Literature Summary

Major Literature

Islam S et al, J Ped Surgery 2012
  • Stages of pleural disease
    • 1:  Pre-collection stage - PNA associated with pleuritis
    • 2:  Exudative stage - simple parapneumonic effusion (PPE)
    • 3:  Fibrinopurulent stage - complicated PPE/empyema
      • Light's criteria = pH <7.2, LDH >1000, glucose <40, positive GS or culture + loculation/septations on imaging
        • Abx >48hrs before tap lowers culture yield but should not affect biochemistry of fluid
    • 4:  Organizational stage - thick pleural peel --> entrap lung --> restrictive lung disease
  • Optimal imaging modality for pleural disease
    • U/S should be initially used (CT provided no advantage over U/S)
    • CT should be reserved for complicated cases
      • Evaluate for parenchymal abscess
      • U/S is inadequate due to body habitus
  • Methods of intervention for PPE
    • Thoracentesis
    • Chest tube
    • Chest tube w/ chemical debridement
    • Video assisted thoracoscopic surgery (VATS)
  • When to intervene
    • Large effusions (affecting >50% of the thorax on CXR) with or without sxs
    • Moderate effusions (affecting 25-50% of the thorax on CXR) with persistent or worsening sxs
    • Any effusions associated w/ loculations
  • How to drain free flowing simple PPE
    • Consider single thoracentesis
    • First thoracentesis fails to adequately drain --> place chest tube
      • In young children requiring conscious sedation, may be beneficial to just place chest tube first instead of doing thoracentesis to avoid repeat procedures w/ sedation
      • <14F tubes should be used even for loculated effusions
  • How to manage empyema
    • Evidence for below guideline
      • VATS
        • If VATS performed w/in 48hrs of empyema diagnosis --> reduces hospital stay by 4 days
        • If VATS performed >4 days after empyema diagnosis --> longer hospitalization and post-op complications
      • VATS vs. tPA (chemical debridement)
        • No difference in length of hospitalization
        • Failure rate of tPA was ~17% --> eventually got VATS
        • VATS more expensive than tPA
    • Guideline
      1. Diagnose empyema
      2. Give tPA
      3. If no clinical improvement --> U/S or CT
        • If persistent pleural disease --> VATS
        • If no pleural disease --> continue abx
          • Abx usually for 2-4 wks (minimum of 10 days after resolution of fever)