Tubes, Scopes, or Scalpels: The Dilemma of Treating Empyema in Children

Jeffrey C. Pence, MD, FACS, FAAP Associate Professor of Surgery Division of Pediatric Surgery Children’s Medical Center Dayton, OH

Objectives

1. Review the epidemiology and pathophysiology of parapneumonic effusion and empyema 2. Discuss the advent and application of video assisted thoracoscopic surgery (VATS) in the treatment of pediatric empyema. 3. Offer discourse regarding the various treatment paradigms employed for pediatric empyema.

4. Suggest a standardized protocol for the multidisciplinary treatment of empyema at the Children’s Medical Center

Epidemiology

• 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 • Overall prevalence of empyema is estimated at 3.3 cases per 100,000 children • The prevalence of parapneumonic empyema has been

increasing

over the past decade

despite

the introduction of Prevnar in 2001

(Byington, et al, 2010)

– 2001: 8.5/100,000 children – 2007: 12.5/100,000 children (

p=0.006)

– Ninety-eight percent were due to nonvaccine serotypes – Primarily due to serotypes 1, 3, 19A, and 7F

The Pleural Space

• Continuous pleural circulation • Space between visceral and parietal pleural surfaces • Interspace volume of 0.3 mL/kg body weight • Balanced – Secretion: apical lymphatic channels – Absorption: basal lung and cardiac pleural lymphatic pores

Pathophysiology

• 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

Pathophysiology Stage I

• Exudative stage • Uncomplicated parapneumonic effusion • <7 days following parenchymal disease • Simple effusions • Sterile • Intervention for symptoms only

Pathophysiology Stage II

• Fibrinopurulent stage • Complicated parapneumonic effusion • 7-14 days following parenchymal disease • Fibrin deposition on pleural surfaces • Loculations • Potential colonization (empyema) • Therapeutic intervention generally required

Pathophysiology Stage III

• Organizing stage • >14 days following parenchymal disease • Dense fibrin deposition on pleural surfaces • Fibrosis • Potential lung entrapment • Therapeutic intervention generally required

Goals of Effective Therapy

• Break the proinflammatory cycle • Reestablish the pleural circulation • Reexpand the pulmonary parenchyma • Optimize parenchymal circulation

Treatment 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

The treatment of empyema is controversial.

• Abundant data supporting the use of fibrinolysis in children to facilitate earlier resolution of empyema • Abundant data to support the utility of VATS as the optimal treatment modality in empyema • Retrospective over the other inferences favor one treatment strategy • As such, referring and treating physicians typically hold 1 of 2 opposing views • Treatment of empyema evokes both individual (experiencial) and institutional bias

First Known Reference to Empyema

“As time goes on, the fever becomes more severe, coughing begins, the side begins to pain, the patient can not lie any more on the healthy side but on the diseased side, the feet and the eyes swell.” Hippocrates, c. 400 BC (from many authorities) de morbis , authenticity questioned by

Hippocratic Succussion

Emypema Necessitans and the First Thoracotomy?

“ When the fifteenth day after the rupture has appeared, prepare a warm bath, set him upon a stool, which is not wobbly, someone should hold his hands, then shake him by the shoulders and listen to see which side a noise is heard. And right at this place, preferably on the left – make an incision, then it produces death more rarely.”

The Advent of Video-Assisted Thoracoscopic Surgery (VATS) for Empyema in Children

• Dr. Bradley Rodgers first reports the utility of VATS for the treatment of empyema in children in 1993 • 9 children (ages 2-16 years) treated from 1981 to 1992 • All patients had failed chest tube drainage over 1-17 days • No postoperative complications • No need for further surgical intervention • VATS reduced the operative morbidity of open thoracotomy while hastening recovery Kern JA and Rodgers BM, J Ped Surg, 28 (9), 1993, pp 1128-1132

Technique

Optimizing Outcomes in the Thoracoscopic Management of Complicated Parapneumonic Effusion in Children

EARLY VATS (n=29)

•

Confirmation of diagnosis

•

Primary thoracoscopic intervention

•

<72 hr following admission VARIABLE Operative Time (min) Duration of Chest Tube Drainage (hr) Duration of Pyrexia (hr) Duration of Mechanical Ventilation (d) Transfusion Requirements (units) Postoperative Length of Stay (d) Total Length of Stay (d) EARLY VATS (mean ± SD) 90 ± 29 79 ± 45 49 ± 26 0.7 ± 0.8 0.1 ± 0.3 6.3 ± 3.0 7.7 ± 3.4

LATE VATS (n=17)

•

Confirmation of diagnosis

•

Attempted drainage procedure(s)

