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)