Parapneumonic effusion

The presentation provides an evidence based overview of parapneumonic effusion and the various management strategies available ....

1. Parapneumonic effusion in children Gopakumar Hariharan Registrar , Paediatrics Royal Hobart Hospital , Tasmania Australia

2. Parapneumonic effusion and empyma in children Case scenario Pathogenesis and Clinical features of parapneumonic effusion Various management strategies Guidelines on management

3. Case scenario 7 year old boy referred from regional hospital with a diagnosis of left sided pneumonia Unwell since one week with fever , cough and breathing difficulty prior to admission Past history of pneumococcal pneumonia in 2009 Ceftriaxone and Flucloxacillin and supportive measures

4. One week post admission 4 days after admission 7 th day post admission Tachypneic and febrile , but no oxygen requirement

5. Chest tube drainage Continued respiratory distress and fever Chest drain inserted Not suggestive of empyema – No leukocytes / growth No significant drainage C ontinued to have low grade fever Repeat ultrasound showed fluid collection and tube to be in good position Repeated tube aspiration done – drained around 200 ml and then needed aspiration a few more times 9 days post admission

6. Tube drainage Stopped draining again . Repeat ultrasound showed suspicion of loculation Urokinase given and further aspiration done - some drainage Always serous fluid , never pus Continued to have low grade fever but clinically well No significant drainage - Removed tube ( total of 8 days insertion)

7. After chest tube removal Continued fever – invest. CRP – 56 (5 days back– 45 ) Respiratory swab - Positive RSV Blood culture – No growth Ultrasound abdomen for subphrenic abscess – negative 2 days post removal

8. Ongoing management Tazocin and Azithromycin ( ID consult ) Improved subsequently and afebrile Augmentin Follow up

9. Immunological tests CD3 ( Mature T cells ) – 2.4 ( 0.7 – 2.0 ) CD 4 ( helper and inducer cells ) – 1.3 ( 0.4 – 1.1 ) CD 8 ( suppressor / cytotoxic T cells ) – 0.9 / micro L ( 0..3 – 0.7 ) CD 19 ( Pan B cells ) – 0.4 / microL ( 0.1 – 0.4 ) CD3- / CD 16+56+ - 0.5 / microL ( 0.1 – 0.5 ) Normal HLA DR expression Memory B cell analysis – Normal IgG – 11.3 g/L ( 5.4 – 18.2 ) IgA – 2.23 g / L ( 0.21 – 2.90 ) IgM – 1.05 g / L ( 0.47 – 2.40 ) C3 – 1.63 g / L ( 0.81 – 1.72 ) C4 – 0.27 g / L ( 0.14 – 0.45 ) Severe streptococcal pneumonia infection Past history of strep Pneumonia Previous vaccination with pneumococcal vaccine

10. Parapneumonic effusion

11. Evolution to Empyma Empyema – Grossly purulent fluid in the pleural cavity Fibrin deposition in pleura and fomation of septation Simple parapneumonic effusion Complicated parapneumonic effusion Exudative stage Fibrinopurulent stage Organisational stage Hamm H, Light RW. Parapneumonic effusion and empyema. Eur Respir J1997;10:1150–6 .

12. Epidemiology and organism profile . Childhood empyema occurs in 0.7% of pneumonias in Australia Strachan R, Jaffé A; Australian Research Network in Empyema. Assessment of the burden of paediatric empyema in Australia. J Paediatr Child Health 2009;45:431–6. doi:10.1111/j.1440-1754.2009.01533.x PMID:19722296 Organism profile and immunization PCV 7 ( 2001 ) – reduced invasive pneumococcal infection However , concomitant increase in empyema cases ( 90% of cases caused by bacterial serotypes 1 , 3 and 19A not included in the 7 valent vaccine ) . More virulent strains Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J 2006;25:250–4. doi:10.1097/01.inf.0000202137.37642.ab PMID:16511389 In July 2011 the PCV7 was replaced by a 13-valent conjugate vaccine

13. Children with pneumonia presenting with prolonged fever, tachypnoea, and high serum C-reactive protein levels are at risk for parapneumonic empyema. Fever pattern CRP pattern

14. Goals of therapy

15. Initial management Supplemental oxygen if saturations below 93%. Fluid management , antipyretics Adequate analgesia – to allow pain free respiration and mobilisation Intravenous antibiotics – in all children with parapneumonic effusion No role for chest physiotherapy apart from early mobilisation and encouragement of deep breathing and coughing, particularly after surgical intervention or tube drainage

