1. PARAPNEUMONIC PLEURAL
TRANSTHORACIC
ULTRASONOGRAPHY FOR
MANAGEMENT OF THE
PARAPNEUMONIC PLEURAL
EFFUSIONS IN CHILDREN
V. Strahinova², H. Shivachev¹, Y. Pahnev¹, Brankov O¹
1. Department of Paediatric surgery, University hospital Pirogov
2. Diagnostic imaging department, University hospital Pirogov
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

2. INTRODUCTION PNEUMONIA - 0,4-6 per 1000
8,3% - 60% of all children hospitalized with Community Acquired Pneumonia - complicated with pleural effusion
The GOAL
to reveal the role of transthoracic ultrasound examination /TUE/ in stage determination of the development of the parapneumonic pleural effusion(PPE)
to define the time and type of surgical intervention required (pleural puncture, thoracic tube drainage, fibrinolytic therapy, VATS, thoracotomy)
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

3. MATERIAL AND METHODS
January 2005 – December children have been treated in our Clinic with clinical and radiological signs of PPE
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

4. MATERIAL AND METHODS
TUE - high frequency linear probes /5-13 MHz/ and broadband convex probes /3-6 MHz/ carried out through trans-thoracal scanning in the intercostal spaces, oblique and perpendicular to the costal arches, respectively on paravertebral, axillary, mamillary and parasternal lines. Patients were examined in sitting and lying positions
Findings - evaluated in 4 stages /modification of the classification of Hilliard T.N established by us/
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

5. MATERIAL AND METHODS PP
Stage I – anechoic collection without septations /free fluid in pleural cavity/ PE PE VP
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

6. MATERIAL AND METHODS
Stage II – heterogenous content of the pleural cavity /septations/
IIa – septations with no thickening of parietal pleura
IIb – septations combined with thickened parietal pleura PP
Spt PE PP
Spt
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

7. MATERIAL AND METHODS
Stage III – thickened pleura, multiple septations, and entrapped underlying lung with various fibrotic changes PP Pu EL
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

8. MATERIAL AND METHODS Example of Stage III
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

9. MATERIAL AND METHODS
All patients underwent TTU scanning and stage of PPE was evaluated
In the cases, where thoracic tube drainage or “pigtail” catheter were required - biochemical and microbiological verification of evacuated exudation /pH values, glucose and LDH levels/ was performed
Intraoperative staging was compared to TTU findings
Materials obtained by VATS or thoracotomy were examined histomorphologically
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

10. RESULTS TUE Staging distribution Stage III Stage I 25% Stage II a 32%
Stage II b
21%
22%
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

11. Intraoperative and pathomorphological stage.
RESULTS
Stage
TTU
(n=170)
Pleural Effusion
( n=130)
Intraoperative and pathomorphological stage.
( n=170)
Exudative
Stage I – 42 children
1st and 2nd Group - 56 children
40 children
Stage IIa – 56 children
3rd group - 22 children
49 children
Fibropurulent
Stage IIb – 35 children
4th and 5th group - 52 children
44 children
total: 91 children
total: 77 children
Total: 93 children
Organisational
Stage III - 37 children
37 children
Total
170 children
130 children
Table 1. Comparative representation of the results from TTU, pleural exudation analysis, intraoperative and pathomorphological findings
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

12. Intraoperative and pathomorphological
RESULTS
Stage of PPE
(1)
ТТU
(n=170)
(2)
Pleural effusion
( n=130)
(3)
Intraoperative and pathomorphological
( n=170) Р
1 - 3
2 - 3
Count %
Exudative 42
27,7 56 43 40
23,5
.341
.029
Fibropurulent 33 22 17 49
28,8
.330
.143 35 21 52 44
25,8
.303
.076 91
53,5 77
59,2 93
54,7
.446
.300
total
170
130
Table 2. Statistical reliability of the results
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

13. RESULTS Sensitivity – 90% Specificity – 80%
TTU - reliable and precise method for determination of the type and time of the first surgical intervention:
Sensitivity – 90%
Specificity – 80%
Positive predictive value 96%
Thoracoscopic findings confirm the TTU results from the preoperative diagnostics in 149 (87.6%) of the cases. The lack of correspondence in the other 21 children (12,4%) was considered to be due to incorrect interpretation and subjectivity of the method: the thickness of parietal pleura, the echogenicity of the septations and the presence of incapsulated pleural effusion
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

14. DISCUSSION
The Necessity to establish a new modification of Hilliard’s classification:
Rapid, precise and harmless method, giving clear criteria for management of PPE
Lack of clear guidelines for management, according to the appropriate stage
Lack of sufficient randomized or controlled studies discussing the exact stage determination
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

15. DISCUSSION Results, according to our concept pointed that
TTU stage 1 and 2a - chest tube drainage or pigtail catheter (98% success rate of the method in Stage 1 and 40.98% in Stage 2a)
TTU stage 2b and 3 – early VATS or thoracotomy
A DIAGNOSTIC PROTOCOL for children with PPE accepted in our hospital – Chest X-Ray and TUE. CT - only in cases with suspected destruction of lung parenchyma
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

16. DISCUSSION Table 3. Management protocol PPE
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

17. CONCLUSION
Compared to other non-ultrasonographic imaging modalities TTU is:
Nonionizing and harmless
broadly available
accurate and dynamic evaluation of the pleural process
determines the exact stage of the parapneumonic effusion in children
low cost
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

18. CONCLUSION
After we accepted TTU as a standard and introduced the method as an indicator for management of the parapneumonic and pleural effusions, we achieved a significant improvement of the diagnosis and an adequate surgical treatment.
University Hospital “N.I.Pirogov”, Sofia, Bulgaria

19. THANK YOU FOR YOUR KIND ATTENTION!
University Hospital “N.I.Pirogov”, Sofia, Bulgaria