Parapneumonic effusion

Parapneumonic effusion in children

Gopakumar Hariharan

Registrar , Paediatrics

Royal Hobart Hospital , Tasmania

Australia

Parapneumonic effusion and empyma in children

Case scenario Pathogenesis and Clinical features of

parapneumonic effusion Various management strategies Guidelines on management

Case scenario 7 year old boy

referred from regional hospital with a diagnosis of left sided pneumonia

Unwell since one week with fever , cough and breathing difficulty prior to admission

Past history of pneumococcal pneumonia in 2009

Ceftriaxone and Flucloxacillin and supportive measures

One week post admission

4 days after admission 7th day post admission

Tachypneic and febrile , but no oxygen requirement

Chest tube drainage Continued respiratory

distress and fever Chest drain inserted Not suggestive of empyema

– No leukocytes / growth No significant drainage Continued to have low grade

fever Repeat ultrasound showed

fluid collection and tube to be in good position

Repeated tube aspiration done – drained around 200 ml and then needed aspiration a few more times

9 days post admission

Tube drainage Stopped draining again . Repeat ultrasound

showed suspicion of loculation Urokinase given and further aspiration done -

some drainage Always serous fluid , never pus Continued to have low grade fever but

clinically well No significant drainage - Removed tube ( total

of 8 days insertion)

After chest tube removal Continued fever –

invest. CRP – 56 (5 days

back– 45 ) Respiratory swab -

Positive RSV Blood culture – No

growth Ultrasound abdomen

for subphrenic abscess – negative

2 days post removal

Ongoing management

Tazocin and Azithromycin ( ID consult ) Improved subsequently and afebrile Augmentin Follow up

Immunological tests

CD3 ( Mature T cells ) – 2.4 ( 0.7 – 2.0 ) CD 4 ( helper and inducer cells ) – 1.3 ( 0.4 – 1.1 ) CD 8 ( suppressor / cytotoxic T cells ) – 0.9 / micro L ( 0..3 – 0.7 ) CD 19 ( Pan B cells ) – 0.4 / microL ( 0.1 – 0.4 ) CD3- / CD 16+56+ - 0.5 / microL ( 0.1 – 0.5 ) Normal HLA DR expression Memory B cell analysis – Normal IgG – 11.3 g/L ( 5.4 – 18.2 ) IgA – 2.23 g / L ( 0.21 – 2.90 ) IgM – 1.05 g / L ( 0.47 – 2.40 ) C3 – 1.63 g / L ( 0.81 – 1.72 ) C4 – 0.27 g / L ( 0.14 – 0.45 )

Severe streptococcal pneumonia infection

Past history of strep Pneumonia Previous vaccination with pneumococcal vaccine

Parapneumonic effusion

Evolution to Empyma

Inflammation of pleura

subsequent leakage of proteins, fluid . Low WBC

Deposition of fibrin – Septation and

loculation – increase in WBC

Fibroblast infiltration + thick exudates and heavy sediment

– prevent lung expansion ( trapped lungs ) – potential

space for infections

Empyema – Grossly purulent fluid in the pleural cavity

Fibrin deposition in pleura and fomation of septation

Simple parapneumonic effusion

Complicated parapneumonic effusion

Exudative stage

Fibrinopurulent stage

Organisational stage

Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir J1997;10:1150–6.

Epidemiology and organism profile

.

Childhood empyema occurs in 0.7% of pneumonias in Australia

Strachan R, Jaffé A; Australian Research Network in Empyema. Assessment of the burden of paediatric empyema in Australia. J Paediatr Child Health 2009;45:431–6. doi:10.1111/j.1440-1754.2009.01533.x PMID:19722296

Organism profile and immunization

• PCV 7 ( 2001 ) – reduced invasive pneumococcal infection • However , concomitant increase in empyema cases ( 90% of cases

caused by bacterial serotypes 1 , 3 and 19A not included in the 7 valent vaccine ) . More virulent strains

Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006;25:250–4. doi:10.1097/01.inf.0000202137.37642.ab PMID:16511389

In July 2011 the PCV7 was replaced by a 13-valent conjugate vaccine

Children with pneumonia presenting with prolonged fever, tachypnoea, and high serum C-reactive protein levels are at risk for parapneumonic empyema.

Fever pattern

CRP pattern

Goals of therapy

Resolution of pleural fluid

Resolve symptoms and prevent progress

ion of empym

a

Sterilization of pleural fluid

Reexpansion of lungs

Initial management

Supplemental oxygen if saturations below 93%.

