From
StayCurrentMD
Empyema with Dr. Aaron Garrison
With CCHMC Pediatric Surgery · hosted by Dr. Todd Ponsky
Part of
Empyema 4 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Community acquired pneumonia is the leading cause of hospitalization in the US and the leading cause of death in children less than five years old worldwide.
Only 15% of children with pneumonia will have a bacterial pathogen detected.
The most common bacterial pathogens causing pneumonia include Staphylococcus aureus, Strep pneumo, and Haemophilus influenzae.
Simple parapneumonic effusion means fluid is present; complicated means it needs an intervention such as chest tube or thoracentesis.
Empyema refers to purulence or pus in the pleural space.
The exudative phase of empyema occurs in the first 2-3 days, when fluid is sterile and not infected.
The fibrinopurulent stage occurs between 2 days and 2 weeks and is the stage typically seen in the operating room.
In the fibrinopurulent stage, cells get into the pleural space and make clot, fibrin, and a purulent thick environment.
The real problem with empyema is compromised lung volumes once the collection organizes, with a thick rind causing lung entrapment that won't expand.
Staphylococcus aureus is the most likely cause of pneumatoceles.
Kids on oscillators and high ventilatory pressures are more likely to generate pneumatoceles.
A lot of pneumatoceles will go away on their own and you don't need to intervene unless they're causing shift or get super infected.
Ultrasound is more sensitive than CT scan to pick up septations in the pleural space.
Ultrasound does not have radiation exposure compared to CT.
The American College of Chest Physicians classification looks at effusion size on x-ray, whether bacteria are grown on thoracentesis, pleural fluid chemistry, and categorizes risk to determine if drainage is recommended.
The rate of primary VATS are going down and the rate of chest tubes and TPA are going up.
The rate of patients that fail chest tubes with TPA that then require a VATS is about 5%.
At Cincinnati Children's, the protocol is six doses of TPA, 12 hours apart, and they don't use DNAase.
For patients with clear effusion who are sick, if you put in a drainage tube without TPA and they're not getting sick in the next 24 hours, you don't give TPA and just watch them.
If patients don't clinically improve in 24 hours after chest tube placement, proceed with the TPA protocol.
The two main contraindications to TPA are necrotizing pneumonia and bronchopleural fistulas.
Significant parenchymal disease and chronic changes are relative contraindications to TPA.
For young kids ages 1-3 with recurrent infections and chronic pneumonia, consider the chance of an airway foreign body.
The most common airway foreign body culprit is peanuts.
Peanuts can't be seen on chest x-ray.
Initial imaging for airway foreign body can look like air trapping, but finding the foreign body on x-ray is rare and a normal chest x-ray can't rule out foreign body aspiration.
Dr. Ponsky's study showed CT scan has 100% reliability to show an airway foreign body, with 100% sensitivity and both positive and negative predictive value.
For otherwise healthy kids with a pulmonary abscess, they don't need surgical treatment at all.
Pulmonary abscesses almost always respond to just antibiotics and don't need drainage.
Drainage of pulmonary abscesses can lead to bronchopleural fistula and persistent air leak.
Bronchopleural fistulas sometimes close on their own, but other times may require advanced intervention such as a broncho valve or seal.
Dr. St. Peter's study showed that chest tube with fibrinolytics such as TPA are not inferior to standard VATS when looking at clinical outcomes.
Dr. St. Peter's study found no difference in hospital admissions, decreased cost with chest tube, and overall kids get less sick when not doing a VATS on them.
Dr. St. Peter's published protocol was three days of TPA, 24 hours apart.
A study in kids showed that DNAase didn't make much difference.
In Dr. Ponsky's study, only about 40% of patients who had bronchoscopy for an inhaled foreign body actually had one present, and the majority of the other 60% had reactive airway disease.
CT imaging can be used to diagnose inhaled foreign body before taking children to the operating room, saving OR time, sedation, and cost for a large proportion of children despite minimal radiation exposure.