Parapneumonic effusion and empyma inchildren Case scenario Pathogenesis and Clinical features ofparapneumonic effusion Various management strategies Guidelines on management
Case scenario 7 year old boy referredfrom regional hospitalwith a diagnosis of leftsided pneumonia Unwell since one weekwith fever , cough andbreathing difficulty priorto admission Past history ofpneumococcalpneumonia in 2009 Ceftriaxone and Flucloxacillin andsupportive measures
One week post admission4 days afteradmission 7th day post admissionTachypneic and febrile , but nooxygen requirement
Chest tube drainage Continued respiratorydistress and fever Chest drain inserted Not suggestive ofempyema – Noleukocytes / growth No significant drainage Continued to have lowgrade fever Repeat ultrasoundshowed fluid collectionand tube to be in goodposition Repeated tube aspirationdone – drained around200 ml and then neededaspiration a few more9 days post admission
Tube drainage Stopped draining again . Repeat ultrasound showedsuspicion of loculation Urokinase given and further aspiration done - somedrainage Always serous fluid , never pus Continued to have low grade fever but clinically well No significant drainage - Removed tube ( total of 8days insertion)
After chest tube removal Continued fever –invest. CRP – 56 (5 days back–45 ) Respiratory swab -Positive RSV Blood culture – Nogrowth Ultrasound abdomen forsubphrenic abscess –negative2 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 infectionPast history of strep PneumoniaPrevious vaccination with pneumococcalvaccine
Evolution to EmpymaInflammation ofpleurasubsequent leakage ofproteins, fluid . Low WBCDeposition of fibrin –Septation andloculation – increase inWBCFibroblast infiltration + thickexudates and heavy sediment– prevent lung expansion (trapped lungs ) – potentialspace for infectionsEmpyema – Grossly purulent fluidin the pleural cavityFibrin deposition in pleura andfomation of septationSimpleparapneumonic effusionComplicatedparapneumonic effusionExudative stageFibrinopurulentstageOrganisationalstageHamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir
Epidemiology and organism profile.Childhood empyema occurs in 0.7% of pneumonias in AustraliaStrachan R, Jaffé A; Australian Research Network in Empyema. Assessment of the burden of paediatric empyema inAustralia. J Paediatr Child Health 2009;45:431–6. doi:10.1111/j.1440-1754.2009.01533.x PMID:19722296Organism profile and immunization• PCV 7 ( 2001 ) – reduced invasive pneumococcal infection• However , concomitant increase in empyema cases ( 90% of casescaused by bacterial serotypes 1 , 3 and 19A not included in the 7valent vaccine ) . More virulent strainsByington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcalconjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006;25:250–4. doi:10.1097/01.inf.0000202137.37642.ab PMID:16511389In July 2011 the PCV7 was replaced by a 13-valent conjugate vaccine
Children with pneumonia presenting with prolonged fever, tachypnoea, andhigh serum C-reactive protein levels are at risk for parapneumonic empyema.Fever patternCRPpattern
Initial management Supplemental oxygen if saturations below 93%. Fluid management , antipyretics Adequate analgesia – to allow pain free respirationand mobilisation Intravenous antibiotics – in all children withparapneumonic effusionNo role for chest physiotherapy apart from early mobilisation andencouragement of deep breathing and coughing, particularly aftersurgical intervention or tube drainage
Conservative managementSmall effusion – ( <10 mm on lateral decubitusradiograph or opacifying less than one-fourth of thehemithorax ) - broad-spectrum oral antibiotics andclose observation with chest radiographs on anoutpatient basisAntibiotics alone or antibiotics +/- simple drainage
Thoracocentesis+ Antibiotics for48 hours +continuedobservationModerate amount of free fluidon chest radiograph andultrasonographyChest tube/fibrinolytics/ VATSContinueantibioticsClinicalimprovementPersistence of fluidcollection and feverand evidence ofloculation on USG
