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 ( rare

Fusobacterium

and

Bacteroides

)

 

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

The Seattle Children’s Hospital Empyema Algorithm Parapneumonic Effusion/Empyema Pleural effusion w/suspected pneumonia (For previously healthy children > 12 months-old) Small Effusion?

(< 10 mm on decubitus, or < ¼ thorax filled on PA CXR?) No Joint pulm/surg consult within the first 24 hrs of hospital admission Yes Antibiotics & Observe Empyema algorithm – page 1 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 Clinical severity high?

( ↑ RR, retractions, splinting, supp O 2 req.) Yes Appropriate IV abx ≥ 48 hrs?

Yes Chest Ultrasound No Yes Loculated fluid?

Yes VATS by the Surgical team (preferred) or Pleural catheter with fibrinolytics by IR No No Antibiotics & Observe 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 No Cont. antibiotics, and observe for 48 hours.

If no improvement, then consider chest US and pleural drainage 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 Chest tubes: Remove when drainage falls to < 2cc/kg/shift.

Try to remove within 48-72 hrs. No need to go to water seal or clamping before removing If VATs was not done, and the pt does not improve within 3 days of pleural catheter placement, then consider VATS Go to 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 Empyema algorithm – page 2 Has the pt been afebrile off of antipyretics for 48 hrs and received at least 5 days of appropriate IV abx or after 10-14 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 •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). No •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

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Carter E, Waldhausen J, Zhang W et al. Management of Children With Empyema: Pleural Drainiage Is Not Always Necessary. Pediatric Pulmonology 2010 45:475-480.

Chernick V, Boat TF, Wilmott RW, Bush A Editors. Kendig’s Disorders of the Respiratory Tract in Children. Saunders Eslevier, Philadelphia, 2006, pp.380-385.

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 2010 169:1123-1128.

Kokoska ER, Chen MK. Position paper on video-assisted thoracoscopic surgery as treatment of pediatric empyema. J Pediatr Surgery 2009 44, 289-293.

Kurian J, Levin TL, Han BK. Comparison of Ultyrasound and CT in the Evaluation of Pneumonia Complicated by Parapneumonic Effusion in Children. AJR 2009 193: 1648-1654.

Proesmans, M, De Boeck, K. Clinical practice: treatment of childhood empyema. Eur J Pediatr 2009 168:639-645.

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 2009 44, 106-111.