Tubes, Scopes, or Scalpels:

The Dilemma of Treating Empyema in Children

Jeffrey C. Pence, MD, FACS, FAAPAssociate Professor of SurgeryDivision of Pediatric Surgery

Children’s Medical CenterDayton, OH

Objectives

1. Review the epidemiology and pathophysiology of parapneumonic effusion and empyema

2. Discuss the advent and application of video-assisted thoracoscopic surgery (VATS) in the treatment of pediatric empyema.

3. Offer discourse regarding the various treatment paradigms employed for pediatric empyema.

4. Suggest a standardized protocol for the multidisciplinary treatment of empyema at the Children’s Medical Center

Epidemiology• Incidence of pneumonia in children ranges from

1.0 to 4.5 cases per 100 children per year• Approximately 0.6% of childhood pneumonias progress

to empyema• Overall prevalence of empyema is estimated at 3.3

cases per 100,000 children• The prevalence of parapneumonic empyema has been

increasing over the past decade despite the introduction of Prevnar in 2001 (Byington, et al, 2010)– 2001: 8.5/100,000 children– 2007: 12.5/100,000 children (p=0.006)– Ninety-eight percent were due to nonvaccine serotypes– Primarily due to serotypes 1, 3, 19A, and 7F

The Pleural Space

• Continuous pleural circulation• Space between visceral and parietal pleural

surfaces • Interspace volume of 0.3 mL/kg body weight• Balanced

– Secretion: apical lymphatic channels– Absorption: basal lung and cardiac

pleural lymphatic pores

Pathophysiology

• Parenchymal disease evokes pleural inflammation• Immune cellular-mediated cytokine release

– Increased vascular permeability– Increased pleural fluid production– Increased procoagulant activity – Decreased fibrinolysis– Decreased pleural resorption

• Clinical sequelae– Parapneumonic effusion– Dyspnea– Fever– Pleuritic pain

Pathophysiology

Stage I• Exudative stage• Uncomplicated parapneumonic effusion• <7 days following parenchymal disease• Simple effusions• Sterile• Intervention for symptoms only

Pathophysiology

Stage II • Fibrinopurulent stage• Complicated parapneumonic effusion• 7-14 days following parenchymal disease• Fibrin deposition on pleural surfaces• Loculations• Potential colonization (empyema)• Therapeutic intervention generally

required

Pathophysiology

Stage III • Organizing stage• >14 days following parenchymal disease• Dense fibrin deposition on pleural surfaces• Fibrosis• Potential lung entrapment• Therapeutic intervention generally

required

Goals of Effective Therapy

• Break the proinflammatory cycle

• Reestablish the pleural circulation

• Reexpand the pulmonary parenchyma

• Optimize parenchymal circulation

Treatment Modalities

• Antibiotics• Thoracentesis• Chest tube or pigtail catheter• Chest tube or pigtail catheter with

fibrinolytic instillation• Thoracoscopy (VATS = Video-assisted

Thoracic Surgery)• Thoracotomy/ Mini Thoracotomy

The treatment of empyema is controversial.

• Abundant data supporting the use of fibrinolysis in children to facilitate earlier resolution of empyema

• Abundant data to support the utility of VATS as the optimal treatment modality in empyema

• Retrospective inferences favor one treatment strategy over the other

• As such, referring and treating physicians typically hold 1 of 2 opposing views

• Treatment of empyema evokes both individual (experiencial) and institutional bias

First Known Reference to Empyema

“As time goes on, the fever becomes more severe, coughing begins, the side begins to pain, the patient can not lie any more on the healthy side but on the diseased side, the feet and the eyes swell.”

Hippocrates, c. 400 BC (from de morbis, authenticity questioned by many authorities)

Hippocratic SuccussionEmypema Necessitans and the First

Thoracotomy?

“When the fifteenth day after the rupture has appeared, prepare a warm bath, set him upon a stool, which is not wobbly, someone should hold his hands, then shake him by the shoulders and listen to see which side a noise is heard. And right at this place, preferably on the left – make an incision, then it produces death more rarely.”

The Advent of Video-Assisted Thoracoscopic Surgery (VATS) for

Empyema in Children• Dr. Bradley Rodgers first reports the utility of

VATS for the treatment of empyema in children in 1993

• 9 children (ages 2-16 years) treated from 1981 to 1992

• All patients had failed chest tube drainage over 1-17 days

• No postoperative complications• No need for further surgical intervention• VATS reduced the operative morbidity of open

thoracotomy while hastening recovery

Kern JA and Rodgers BM, J Ped Surg, 28 (9), 1993, pp 1128-1132

Technique

Optimizing Outcomes in the Thoracoscopic Management of Complicated Parapneumonic Effusion in Children

EARLY VATS (n=29)

• Confirmation of diagnosis

• Primary thoracoscopic intervention

• <72 hr following admission

LATE VATS (n=17)

• Confirmation of diagnosis

• Attempted drainage procedure(s)

• Secondary thoracoscopic intervention

• >72 hr following admission

VARIABLE EARLY VATS (mean ± SD)

LATE VATS (mean ± SD)

p -VALUE

Operative Time (min) 90 ± 29 104 ± 36 0.03 Duration of Chest Tube Drainage (hr)

79 ± 45 99 ± 35 0.01

Duration of Pyrexia (hr) 49 ± 26 89 ± 107 0.12 (ns) Duration of Mechanical Ventilation (d)