Choice of Antibiotics Recommendations not evidence based Initial treatment should guided by local antibioticpolicy Cefuroxime with dicloxacillin/chloramphenicol whereequal efficacy was found ( Randomized )( Palacios GC, Gonzalez SN, Perez FL, et al. Cefuroxime vs a dicloxacillin/ chloramphenicol combination forthe 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 ClindamycinIn communityacquired infection
Role of ultrasonography Bedside tool Confirm fluid presence Stages complexity Assess volume Guide drainage siteUltrasound was demonstrated to be of equal clinicalvalue compared to CT scanning in detectingparapneumonic effusionsKurian J, Levin TL, Han BK, Taragin BH, Weinstein S (2009)Comparison of ultrasound and CT in the evaluation of pneumoniacomplicated by parapneumonic effusion in children. JR 193:1648–1654
CT scan detects more parenchymal abnormalities than chestradiography. However, the additional information does not alter managementand is unable to predict clinical outcome. No role for the routine use of CT scanning in children if treatedwith urokinase and percutaneous chest drain. Expose children to unnecessary radiation ( 20 to 400 CXRradiation) CostlyCT scan ( To exclude pulmonary abscess or other pus collection )• Persistent fever• A rise in WBC and C-reactive protein
Thoracocentesis ( moderate to largeeffusions )Adegboye VO, Falade A, Osinusi K, Obajimi MO. Reexpansion pulmonary oedemaas a complication of pleural drainage. Niger Postgrad Med J 2002;9:214–20 Reaccumulation of fluid - after the initial thoracentesis – insertchest 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 respiratorystatus.
Pleural fluid analysis Gram stain and bacterial culture Differential cell countBiochemical analysis of pleural fluid is unnecessary in themanagement of uncomplicated parapneumonic effusions/empyema ( BTS )Modified by prior antibiotic therapyAdditional techniques• Enrichment culture for aerobic and anaerobic organisms,• Serum or urine latex agglutination tests for detection of pneumococcalantigen• Specific or broad range polymerase chain reaction (PCR)Eastham KM, Freeman R, Clark J, et al. Clinical features, aetiology and outcome of empyema inthe North East of England. Thorax 2004;59:522–5.
Management of loculated or organizedpleural effusion Fibrinolytic therapy Videoassisted thoracoscopic surgery Minithoracotomy DecorticationA chest drain is left in place after each of theseprocedures for continued drainage of fluid or pus.No consensus on the role of medical versus surgicalmanagement
Large amounts offree flowingpleural fluidCompromisedpulmonaryfunction (eg,severehypoxemia,hypercapnia)Evidence offibrinopurulent effusions(eg, pH <7.0, glucose<40 mg/dL [2.22mmol.L , LDH morethan 1000 IU , Positivegram stain , Frank pusFailure to respondin 48 to 72 hours ofantibiotic therapyIndicationsFor chest tubedrainage
Choice of chest tubes Smaller catheters (8–12 FG) - as effective as largerbore tubes.(Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion: pleurodesis using asmall bore catheter. A prospective randomized study. Respir Med 1998;92:593–6 )Advantages More comfortable Better patient mobility Shorter hospital stayUltrasonographically guided insertion of small pigtail catheters for treatment ofearly loculated empyema has been well studied in children and found to beeffective.Pierrepoint MJ, Evans A, Morris SJ, et al. Pigtail catheter in the treatment of empyemathoracis. Arch Dis Child 2002;87:331–2Pigtail catheter -Seldinger technique
Fibrinolytic agents Urokinase – only agent studied in a controlled fashion inchildren ( recommended by the BTS )Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in thetreatment of childhood empyema. Thorax 2002;57:343–7 ) In one retrospective case series, thoracostomy tube drainagewas increased with Alteplase compared to urokinase The choice of agent depends upon availability, with urokinasebeing preferred if it is available, followed by alteplase(recombinant tissue plasminogen activator) and streptokinase.Intrapleural fibrinolytics shorten hospital stay and are recommended for anycomplicated parapneumonic effusion (thick fluid with loculations) orempyema (overt pus)
