Current issues in the diagnosis and management of pediatric empyema

Aetiology of paediatric pneumonia with effusion in the Dominican Republic and the potential impact of pneumococcal conjugate vaccines

Pleural effusion is a serious complication of pneumonia, and Streptococcus pneumoniae is a leading cause. We describe the aetiology of pneumonia with effusion among children in the Dominican Republic before the introduction of the 13-valent pneumococcal conjugate vaccine (PCV) in 2013 and the performance characteristics of a rapid immunochromatographic test (ICT) for detecting S. pneumoniae in pleural fluid. From July 2009 to June 2011, we enrolled children <15 years old admitted with pneumonia and pleural effusion to Robert Reid Cabral Children’s Hospital, Dominican Republic. Pleural fluid was tested by culture, polymerase chain reaction (PCR) for bacterial (S. pyogenes, S. pneumoniae) and viral (respiratory syncytial virus and human rhinovirus) pathogens, and by ICT for S. pneumoniae. We calculated the performance of ICT and culture compared with PCR. Among 121 cases, the median age was 31 months (range 1 week to 14 years). Pleural fluid culture (n = 121) and PCR testing (n = 112) identified an aetiology in 85 (70.2%) cases, including 62 S. pneumoniae (51.2%) and 19 Staphylococcus aureus (15.7%). The viruses tested were not detected. The most prevalent pneumococcal serotypes were 14 (n = 20), 1 (n = 13), and 3 (n = 12). Serotype coverage of the 10- and 13-valent PCVs would be 70.5% and 95.1%, respectively. The sensitivity of point-of-care ICT was 100% (95% confidence interval [CI] 94.1%–100%), while specificity was 86.3% (95% CI 73.7%–94.3%). S. pneumoniae caused more than half of paediatric pneumonia with effusion cases; introduction of PCV in the Dominican Republic could reduce the burden by 36–49%. ICT is a practical, valid diagnostic tool for clinical care and surveillance in settings with limited laboratory capacity.

Rapid detection of Streptococcus pyogenes in pleural fluid samples from pediatric patients with empyema

A total of 120 pleural fluid specimens from 113 pediatric patients were tested using two rapid antigen detection assays for Streptococcus pyogenes. Results were compared to culture, Gram stain, and PCR results. Each rapid antigen assay detected 9 out of 10 (90%) PCR-positive samples, with 100% specificity. These antigen detection assays are useful to provide microbiological diagnosis of empyema caused by S. pyogenes.

Bilateral reexpansion pulmonary edema associated with pleural empyema: a case report

Reexpansion pulmonary edema is an uncommon complication following rapid reexpansion of the lungs. The risk increases with a prolonged duration of pulmonary collapse, the amount of drained liquid or air, and with decreased time of draining. Treatment is supportive. In general, the prognosis is favorable. A nine-year-old boy was presented with fever, cough, and respiratory distress. Pneumonia and left-sided pleural empyema were determined and a chest tube was emplaced. Clinical deterioration occurred in just a few minutes following chest tube insertion. His chest radiography revealed a pulmonary edema in the left lung. Despite mechanical ventilation, antibiotics, and diuretic treatment, no significant improvement occurred. Acute respiratory distress syndrome and multiple organ dysfunctions developed in the follow-up. The patient died on day 5 of hospitalization. In this report, a complicated reexpansion pulmonary edema with a lathal outcome in a 9-year-old child is presented.

Video-Assisted Thoracoscopic Surgery as a Primary Intervention in Pediatric Parapneumonic Effusion and Empyema

The use and effectiveness of video-assisted thoracoscopic surgery (VATS) for the treatment of empyema and complex parapneumonic collections in pediatric patients is well documented. Timing of this intervention still remains controversial. We reviewed our experience with VATS to determine if it should be used as the initial procedure in children with pleural collections. We reviewed all pediatric (age younger than 17 years) patients with a diagnosis of pneumonia admitted between July 1998 and June 2008. Demographics, comorbidities, laboratory data, and hospital length of stay (LOS) were evaluated. Patients were divided into groups: those who only had thoracentesis or thoracostomy (Group A), those who underwent a procedure and then required VATS (Group B), and those who went directly to VATS (Group C). We identified 382 patients admitted with pneumonia. Of these, 79 (21%) required a thoracic drainage procedure. Overall, 49 (67%) of patients with a thoracic fluid collection underwent VATS at some point. With regard to type of intervention, there was no statistical difference noted in clinical variables. Thirty (38%) patients were in Group A, 18 (22%) in Group B, and 31 (39%) in Group C. LOS for Group C (10.5 days) was significantly ( P < 0.05) shorter than for both Group A (14.8 days) and Group B (15 days). Only two (6%) patients required conversion to open thoracotomy. A high percentage of children initially treated by tube thoracostomy eventually require additional interventions, leading to increased LOS. As a result of its simplicity, safety, and efficacy, VATS pleural evacuation can be recommended as the initial intervention in pediatric parapneumonic effusions and empyema in patients who do not require emergent drainage.

