specificity

7. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Imaging - CXR Chest. 2010 Feb;137(2):467-79.

8. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Imaging - Ultrasound Chest. 2010 Feb;137(2):467-79.

9. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Imaging - CT Chest. 2010 Feb;137(2):467-79.

10. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Non-surgical Pediatric Pulmonology 39:127-134 (2005)

11. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Non-surgical SAJCH 2007;1(3):121-8.

12. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Drainage Pediatrics. 2002 Sep;110(3):e37 1995-2000, retrospective, non-randomized, single center 34 patients with needle aspiration, 34 patients with pigtail drain placement – All with similar antibiotic treatment, loculation Similar complication rates and length of stay Re-intervention – Method (primary aspiration 38% v primary drainage 15%) – pH <7.2 – Glucose <40 – Loculations

13. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Drainage Arch Dis Child2002;87:331-332. 1998-2001, retrospective, non-randomized, single center Compared 24 patients with thoracotomy + debridement, stiff chest drain + urokinase, pigtail catheter + urokinase Thoracotomy & pigtail associated with decreased drain time, time to becoming afebrile, time to improvement and procedure to discharge

14. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Fibrinolytics Principles – Degrade fibrin, blood clots --> decreased loculations – Streptokinase, urokinase are indirect and direct plasminogen activators – tPA – Goal is to enhance chest tube drainage and avoid surgical debridement – Side Effects: allergic reactions to streptokinase, intrapleural hemorrhage

15. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Fibrinolytics N Engl J Med 2005;352:865–874 Cochrane Database Syst Rev 2004;(2):CD002312

16. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Fibrinolytics N Engl J Med 2005;352:865–874 Double-blind, 454 patients with pleural space infections at 52 UK centers – Purulent pleural fluid, pH <7.2 with s/s infection, + cultures No benefit with regard to mortality, referral to surgery, length of stay

17. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Fibrinolytics Cochrane Database Syst Rev 2004;(2):CD002312 Cohrane review of 7 studies, 761 patients No significant risk of death (RR 1.08) Reduction in risk of treatment failure (surgical intervention) (RR 0.63) Fibrinolytics confer significant benefit and reduce requirement for surgical intervention – Not significant in high quality studies

18. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - VATS Literature review of published reports on thoracic empyema (1987-2002) 44 retrospective studies, 1369 pediatric patients – Chest tube alone, chest tube + fibrinolytics, VATS, thoracotomy Outcome measures – LOS, duration of antibiotic therapy, fever duration, duration of chest tube drainage J Pediatr Surg 2004;39:381–386

19. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management Literature review of publications involving pediatric thoracic empyema (1981-2004) 67 retrospective studies, 3418 non-op initial tx, 363 primary operative Pediatrics. 2005 Jun;115(6):1652-9

20. Thursday, October 18, 2012Meghan Flanagan, MD Semin Respir Crit Care Med. 2008 Aug;29(4):414-26 Parapneumonic Effusion Management - Algorithm

21. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Algorithm Semin Respir Crit Care Med. 2008 Aug;29(4):414-26

22. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Algorithm Pediatr Pulmonol 2006;41:1226–1232

23. Thursday, October 18, 2012Meghan Flanagan, MD Parapneumonic Effusion Management - Algorithm Curr Opinion Pediatrics. 2007 Jun;19(3):328-32