16. Conservative management Small effusion – ( <10 mm on lateral decubitus radiograph or opacifying less than one-fourth of the hemithorax ) - broad-spectrum oral antibiotics and close observation with chest radiographs on an outpatient basis Antibiotics alone or antibiotics +/- simple drainage

17. Clinical improvement Persistence of fluid collection and fever and evidence of loculation on USG

18. Choice of Antibiotics Recommendations not evidence based Initial treatment should guided by local antibiotic policy Cefuroxime with dicloxacillin /chloramphenicol where equal efficacy was found ( Randomized ) ( Palacios GC, Gonzalez SN, Perez FL, et al. Cefuroxime vs a dicloxacillin / chloramphenicol combination for the treatment of parapneumonic pleural effusion and empyema in children. Pulm Pharmacol Ther 2002;15:17–23 ) Cefuroxime Co- amoxiclav Penicillin and flucloxacillin Amoxicillin and flucloxacillin Clindamycin In community acquired infection

19. Role of ultrasonography Bedside tool Confirm fluid presence Stages complexity Assess volume Guide drainage site U ltrasound was demonstrated to be of equal clinical value compared to CT scanning in detecting parapneumonic effusions Kurian J, Levin TL, Han BK, Taragin BH, Weinstein S (2009) Comparison of ultrasound and CT in the evaluation of pneumonia complicated by parapneumonic effusion in children. JR 193:1648–1654

20. CT scan detects more parenchymal abnormalities than chest radiography. However , the additional information does not alter management and is unable to predict clinical outcome. No role for the routine use of CT scanning in children if treated with urokinase and percutaneous chest drain. E xpose children to unnecessary radiation ( 20 to 400 CXR radiation) Costly CT scan ( To exclude pulmonary abscess or other pus collection ) Persistent fever A rise in WBC and C-reactive protein

21. Thoracocentesis ( moderate to large effusions ) Adegboye VO, Falade A, Osinusi K, Obajimi MO. Reexpansion pulmonary oedema as a complication of pleural drainage. Niger Postgrad Med J 2002;9:214–20 Reaccumulation of fluid - after the initial thoracentesis – insert chest tube Repeated thoracentesis is not recommended ( BTS ) Aspiration quantitity - limited to 10 to 20 mL/kg - Rapid removal of large amounts of pleural fluid - pulmonary edema - worsening of respiratory status.

22. Pleural fluid analysis Gram stain and bacterial culture Differential cell count Biochemical analysis of pleural fluid is unnecessary in the management of uncomplicated parapneumonic effusions/ empyema ( BTS ) Modified by prior antibiotic therapy Additional techniques E nrichment culture for aerobic and anaerobic organisms , Serum or urine latex agglutination tests for detection of pneumococcal antigen Specific or broad range polymerase chain reaction (PCR ) Eastham KM, Freeman R, Clark J, et al. Clinical features, aetiology and outcome of empyema in the North East of England. Thorax 2004;59:522–5.

23. Management of loculated or organized pleural effusion Fibrinolytic therapy Videoassisted thoracoscopic surgery Minithoracotomy Decortication A chest drain is left in place after each of these procedures for continued drainage of fluid or pus. No consensus on the role of medical versus surgical management

24. Indications For chest tube drainage

25. Choice of chest tubes Smaller catheters (8–12 FG) - as effective as larger bore tubes. ( Clementsen P, Evald T, Grode G, et al. Treatment of malignant pleural effusion : pleurodesis using a small bore catheter. A prospective randomized study . Respir Med 1998;92:593–6 ) Advantages More comfortable Better patient mobility Shorter hospital stay Ultrasonographically guided insertion of small pigtail catheters for treatment of early loculated empyema has been well studied in children and found to be effective. Pierrepoint MJ, Evans A, Morris SJ, et al. Pigtail catheter in the treatment of empyema thoracis . Arch Dis Child 2002;87:331–2 P igtail catheter - Seldinger technique

26. Fibrinolytic agents U rokinase – only agent studied in a controlled fashion in children ( recommended by the BTS ) Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002;57:343–7 ) In one retrospective case series, thoracostomy tube drainage was increased with Alteplase compared to urokinase The choice of agent depends upon availability, with urokinase being preferred if it is available, followed by alteplase (recombinant tissue plasminogen activator) and streptokinase . Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion (thick fluid with loculations ) or empyema (overt pus)

