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

Eric D. ZeeBay Area Pediatric Pulmonary

California Pacific Medical CenterChildren’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/EmpyemaPleural effusion w/suspected pneumonia

Chest Ultrasound

Antibiotics &Observe

Yes

No

NoDrainage of fluid by Chest tube or VATS by the Surgical team (VATS preferred)orPleural catheter with fibrinolytics by IRNote: 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 O2 req.)

Yes

NoAntibiotics &

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, & DecubitusInitial 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; orThe patient requires ICU admission; or

> 40% FIO2 needed to keep SaO2 > 90%; orToxic appearing and/or impending

respiratory failure

Yes

NoCont. antibiotics, andobserve 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 48-72 hrs. No need to go to water seal or clamping before removing

Empyema algorithm – page 2The 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 antibioticsFor 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 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

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 thesecond 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.

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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.