Tubes, Scopes, or Scalpels: The Dilemma of Treating Empyema in Children

1. Tubes, Scopes, or Scalpels:The Dilemma of Treating Empyemain Children Jeffrey C. Pence, MD, FACS, FAAP Associate Professor of Surgery Division of Pediatric Surgery Children’s Medical Center Dayton, OH

2. Objectives • Review the epidemiology and pathophysiology of parapneumonic effusion and empyema • Discuss the advent and application of video-assisted thoracoscopic surgery (VATS) in the treatment of pediatric empyema. • Offer discourse regarding the various treatment paradigms employed for pediatric empyema. • Suggest a standardized protocol for the multidisciplinary treatment of empyema at the Children’s Medical Center

3. 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 parapneumonicempyema 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 nonvaccineserotypes • Primarily due to serotypes 1, 3, 19A, and 7F

4. 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

5. 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

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

7. 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

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

9. Goals of Effective Therapy • Break the proinflammatory cycle • Reestablish the pleural circulation • Reexpand the pulmonary parenchyma • Optimize parenchymal circulation

10. 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

11. The treatment of empyemais 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 • Retrospectiveinferences 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

12. 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)

13. Hippocratic SuccussionEmypemaNecessitans 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.”

14. 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 PedSurg, 28 (9), 1993, pp 1128-1132

15. Technique

24. Conclusions 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 intrapleuralfibrinolytic therapy, not addressed herein, awaits further prospective study.

25. Comparison of Urokinase and Video-assisted ThoracoscopicSurgery for Treatment of Childhood Empyema SamathaSonnappa, Gordon Cohen, Catherine M. Owens, Carin van Doorn, John Cairns, SanjaStanojevic, Martin J. Elliott, and Adam Jaffe´ Department of Respiratory Medicine, Department of Cardio-Thoracic Surgery, and Department of Radiology, Great Ormond Street Hospital for Children NHS Trust; PortexAnaesthesia, Intensive Therapy and Respiratory Unit, Institute of Child Health; and Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom American Journal of Respiratory & Critical Care Medicine, v. 174 issue 2, 2006, p. 221-7

26. Sonnappa, et al. (2006) Study Design • Prospective randomized trial over 3 years • 60 children (30 per study arm) • Percutaneous drain with intrapleuralurokinase 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

27. Sonnappa, et al. (2006) Results UKVATSp-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

28. Sonnappa, et al. (2006) Results Urokinase • 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

29. Sonnappa, et al. (2006) Conclusions • No difference in clinical outcome between intrapleuralurokinase and VATS for the treatment of childhood empyema • Urokinase is a more economical treatment option • Intrapleuralurokinase should be the primary treatment choice for the treatment of childhood empyema

30. Thoracoscopicdecorticationvstube thoracostomy with fibrinolysis for empyemain children: a prospective, randomized trial Shawn D. St. Peter, KuojenTsao, 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, USA Department of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO 64108, USA Journal of Pediatric Surgery, 44, 2009, p. 106-111

31. 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

32. St. Peter et al. (2009) Results Clinical Outcomes VATS FibrinolysisP (n = 18) (n = 18) Length of posttherapy 6.9 ± 3.7 6.8 ± 2.9 .96 hospitalization (d) Posttherapy days 2.3 ± 1.7 2.3 ± 2.1 .90 of O2 support Days to afebrile after 3.1 ± 2.7 3.8 ± 2.9 .46 intervention Analgesia doses 22.3 ± 28.5 21.4 ± 12.0 .90 Hospital charges (x1000) $11.7 ± $2.9 $7.6K ± $5.4 .02

33. 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

34. St. Peter, et al. (2009) Conclusions • No difference in days of hospitalization after intervention • Nodifference 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

35. Proposed Algorithm 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