27. Surgical management Failure of chest tube drainage, antibiotics, and fibrinolytics should prompt early discussion with a thoracic surgeon Early operative management Reduced duration of chest tube (4.4 versus 10.6 days) Reduced Hospital stay (10.8 versus 20 versus ) Reduced Antibiotic therapy duration ( 12.8 versus 21.3 versus ) Reduced Mortality (0 versus 3.3 versus 0 ) Low reintervention rate ( 2.5% versus 23.5% )

28. Video assisted thoracoscopic surgery VATS - achieves debridement of fibrinous pyogenic material, breakdown of loculations , and drainage of pus from the pleural cavity under direct vision. It leaves three small scars. The use of early VATS (<48 hours after admission) versus late VATS (>48 hours after admission) significantly decreased the length of hospitalization Karen D. Schultz, Leland L. Fan, Jay Pinsky , Lyssa Ochoa, E. O'Brian Smith, SheldonL . Kaplan and Mary L . The Changing Face of Pleural Empyemas in Children: Epidemiology andManagement . Brandt Pediatrics 2004;113;1735

29. VATS versus conventional medical therapy ( with or without fibrinolysis ) Increased hospital stay and duration of chest tube drainage were noted in the group treated with medical therapy .

30. VATS with medical therapy with fibrinolysis VATS Shorter hospital stay Improved drainage Enhances chance of full expansion of collapsed lungs Wait MA, Sharma S, Hohn J, et al. A randomised trial of empyema therapy. Chest 1997;111:1548–51 . High failure rate in late presenting cases Not suitable for advanced organised empyema. Klena JW, Cameron BH, Langer JC, et al. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998;187:404–8. Harder to perform in apatient who has been receiving intrapleural urokinase as theloculations become very adhesive, although this may be due to the delay rather than the urokinase itself. Jaffe ´ A, Cohen G. Thoracic empyema. Arch Dis Child 2003;88:839–41

31. Other surgical options Mini-thoracotomy achieves debridement and evacuation in a similar manner to VATS but it is an open procedure leaving a small linear scar along the rib line. Decortication   —  An open posterolateral thoracotomy and excision of the thick fibrous pleural rind with evacuation of pyogenic material. This is a longer and more complicated procedure than minithoracotomy and leaves a larger linear scar along the rib line Op en thoracotomy indications Late presenting empyema with significant pleural fibrous rind Complex empyema and C hronic empyema Fraga JC, Kim P. Surgical treatment of parapneumonic plearl effusion and its complications. J Pediatr 2002;78( Suppl 2):161–73. [

32. Treatment failure and complications Persistent fever - incorrect antibiotic choice or failure of the antibiotics to penetrate the infected lung tissue or cavity. Observe pattern of fever – if improving persist with the chosen treatment regimen Consider lung necrosis and inflammation Additionally in these circumstances, a decrease in white blood cells and C-reactive protein is reassuring. Antibiotics recommended for 5 days after child becomes afebrile followed by oral antibiotics

33. Other complications Persistent lobar collapse - unusual . An indication for bronchoscopy to exclude a foreign body. Bronchopleural fistula occurs occasionally following the insertion of a chest drain or surgery for the treatment of empyema due to the fragility of lung parenchyma, - leads to a persistent air leak. Avoid negative suction on the chest drain - to improve the chances of tissue healing. Very occasionally surgical intervention is required to repair the fistula.

34. OUTPATIENT FOLLOW-UP Follow up until symptomatic resolution and chest X ray has returned to near nomal ( BTS ) The chest radiograph returns to normal in the majority of children (60–83%) by 3 months, in over 90% by 6 months, and in all by 18 months. ( Chan PW, Crawford O, Wallis C, et al. Treatment of pleural empyema. J Pediatr Child Health 2000;36:375–7 ) Immunodeficiency or cystic fibrosis evaluation - History of recurrent bacterial infections or poor growth Cystic fibrosis – esp in S. aureus or Pseudomonas aeruginosa infection

35. TSANZ guidelines

36. Summary A ntero-posterior/posterior-anterior chest X-ray - performed in all children in suspected empyma . There is no need for a routine lateral film. Ultrasound – performed in all empyema Routine pre-operative CT should not be performed - reserved for complicated cases Paediatric Empyema Thoracis : Recommendations for Management - Position statement from the Thoracic Society of Australia and New Zealand.

37. Summary High dose antibiotic therapy Appropriate antibiotics should be used to cover at least Streptococcus pneumonia and Staphylococcus aureus . Moderate to large effusions require drainage. Chest drainage alone is not recommended and the intervention of choice is either percutaneous small bore drainage with urokinase or VATS Oral antibiotics should be given for between 1 and 6 weeks duration following discharge. Final outcome is almost always excellent in children

38. Thank you