•

Secondary thoracoscopic intervention

•

>72 hr following admission LATE VATS (mean ± SD) 104 ± 36 99 ± 35 89 ± 107 1.2 ± 1.7 0.8 ± 1.3 7.8 ± 4.9 13.6 ± 5.8 p -VALUE 0.03 0.01 0.12 (ns) 0.19 (ns) 0.05 (ns) 0.15 (ns) <0.01

Optimizing Outcomes in the Thoracoscopic Management of Complicated Parapneumonic Effusion in Children

Conclusions This extended retrospective study further affirms the efficacy of early VATS in the primary treatment of fibrinopurulent to organizing parapneumonic effusion in pediatric patients. These data support the expedient recognition, prompt referral, and effectual thoracoscopic drainage of advanced parapneumonic effusions for the purpose of optimizing clinical outcomes. The comparable efficacy of primary intrapleural fibrinolytic therapy, not addressed herein, awaits further prospective study.

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema Samatha Sonnappa, Gordon Cohen, Catherine M. Owens, Carin van Doorn, John Cairns, Sanja Stanojevic, Martin J. Elliott, and Adam Jaffe´

Department of Respiratory Medicine, Department of Cardio-Thoracic Surgery, and Department of Radiology, Great Ormond Street Hospital for Children NHS Trust; Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health; and Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom American Journal of Respiratory & Critical Care Medicine , v. 174 issue 2, 2006, p. 221-7

Sonnappa, et al. (2006) Study Design • Prospective randomized trial over 3 years • 60 children (30 per study arm) • Percutaneous drain with intrapleural urokinase or VATS • Primary outcome measured number of hospital days following intervention • Secondary outcome measures were chest drain days, total hospital stay, failure rate, radiologic outcome at 6 months, and total treatment costs

Sonnappa, et al. (2006) Results

UK Hospital days Chest drain days Total inpatient days Failure rates Abnormal CXR Cost (median, USD) 6 (4-25) 7 (4-25) 5 (16%) 18/20 6914 VATS 6 (3-16) -1 d 8 (4-17) 5 (16%) 21/24 10146 p-Value 0.31

0.55

0.64

0.27

<0.001

Sonnappa, et al. (2006) Results Urokinase • Chest drain dislodgement in 4 patients requiring reinsertion (prolonging hospitalization) • Five patients (16.6%) required secondary VATS for definitive therapy VATS • Four patients (13%) required conversion to mini thoracotomy

Sonnappa, et al. (2006) Conclusions •

No

difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema • Urokinase is a more economical treatment option • Intrapleural urokinase should be the

primary

treatment choice for the treatment of childhood empyema

Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

Shawn D. St. Peter, Kuojen Tsao, Christopher Harrison, Mary Ann Jackson, Troy L. Spilde, Scott J. Keckler, Susan W. Sharp, Walter S. Andrews, George W. Holcomb III, Daniel J. Ostlie Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA Department of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO 64108, USA Journal of Pediatric Surgery , 44, 2009, p. 106-111

St. Peter et al. (2009) • Prospective randomized trial • March 2006 to November 2007 • 36 children • Percutaneous drain with intrapleural recombinant human tissue plasminogen activator (tPA) or VATS • Primary end point measured length of postoperative hospitalization • Secondary clinical outcome variables

Clinical Outcomes

St. Peter et al. (2009) Results

VATS (n = 18) 6.9 ± 3.7 Length of posttherapy hospitalization (d) Posttherapy days of O2 support Days to afebrile after intervention Analgesia doses Hospital charges (x1000) 2.3 ± 1.7 3.1 ± 2.7 Fibrinolysis (n = 18) 6.8 ± 2.9 2.3 ± 2.1 3.8 ± 2.9

P .96

.90

.46

22.3 ± 28.5 21.4 ± 12.0 .90

$11.7 ± $2.9 $7.6K ± $5.4 .02

St. Peter, et al. (2009) Results • Three patients (16.6%) in the fibrinolysis group required VATS for definitive therapy • Two patients in VATS group required ventilator therapy post intervention • One patient in VATS group required temporary dialysis due to progressive sepsis

St. Peter, et al. (2009) Conclusions • •

No

difference in days of hospitalization after intervention

No

difference in oxygen requirement, days until afebrile, or analgesic requirements • VATS is associated with significantly higher charges • Fibrinolysis may pose less risk of clinical deterioration • tPA should be the

primary

empyema treatment for childhood

Proposed Algorithm CXR Pneumonia Parapneumonic effusion Ultrasound (+/- decubitus x-rays) Simple /free-flowing Symptomatic Asymptomatic Thoracentesis Observe Complex/loculated Ultrasound-guided percutaneous catheter (PTC) tPA (0.1 mg/kg/dose in 30 mL NS) IP q24 hr x 3 Symptomatic CT chest Persistent pleural space disease VATS Asymptomatic