Interventional radiology treatment of empyema and lung abscesses

Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.

Thoracic empyema, application of video-assisted thoracic surgery and its current management

PURPOSE OF REVIEW

Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention.

RECENT FINDINGS

We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy.

SUMMARY

We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.

Paediatric thoracic tumours presenting as empyema

Ultrasonography (US) is considered to be adequate for the preoperative evaluation of childhood empyema. This study was aimed to improve awareness that paediatric intra-thoracic tumours can mimic childhood post-pneumonic empyema and highlights the value of computed tomogram (CT) scan with intravenous (IV) contrast in preoperative evaluation of childhood empyema. The data were analysed on eight children (four boys and four girls) presented at the median age of 6.2 years (1.8-15 years) for the management of empyema and later confirmed to have intra-thoracic tumours. Intra-thoracic tumours in 8 (5.3%) children out of 150 cases of post-pneumonic empyema were managed during the study period. All eight had clinical features, increased white cell count, raised inflammatory markers and biochemical parameters suggestive of childhood empyema. Chest X-ray showed localised opacity in 3/8 while in other five suggested significant pleural collection with mediastinal shift. Additional investigations in referring hospital were suggestive of empyema in four children; US in three, CT scan without IV contrast in one. Referring hospital carried out non-diagnostic thoracocentesis in four children with blood stained pleural tap in two. In four children corroborative evidence suggestive of infection within pleural cavity and acute respiratory distress led to an emergency mini-thoracotomy resulting in significant intra-operative bleeding in two children. Histology on biopsy of the infected material showed primitive neuroectodermal tumour (PNET) in one, pleuropulmonary blastoma in one, metastatic malignant melanoma in one and cytology of pleural fluid diagnosed lymphoma in one. Pre-operative CT scan with IV contrast in four children correctly identified underlying intra-thoracic tumour (two benign teratoma, two PNET). In two cases CT with IV contrast was performed because chest X-ray suggested mediastinal loculated empyema while in other two high clinical index of suspicion prompted preoperative evaluation with CT scan with IV contrast. We advocate caution and increased awareness before considering therapeutic options in childhood empyema and recommend preoperative CT scan with IV contrast in some selected and unusual cases.

Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage

OBJECTIVE

Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage.

DESIGN

A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol.

RESULTS

Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group.

CONCLUSIONS

The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

Imaging in immunocompetent children who have pneumonia

This article discusses the common clinical scenarios regarding otherwise healthy children who develop suspected pneumonia in which imaging becomes an issue. The following topics are covered concerning the roles of imaging in the management of pneumonia: evaluation for possible pneumonia, determination of a specific etiologic agent, exclusion of other pathology, evaluation of the child with failure of pneumonia to clear, and evaluation of complications related to pneumonia.

Is open thoracotomy still a good treatment option for the management of empyema in children?

BACKGROUND

The incidence of pediatric postpneumonic empyema increases, and there is little consensus on its management. Open thoracotomy has been linked with high morbidity and prolonged hospitalization. Our aim was to review the outcome after open thoracotomy and to provide a set of data for comparison with other treatment modalities.

METHODS

Forty-four children (median age, 8 years, 2 months to 16 years) undergoing surgery for postpneumonic empyema between 1993 and 2002 in our unit were studied.

RESULTS

The median time from onset of symptoms to admission in a pediatric unit was 8 days (range, 2 to 63 days), the median time from pediatric admission to surgical referral was 3 days (range, 0 to 19 days), and the median time from surgical admission to thoracotomy was 1 day (range, 0 to 2 days). Eight children had a chest drain before surgical admission. Six patients, who were referred late (19 to 69 days), had lung abscesses. A limited muscle sparing thoracotomy (44 patients), formal decortication (36 patients), lung debridement (5 patients), and lobectomy (1 patient) were performed. After thoracotomy, median time to apyrexia was 1 day (range, 0 to 27 days) and drain removal was 3 days (range, 1 to 16 days). A pathogen was isolated in 21 patients. There were no deaths. Four children with abscesses remained septic and had lobectomies (2 patients) and debridements (2 patients). The median postoperative hospital stay was 5 to 53 days. One child had postpneumonic empyema develop and had decortication 3 months postoperatively. At follow-up, all children were doing well and had satisfactory radiographs. The Kaplan-Meier 5-year and 10-year survival rate, freedom from any reoperation, and freedom from hospital readmission were 100%, 87%, and 98%, respectively.

CONCLUSIONS

Open thoracotomy remains an excellent option for management of stage II-III empyema in children. When open thoracotomy is performed in a timely manner there is low morbidity and it provides rapid resolution of symptoms with a short hospital stay. However, delayed referrals may result in advanced pulmonary sepsis and a protracted clinical course. The late results are encouraging. Use of thoracoscopy or fibrinolysis should be considered on the basis of their own merit, not on the assumption of probable adverse outcomes after thoracotomy.