Fluid management , antipyretics Adequate analgesia – to allow pain free

respiration and mobilisation Intravenous antibiotics – in all children with

parapneumonic effusion

No role for chest physiotherapy apart from early mobilisation and encouragement of deep breathing and coughing,

particularly after surgical intervention or tube drainage

Conservative management

Small effusion – ( <10 mm on lateral decubitus radiograph or opacifying less than one-fourth of the hemithorax ) - broad-spectrum oral antibiotics and close observation with chest radiographs on an outpatient basis

Antibiotics alone or antibiotics +/- simple drainage

Thoracocentesis +

Antibiotics for 48 hours + continued

observation

Moderate amount of free fluid on chest radiograph

and ultrasonography

Chest tube/ fibrinolytics/

VATS

Continue antibiotics

Clinical improvement

Persistence of fluid collection and fever

and evidence of loculation on USG

Choice of Antibiotics Recommendations not evidence based Initial treatment should guided by local antibiotic

policy Cefuroxime with dicloxacillin/chloramphenicol

where equal efficacy was found ( Randomized ) ( Palacios GC, Gonzalez SN, Perez FL, et al. Cefuroxime vs a dicloxacillin/ chloramphenicol combination for the treatment of parapneumonic pleural effusion and empyema in children. Pulm Pharmacol Ther 2002;15:17–23 )

Cefuroxime Co-amoxiclav Penicillin and flucloxacillin Amoxicillin and flucloxacillin Clindamycin

In community acquired infection

Role of ultrasonography

Bedside tool Confirm fluid presence Stages complexity Assess volume Guide drainage site

Ultrasound was demonstrated to be of equal clinicalvalue compared to CT scanning in detecting parapneumonic effusions

Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S (2009) Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. JR 193:1648–1654

CT scan detects more parenchymal abnormalities than chest radiography.

However, the additional information does not alter management and is

unable to predict clinical outcome. No role for the routine use of CT scanning in children if treated with

urokinase and percutaneous chest drain. Expose children to unnecessary radiation ( 20 to 400 CXR radiation) Costly

CT scan ( To exclude pulmonary abscess or other pus collection ) • Persistent fever• A rise in WBC and C-reactive protein

Thoracocentesis ( moderate to large effusions )

Adegboye VO, Falade A, Osinusi K, Obajimi MO. Reexpansion pulmonary oedema as a complication of pleural drainage. Niger Postgrad Med J 2002;9:214–20

Reaccumulation of fluid - after the initial thoracentesis – insert chest tube

Repeated thoracentesis is not recommended ( BTS )

Aspiration quantitity - limited to 10 to 20 mL/kg -

Rapid removal of large amounts of pleural fluid - pulmonary edema - worsening of respiratory status.

Pleural fluid analysis Gram stain and bacterial culture Differential cell count

Biochemical analysis of pleural fluid is unnecessary in the management of uncomplicated parapneumonic

effusions/ empyema ( BTS )

Modified by prior antibiotic therapy

Additional techniques • Enrichment culture for aerobic and anaerobic organisms,• Serum or urine latex agglutination tests for detection of

pneumococcal antigen • Specific or broad range polymerase chain reaction (PCR)

Eastham KM, Freeman R, Clark J, et al. Clinical features, aetiology and outcome of empyema in the North East of England. Thorax 2004;59:522–5.

Management of loculated or organized pleural effusion

Fibrinolytic therapy Videoassisted thoracoscopic surgery Minithoracotomy Decortication

A chest drain is left in place after each of these procedures for continued drainage of fluid or pus.

No consensus on the role of medical versus surgical management

Large amounts of free flowing pleural fluid

Compromised pulmonary function (eg,

severe hypoxemia, hypercapnia)

Evidence of fibrinopurulent

effusions (eg, pH <7.0, glucose <40

mg/dL [2.22 mmol.L , LDH more than 1000

IU , Positive gram stain , Frank pus

Failure to respond in 48 to

72 hours of antibiotic therapy

Indications For chest tubedrainage

Choice of chest tubes Smaller catheters (8–12 FG) - as effective as

larger bore tubes. (Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion: pleurodesis using a small bore catheter. A prospective randomized study. Respir Med 1998;92:593–6 )

Advantages More comfortable Better patient mobility Shorter hospital stay

Ultrasonographically guided insertion of small pigtail catheters for treatment of early loculated empyema has been well studied in children and found to be effective.

Pierrepoint MJ, Evans A, Morris SJ, et al. Pigtail catheter in the treatment of empyema thoracis. Arch Dis Child 2002;87:331–2

Pigtail catheter - Seldinger technique

Fibrinolytic agents

Urokinase – only agent studied in a controlled fashion in children ( recommended by the BTS )

Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57:343–7 )

In one retrospective case series, thoracostomy tube drainage was increased with Alteplase compared to urokinase

The choice of agent depends upon availability, with urokinase being preferred if it is available, followed by alteplase (recombinant tissue plasminogen activator) and streptokinase.

Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion (thick fluid with loculations) orempyema (overt pus)

Surgical management Failure of chest tube drainage, antibiotics, and fibrinolytics should prompt early discussion with a thoracic surgeon

Early operative management • Reduced duration of chest tube (4.4 versus

10.6 days)• Reduced Hospital stay (10.8 versus 20 versus

) • Reduced Antibiotic therapy duration ( 12.8

versus 21.3 versus ) • Reduced Mortality (0 versus 3.3 versus 0 )• Low reintervention rate ( 2.5% versus

23.5% )

Video assisted thoracoscopic surgery VATS - achieves debridement of fibrinous pyogenic material, breakdown of loculations, and drainage of pus from the pleural cavity under direct vision. It leaves three small scars.

The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization

Karen D. Schultz, Leland L. Fan, Jay Pinsky, Lyssa Ochoa, E. O'Brian Smith, SheldonL. Kaplan and

Mary L . The Changing Face of Pleural Empyemas in Children: Epidemiology

andManagement. BrandtPediatrics 2004;113;1735

VATS versus conventional medical therapy ( with or without fibrinolysis )

Increased hospital stay and duration of chest tube drainage were noted in the group treated with medical therapy.

VATS with medical therapy with fibrinolysis

VATS

• Shorter hospital stay • Improved drainage• Enhances chance of full expansion of collapsed lungs

Wait MA, Sharma S, Hohn J, et al. A randomised trial of empyema therapy. Chest 1997;111:1548–51.

• High failure rate in late presenting cases • Not suitable for advanced organised empyema.

Klena JW, Cameron BH, Langer JC, et al. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998;187:404–8.

Harder to perform in apatient who has been receiving intrapleural urokinase as theloculations become very adhesive, although this may be due to the delay rather than the urokinase itself.

Jaffe´ A, Cohen G. Thoracic empyema. Arch Dis Child 2003;88:839–41

Other surgical options Mini-thoracotomy achieves debridement and evacuation in a similar manner to VATS but it is an open procedure leaving a small linear scar along the rib line.Decortication —  An open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. This is a longer and more complicated procedure than minithoracotomy and leaves a larger linear scar along the rib line

Open thoracotomy indications

• Late presenting empyema with significant pleural fibrous rind• Complex empyema and • Chronic empyema Fraga JC, Kim P. Surgical treatment of parapneumonic plearl effusion and itscomplications. J Pediatr 2002;78(Suppl 2):161–73. [

Treatment failure and complications Persistent fever - incorrect antibiotic choice or failure of

the antibiotics to penetrate the infected lung tissue or cavity.

Observe pattern of fever – if improving persist with the chosen treatment regimen

Consider lung necrosis and inflammation

Additionally in these circumstances, a decrease in white blood cells and C-reactive protein is reassuring.

Antibiotics recommended for 5 days after child becomes afebrile followed by oral antibiotics

Other complications Persistent lobar collapse - unusual . An

indication for bronchoscopy to exclude a foreign body.

Bronchopleural fistula occurs occasionally following the insertion of a chest drain or surgery for the treatment of empyema due to the fragility of lung parenchyma, - leads to a persistent air leak.

Avoid negative suction on the chest drain - to improve the chances of tissue healing.

Very occasionally surgical intervention is required to repair the fistula.

OUTPATIENT FOLLOW-UP Follow up until symptomatic resolution and

chest X ray has returned to near nomal ( BTS )

The chest radiograph returns to normal in the majority of children (60–83%) by 3 months, in over 90% by 6 months, and in all by 18 months.

( Chan PW, Crawford O, Wallis C, et al. Treatment of pleural empyema. J Pediatr Child Health 2000;36:375–7 )Immunodeficiency or cystic fibrosis evaluation - History of recurrent bacterial infections or poor growth

Cystic fibrosis – esp in S. aureus or Pseudomonas aeruginosa infection

TSANZ guidelines

Summary

Antero-posterior/posterior-anterior chest X-ray - performed in all children in suspected empyma . There is no need for a routine lateral film.

Ultrasound – performed in all empyema

Routine pre-operative CT should not be performed - reserved for complicated cases

Paediatric Empyema Thoracis: Recommendations for Management - Position statement from the Thoracic Society of Australia and New Zealand.

Summary High dose antibiotic therapy Appropriate antibiotics should be used to

cover at least Streptococcus pneumonia and Staphylococcus aureus.

Moderate to large effusions require drainage. Chest drainage alone is not recommended

and the intervention of choice is either percutaneous small bore drainage with urokinase or VATS

Oral antibiotics should be given for between 1 and 6 weeks duration following discharge. Final outcome is almost always excellent in children

Thank you