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
Avensino JR, Goldman B, Savin RS et al. Primary Operative Versus Nonoperative Therapy for Pediatric Empyema: A Meta-analysis. Pediatrics 2005 115:6 1652-1659
Aziz A, Healey JM, Qureshi, F et al. Comparative anatoluysis of Chest Tube Thoracostomy and Video-Assisted Thoracoscopic Surgery in Empyema and Parapneumonic Effusion Associated with Pneumonia in Children. Surg infections 2008 9:3 317-323.
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.