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The treatment of pediatric empyema pneumonia includes both a medical and surgical approach,

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but the decision making and treatment algorithms can be a little complex.

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And that's why today we are going to review the management options with an expert.

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It really changed in the last 10 years about how we take care of this process.

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That's Dr. Aaron Garrison, a pediatric surgeon at Cincinnati Children's Hospital.

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He's going to walk us through everything you need to know about the management and treatment of empyema

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and other paramedic processes in children.

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There are a lot of chest X-rays in this episode, so be sure to watch in the state current app.

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We have all the images posted below the media player.

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Stick around. This is the state current podcast.

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So first, we should review some terminology.

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There are subtle, yet important differences in terms surrounding lung pathology.

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Simple just means fluid.

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Complicated means it needs an intervention, so some kind of chest tube or thoracentesis

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or any kind of intervention puts you into a complicated paraneumonic effusion.

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To take matters further, an empyema patient is required to be able to perform a chest X-ray.

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Further, an empyema refers to perulence or pus in that pleural space.

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Acidotic protein in there because of a lot of inflammation, so the blood vessels are more permeable,

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so you get a lot of exudate in the pleural space, which leads to white cells and pus.

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When considering what causes lung disease in children, we have to look at the numbers.

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Community acquired pneumonia is the leading cause of hospitalization in the US,

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and it's the leading cause of death in children less than five years old worldwide.

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But we can't always nail down that causative pathogen.

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Interestingly, of all the pneumonia that we see, only 15% of those kids will have a bacterial pathogen detected.

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There are some standard pathogens that we should consider as the most common.

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These include staph aureus, strep pneumo, and haemophilus influenzae.

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When there is infection and inflammation from these bugs, things get a little out of whack.

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You get more fluid generated and decreased absorption,

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and so you get an imbalance of fluid and generation of compression in the pleural space.

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So wait, I think I'm missing a few steps.

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Children get infected with one of these bugs. They accumulate pleural fluid.

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But then, how does the empyema form?

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There's three stages of empyema formation.

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So in the first couple days, two to three days is kind of the exudative phase.

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That's when you get fluid generated. It's sterile. It's not infected.

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And it's not for sure that you're going to progress to the next stage,

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but if you still don't have good source control or if the infection progresses,

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then you progress to the next stage.

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Oh, okay. That makes sense.

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But at what stage am I catching this empyema when I get into the operating room?

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The fibrinopurulent stage. And I think this is the one that you see when you're actually in the OR with these patients.

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So that's between two days and two weeks about.

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And that's because those cells that get into the pleural space, they make clot, they make fibrin,

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they make all those white cells just kind of lead to a more purulent, thick environment.

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Scroll down below the media player. We have a link to videos showing the intraoperative VATS view.

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The video sort of shows what the fibrinopurulent stage is like, right?

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So there's all this clot or just plugs. And this is for those of you who aren't in the OR all the time.

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What it looks like when we do a VATS, the lung is just kind of compressed down.

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There's not a whole lot of space between the lung and the chest wall.

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And it's filled with that rind.

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The real problem here is the compromised lung volumes once this collection organizes.

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And so you get a thick rind and your lung becomes entrapped and won't expand.

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There are other pneumatic processes caused by these same bugs.

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So it's staph aureus, the most likely cause of pneumatoceles.

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Scroll down below the media player. There you can see the x-ray of this pneumatocel

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and all the other diagnoses that we'll be talking about today.

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So infectious-wise, I think a pneumatocel you should think staph aureus.

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But kids who have been on oscillators and high ventilatory pressures are more likely to generate them as a result.

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That area of airspace in the right lower lobe looks pretty concerning.

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Interestingly, a lot of these will go away on their own.

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So you don't need to intervene on them unless they're causing shift or get super infected.

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Okay, so pneumatoceles aside, let's say I have a pediatric patient that presents with fevers, cough, unilateral breath sounds, and mild respiratory distress.

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With this history, a two-view chest x-ray is a really good place to start.

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And you're trying to figure out specific characteristics.

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Basically trying to see if there's an effusion, right, if it's going to be free-flowing, if it's loculated, and if you're going to need another study.

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Right, so we got that image and it looks like this. You can also find it below.

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That looks pretty concerning for an effusion. Probably a paraneumatic from the patient history.

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I have a few choices on what imaging comes next.

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The ultrasound is probably better than the CT scan and in fact is more sensitive to pick up whether or not there are septations in the pleural space.

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So we would probably pick an ultrasound as the next test. It also does not have radiation exposure.

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This ultrasound looks pretty septated.

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A lot of these effusions need a chest tube for drainage or even a VATS, but not all of them.

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This is from the American College of Chest Physicians where they look at the size of the effusion on x-ray.

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They look at whether or not you have grown bacteria or not, on thoracentesis, pleural fluid chemistry, and then they make a category and they tell you whether the outcome is high risk or low risk.

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And then those that are severe are recommended drainage.

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While guidelines like that are helpful, always remember to take into account the full clinical picture for each child because when choosing between a VATS and a chest tube for an empyema, there's a lot to consider.