Surgical managementFailure of chest tube drainage, antibiotics, andfibrinolytics should prompt early discussion with athoracic surgeonEarly operative management• Reduced duration of chest tube (4.4 versus 10.6days)• Reduced Hospital stay (10.8 versus 20 versus )• Reduced Antibiotic therapy duration ( 12.8 versus21.3 versus )• Reduced Mortality (0 versus 3.3 versus 0 )• Low reintervention rate ( 2.5% versus 23.5% )
Video assisted thoracoscopic surgeryVATS - achieves debridement of fibrinous pyogenicmaterial, breakdown of loculations, and drainage ofpus from the pleural cavity under direct vision. Itleaves three small scars.The use of early VATS (<48hours after admission) versuslate VATS (>48 hours afteradmission) significantlydecreased the length ofhospitalizationKaren D. Schultz, Leland L. Fan, Jay Pinsky, LyssaOchoa, E. OBrian Smith, SheldonL. Kaplan and Mary L. The Changing Face of Pleural Empyemas inChildren: Epidemiology andManagement.BrandtPediatrics 2004;113;1735
VATS versus conventional medical therapy (with or without fibrinolysis )Increased hospital stay and duration of chest tubedrainage were noted in the group treated with medicaltherapy.
VATS with medical therapy with fibrinolysisVATS• Shorter hospital stay• Improved drainage• Enhances chance of full expansion of collapsed lungsWait MA, Sharma S, Hohn J, et al. A randomised trial of empyema therapy. Chest1997;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 debridementfor pediatric empyema. J Am Coll Surg 1998;187:404–8.Harder to perform in apatient who has been receiving intrapleuralurokinase as theloculations become very adhesive, although thismay 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 optionsMini-thoracotomy achieves debridement andevacuation in a similar manner to VATS but it is anopen procedure leaving a small linear scar along therib line.Decortication — An open posterolateral thoracotomyand excision of the thick fibrous pleural rind withevacuation of pyogenic material. This is a longer andmore complicated procedure than minithoracotomyand leaves a larger linear scar along the rib lineOpen thoracotomy indications• Late presenting empyema with significant pleural fibrous rind• Complex empyema and• Chronic empyemaFraga 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 theantibiotics to penetrate the infected lung tissue or cavity. Observe pattern of fever – if improving persist with thechosen treatment regimen Consider lung necrosis and inflammation Additionally in these circumstances, a decrease in white bloodcells and C-reactive protein is reassuring. Antibiotics recommended for 5 days after child becomesafebrile followed by oral antibiotics
Other complications Persistent lobar collapse - unusual . Anindication for bronchoscopy to exclude a foreignbody. Bronchopleural fistula occurs occasionallyfollowing the insertion of a chest drain or surgery forthe treatment of empyema due to the fragility of lungparenchyma, - leads to a persistent air leak. Avoid negative suction on the chest drain - toimprove the chances of tissue healing. Very occasionally surgical intervention is required torepair the fistula.
OUTPATIENT FOLLOW-UP Follow up until symptomatic resolution and chest Xray has returned to near nomal ( BTS ) The chest radiograph returns to normal in themajority of children (60–83%) by 3 months, in over90% by 6 months, and in all by 18 months.( Chan PW, Crawford O, Wallis C, et al. Treatment of pleural empyema. J Pediatr Child Health2000;36:375–7 )Immunodeficiency or cystic fibrosis evaluation - History of recurrentbacterial infections or poor growthCystic fibrosis – esp in S. aureus or Pseudomonas aeruginosa infection
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 casesPaediatric Empyema Thoracis: Recommendations for Management -Position statement from the Thoracic Society of Australia and NewZealand.
Summary High dose antibiotic therapy Appropriate antibiotics should be used to cover atleast Streptococcus pneumonia and Staphylococcusaureus. Moderate to large effusions require drainage. Chest drainage alone is not recommended and theintervention of choice is either percutaneous smallbore drainage with urokinase or VATS Oral antibiotics should be given for between 1 and6 weeks duration following discharge.Final outcome is almost always excellent in children