0.7 ± 0.8 1.2 ± 1.7 0.19 (ns)

Transfusion Requirements (units) 0.1 ± 0.3 0.8 ± 1.3 0.05 (ns) Postoperative Length of Stay (d) 6.3 ± 3.0 7.8 ± 4.9 0.15 (ns) Total Length of Stay (d) 7.7 ± 3.4 13.6 ± 5.8 <0.01

Optimizing Outcomes in the Thoracoscopic Management of Complicated Parapneumonic Effusion in Children

This extended retrospective study further affirms the efficacy of early VATS in the primary treatment of fibrinopurulent to organizing parapneumonic effusion in pediatric patients. These data support the expedient recognition, prompt referral, and effectual thoracoscopic drainage of advanced parapneumonic effusions for the purpose of optimizing clinical outcomes. The comparable efficacy of primary intrapleural fibrinolytic therapy, not addressed herein, awaits further prospective study.

Conclusions

Comparison of Urokinase and Video-assisted Thoracoscopic Surgery for Treatment of Childhood Empyema

Samatha Sonnappa, Gordon Cohen, Catherine M. Owens, Carin van Doorn, John Cairns, Sanja Stanojevic, Martin J. Elliott, and Adam Jaffe´

Department of Respiratory Medicine, Department of Cardio-Thoracic Surgery, and Department of Radiology, Great Ormond Street Hospitalfor Children NHS Trust; Portex Anaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health; and Department of PublicHealth and Policy, London School of Hygiene and Tropical Medicine, London, United KingdomAmerican Journal of Respiratory & Critical Care Medicine, v. 174 issue 2, 2006, p. 221-7

Sonnappa, et al. (2006)

Study Design

• Prospective randomized trial over 3 years• 60 children (30 per study arm)• Percutaneous drain with intrapleural urokinase or VATS• Primary outcome measured number of hospital days

following intervention• Secondary outcome measures were chest drain days,

total hospital stay, failure rate, radiologic outcome at 6 months, and total treatment costs

Sonnappa, et al. (2006)

Results

UK VATS p-Value

Hospital days 6 (4-25) 6 (3-16) 0.31

Chest drain days -1 d 0.55

Total inpatient days 7 (4-25) 8 (4-17) 0.64

Failure rates 5 (16%) 5 (16%)

Abnormal CXR 18/20 21/24 0.27

Cost (median, USD) 6914 10146 <0.001

Sonnappa, et al. (2006)

ResultsUrokinase• Chest drain dislodgement in 4 patients requiring

reinsertion (prolonging hospitalization)• Five patients (16.6%) required secondary VATS for

definitive therapy

VATS• Four patients (13%) required conversion to mini-

thoracotomy

Sonnappa, et al. (2006)

Conclusions

• No difference in clinical outcome between intrapleural urokinase and VATS for the treatment of childhood empyema

• Urokinase is a more economical treatment option

• Intrapleural urokinase should be the primary treatment choice for the treatment of childhood empyema

Journal of Pediatric Surgery, 44, 2009, p. 106-111

Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

Shawn D. St. Peter, Kuojen Tsao, Christopher Harrison, Mary Ann Jackson, Troy L. Spilde, Scott J. Keckler, Susan W. Sharp, Walter S. Andrews, George W. Holcomb III, Daniel J. Ostlie

Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USADepartment of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO 64108, USA

St. Peter et al. (2009)

• Prospective randomized trial• March 2006 to November 2007• 36 children• Percutaneous drain with intrapleural

recombinant human tissue plasminogen activator (tPA) or VATS

• Primary end point measured length of postoperative hospitalization

• Secondary clinical outcome variables

St. Peter et al. (2009)

Results

Clinical Outcomes VATS Fibrinolysis P(n = 18) (n = 18)

Length of posttherapy 6.9 ± 3.7 6.8 ± 2.9 .96hospitalization (d)

Posttherapy days 2.3 ± 1.7 2.3 ± 2.1 .90of O2 support

Days to afebrile after 3.1 ± 2.7 3.8 ± 2.9 .46intervention

Analgesia doses 22.3 ± 28.5 21.4 ± 12.0 .90

Hospital charges (x1000) $11.7 ± $2.9 $7.6K ± $5.4 .02

St. Peter, et al. (2009)

Results

• Three patients (16.6%) in the fibrinolysis group required VATS for definitive therapy

• Two patients in VATS group required ventilator therapy post intervention

• One patient in VATS group required temporary dialysis due to progressive sepsis

St. Peter, et al. (2009)

Conclusions

• No difference in days of hospitalization after intervention• No difference in oxygen requirement, days until afebrile,

or analgesic requirements• VATS is associated with significantly higher charges• Fibrinolysis may pose less risk of clinical deterioration

• tPA should be the primary treatment for childhood empyema

CXR

Pneumonia

Parapneumonic effusion

Ultrasound (+/- decubitus x-rays)

Simple /free-flowing Complex/loculated

Symptomatic Asymptomatic Ultrasound-guided percutaneous catheter (PTC)

Thoracentesis Observe tPA (0.1 mg/kg/dose in 30 mL NS) IP q24 hr x 3

Symptomatic Asymptomatic

CT chest

Persistent pleural space disease

VATS

Proposed Algorithm