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This is a topic that we've actually covered before with Dr. St. Peter in a previous podcast.

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So after this, be sure to give it a listen and the full article is linked below.

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Their study was this where they had clinical confirmation of an empyema, meaning like white cells greater than 10,000.

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They put in one chest tube, they do three doses of TPA, and then they would ultrasound their CT and see whether or not they need to go on to VATS or just continue antibiotics.

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This study is pretty practice changing.

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It shows that a chest tube and fibrinolynic such as tissue plasminogen activator or a TPA are not inferior to the standard VATS when looking at clinical outcomes.

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What they found was that there was really no difference in hospital admissions, decreased cost with the chest tube, and that really overall kids just get less sick when you're not doing a VATS on them.

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The trends are pretty clear. The rate of primary VATS are going down and the rate of chest tubes of TPA are going up.

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The rate of patients that fail chest tubes of TPA that then require a VATS, they're about the same around 5%.

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But we don't have an algorithm to predict those cases successfully yet.

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The published protocol by Dr. St. Peter was three days of TPA, 24 hours apart.

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At Cincinnati Children's we have a slightly different protocol. We give six doses 12 hours apart.

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And additionally, we don't use DNAs.

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DNAs is just amycolytic. It just breaks up and works differently. But there was a study in kids that it didn't make much difference.

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Now, we cannot go through a lecture without Dr. Todd Ponsky's input on how these ideas can change his clinical practice.

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And he's right. We need to think about how are we going to select which kids go down this TPA algorithm in the first place.

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For some, a chest tube alone could control their symptoms.

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Take a patient. They have a clear effusion. They're sick. You put in a drainage tube and you don't do TPA.

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You just watch them for the next 24 hours. And if they're not getting sick, you don't give TPA. You just watch them.

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So if they're getting better, they may not need TPA. But if they don't clinically improve in 24 hours, we should proceed with the TPA protocol.

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This is a newly revised algorithm at Cincinnati Children's to include all of these treatment pathways.

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Don't worry. We've linked it below. But remember, there are some contraindications to TPA usage.

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Those are the two main contraindications, necrotizing pneumonia, bronchocleral fistulas, and then significant parenchymal disease and chronic changes are relative contraindications.

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Now, for these kids that fail a TPA and chest tube approach, they're still going to need a VATS for definitive therapy.

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And that does account for some kids. When positioning these kids in the operating room, remember to position them appropriately.

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Put them in the lateral decubitus position with an axillary roll.

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Proper positioning in a small child can really help open up the chest. Let's see what it looks like when you get inside.

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And then this is really what a decortication is. Once you get down to all the peel, you just take that off the lung so that it expands.

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Now, often, empyemas and effusions are a paraneumatic process from infectious pathogens that cause pneumonia.

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But for young kids, think ages one to three, we can't forget the chance of an airway foreign body.

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Those can also cause recurrent infections and chronic pneumonia.

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The most common culprit? Peanuts. And peanuts can't be seen on chest x-ray.

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Initial imaging for an airway foreign body can look like air trapping, but you need a high index of suspicion for these patients because finding the foreign body on x-ray is pretty rare.

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And a normal chest x-ray can't rule out a foreign body aspiration.

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That's why these kids usually end up in the operating room for bronchoscopy and removal of that foreign body.

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If you have a high index of suspicion, every kid pretty much went to the OR for a bronch.

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The thing is, the majority of these kids hadn't aspirated at all.

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And so Dr. Pomsky looked into figuring out if we could diagnose foreign body aspiration another way.

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New literature is showing that a CT scan has, in our study, 100% reliability to show you an airway foreign body, both positive and negative predictive value.

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In this study, only about 40% of patients who had bronchoscopy for an inhaled foreign body actually had one present.

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And the majority of the other 60% of patients, they had reactive airway disease.

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And that was only made worse by the intraoperative manipulation by bronchoscopy.

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Instead, CT imaging could be used to diagnose inhaled foreign body before taking them to the operating room.

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Even with the minimal amount of radiation exposure, this approach saves operating room time, sedation, and cost for a large proportion of children.

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Check out the linked article below.

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Okay, let's switch gears and talk about another infectious lung pathology.

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Air fluid level, it's a pulmonary abscess.

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I got a CT scan to confirm that.

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For otherwise healthy kids with a pulmonary abscess, they don't need surgical treatment at all.

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Take home message, pulmonary abscess is almost always respond to just antibiotics, don't need drainage.

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Drainage and pulmonary abscesses can lead to bronchopluoro-fistula, and those can lead to a persistent air leak.

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Sometimes they close on their own, but other times they may require advanced intervention, maybe a bronchovalve or tesseal.

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Thanks for joining us for a view of the management of pediatric empyema and other pneumatic pathology.

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Remember, check the link below for access to the entire lecture and to find the articles discussed in this episode, along with the images.

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Tell us what you like, what you didn't like, what do you want to hear about in future episodes?

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Until then, this is Brittany, and remember, knowledge should be free.