Current ManagementPleural Effusion, Empyema,

Complicated Pneumonia

Update in Pediatrics

Vincent Adolph, MD

Pediatric Surgery

July 20, 2019

• No Financial Conflicts of Interest

• Thrombolytic use is off-label

• Describe the difference between pleural effusion and empyema

• Explain the role of imaging in patients with complicated pneumonia

• Explain the options for management of pleural effusion and empyema

• Know how to evaluate for parenchymal complications of pneumonia

• Evaluation / Decision making

• Antibiotic Selection

• Definitions

• Imaging

• Treatment

• Determining treatment failure

• Pulmonary Necrosis / Abscess / Pneumatocele

• Recurrent Pneumonia / Congenital Lung Lesions

• Duration of Antibiotic Therapy

• Assess Symptoms

• Resp sx, O2, fever, oral intake

• Parenchymal Process vs Pleural Disease

• Effusion vs Empyema

• Parenchymal Complications

Abscess, Necrosis, Pneumatocele

• Hypoxemia (SaO2 < 92%)

• Tachypnea (infants RR > 70 , older >50)

• Retractions, nasal flaring, grunting, etc

• Inadequate oral intake

• Other chronic conditions

• Toxic appearance

• Suspicion of Staph or group A Strep

• Failure of outpatient therapy

• Complications (effusion, empyema, abscess)

• Impending respiratory failure

• Inability to maintain sats > 92%

• Apnea or irregular respirations

• Hypotension / Refractory tachycardia

• Multi-lobar infiltrates

• Mental status changes

• Pleural disease (effusion / empyema)

• SS ds, immuno-compromise

Empiric Antibiotics

• Effusion

• Transudate

• Simple, free-flowing fluid

• Empyema

• Grossly purulent, WBC > 10,000 (<?)

• pH < 7.0, LDH > 1,000, Glucose < 40

• Positive gram stain

CXR

AP +/- decubitus (affected side down)

Ultrasound

Assess for pleural fluid volume / character

CT

Assess for parenchymal complications

IV contrast to assess for necrosis

• tPA (Urokinase, Streptokinase)

• tPA: 4 mg in 40 ml NS

• Dwell time of 1 hour

• 3 doses over 48 hrs

• tPA: 0.1 mg/kg (up to 3 mg in 30 ml NS

• Every 8 hours for nine doses (3 days)

• Contraindications:

• Active air leak (broncho-pleural fistula)

• Recently healed leak ?

AP Supine Right lateral Decubitus

48-72 hours for CT / thrombolysis

Failure to improve

Fever, Resp status, oral intake, O2 need

Re-image

Assess pleural space

Assess lung parenchyma

• Indications:

• Failure to improve with CT / thrombolytics

• VATS (Video-Assisted Thorascopic Surgery)

• Thorascopic debridement

• Thoracotomy

• Decortication – removal of thick fibrous pleural rind

• Abscess

• Usually respond to longer course of antibiotics

• Selective aspiration / drainage

• Pneumothorax, pyo-pneumothorax

• Broncho-pleural fistula

• Pulmonary Necrosis

• Prolonged antibiotic course

• Very high risk with drainage, debridement, bx

• Pneumatocele

• Recurrent Pneumonia in same lobe

• Pneumatocele

• Congenital Pulmonary Malformations

• CCAM

• (Congenital Cystic Adenomatoid Malformation)

• Sequestration

• Intrapulmonary

• Extrapulmonary

• Bronchogenic Cysts

Uncomplicated Pneumonia

One week after fever resolves

Complicated Pneumonia

Empyema:

7-10 days after CT out, clinically well, afebrile

Abscess/ Necrosis:

10-14 days after resolution – minimum

Some recommend 2-4 weeks

• Describe the difference between pleural effusion and empyema

• Explain the role of imaging in patients with complicated pneumonia

• Explain the options for management of pleural effusion and empyema

• Know how to evaluate for parenchymal complications of pneumonia