Synchronous bilateral VATS decortication for paediatric bilateral empyema

Bilateral empyema is a rare condition in children. In the current era of minimally invasive surgical treatment, our experience with two cases suggests that video thoracoscopic drainage and decortication for children with bilateral empyema is safe, effective, and potentially less expensive.     

Life-Threatening Chest Injuries in Children

The clinician caring for the pediatric trauma patient should be aware that thoracic injuries are encountered relatively infrequently and can be difficult to diagnose but are associated with a high degree of lethality. Judicious use of appropriate laboratory and radiographic studies, in combination with a high degree of clinical suspicion and close observation, are required in any pediatric patient who presents with significant blunt or penetrating trauma involving the thorax.     

Neonatal pleural empyema with group A Streptococcus

Abstract A case of early neonatal septicaemia with pneumonia and pleural empyema is reported. The causal microorganism was β-haemolytic Streptococcus pyogenes group A originating from the mother, who had a perineal infection and bacteraemia.     

Imaging of parapneumonic pleural effusions and empyema in children

Pleural empyema in children is increasing in incidence. The British Thoracic Society published guidelines for the management of empyema in children in 2005, including recommendations regarding imaging. In this article we review the pathophysiology, treatment options and imaging findings of complicated parapneumonic effusion and empyema in children. We also review the published evidence that supports the roles imaging is called upon to play in the management of these conditions. Imaging in the form of chest radiography and US is recommended to identify and guide drainage of complicated parapneumonic effusions. CT is recommended in special circumstances only. Imaging techniques have not been shown to accurately stage empyema, predict outcome or guide decisions regarding surgical versus medical management.     

Evolving experience in the management of pleural empyema.

The objective of this study was to determine treatment strategies for children admitted with pleural empyema. We reviewed the medical records of 93 consecutive patients with pleural empyema who presented in the last three years. Mean age was 3.8 years (range 3.5 months to 14 years) and the male to female ratio was 52 : 41. The left side was involved in 51 (54.8 %) cases and there was only one case with bilateral effusion. After the chest X-ray and analysis of pus obtained by thoracocentesis, the initial treatment modality was chest tube drainage in 81 (87 %) patients. Children required chest tube drainage for an average of 11.9 +/- 4.8 days. Out of the 81 children, 6 needed thoracotomy due to organized pleural fluid and another 4, who developed loculated pleural effusions, were treated with intrapleural urokinase (UK) administration. Twelve children, who had a delayed presentation with organized loculated pleural fluid and pleural thickening, underwent decortication and one, who was found to have a foreign body, found during surgery, needed an upper lobe resection. Medical management with adequate chest tube drainage and appropriate antibiotics has resulted in full resolution in the majority of patients with empyema. In cases of loculated pleural effusions identified at the early stages of the chest tube drainage, intrapleural UK administration was found to be a safe and efficient treatment modality. Thoracotomy should be reserved for late and organized empyema cases.     

Intrapleural urokinase therapy in a neonate with pleural empyema

Pleural empyema is rare in neonates, and treatment with systemic antibiotics and tube drainage may fail because of the thick viscous fluid, bacterial products with fibrin deposition, and multiple loculations. Intrapleural fibrinolytic therapy with urokinase is an effective and non‐invasive treatment option that avoids surgical intervention, although its use in neonates has not been studied extensively. In this report, we describe the case of a 13‐day‐old male neonate with Escherichia coli sepsis and pneumonia, which rapidly progressed to parapneumonic effusion and pleural empyema. After inadequate response to i.v. antibiotics and chest tube drainage, the patient was successfully treated with intrapleural urokinase.     

Neonatal pleural empyema caused by emm type 6 group A streptococcus

Since the mid‐1980s, there have been increasing reports of severe invasive group A streptococcal (GAS) disease in children and adults. There are few reports, however, of neonatal invasive disease, particularly neonatal pleural empyema caused by GAS. Although many mechanisms have been reported for the pathophysiology of invasive GAS infections, similar reports for neonates were unable to be located. Reported herein is the case of a 3‐day‐old girl with pleural empyema caused by GAS that demonstrated a high invasive capacity for human epithelial cells.     

Induction of pleural empyema in rats by thoracentesis with intrapleural pressure monitoring

Our objective was to evaluate experimental induction of empyema in rats by intrapleural inoculation of Staphylococcus aureus by means of thoracentesis with pleural pressure monitoring. Forty female albino Wistar rats, anesthetized with droperidol and fentanyl, underwent intrapleural inoculation of a 0.2-ml solution. Group I (N=25) received 10¹⁰ colony-forming units/ml of Staphylococcus aureus cultivated in brain-heart infusion agar (BHI); group II (N=15), the control group, received sterile BHI agar. Rats were inoculated after right hemithorax thoracentesis with a needle connected to an oscilloscope for pressure monitoring to confirm that the needle was inside the pleural space. Animals were killed after 3 (groups Ia and IIa) to 5 (groups Ib and IIb) days with sodium pentobarbital. The macroscopic changes, amount of pleural fluid, and anatomopathological aspects of pleura and lungs were recorded, as well as death causes and bacteriological findings of pleural fluid for animals that died before the time established for euthanasia. In group I, three animals died of thoracentesis complications, and five others died in the first 24 h due to septicemia; blood and spleen cultures isolated the bacteria previously inoculated. In group II, there was one death of unknown cause. Of the 17 rats inoculated with bacteria, nine (group Ia) were killed on the 3rd day; all had bacteria in pleural fluid (volume 0.5–3.8 ml). The other eight rats (group Ib) were killed on the 5th day; three (39.5%) had pleural fluid with bacteria (0.5–1.5 ml), and five (60.5%) had no pleural fluid. Rats from group II killed on the 3rd (group IIa) and 5th (group IIb) days had no pleural fluid. Pathologic examination revealed inflammatory infiltrate (93.75%) and fibrin (18.75%) in pleura, and inflammatory interstitial infiltrate (12.5%) in the right lung in group I; no changes were observed in 93.3% of the lungs in group II. Macroscopic examination revealed only turbid and bloody pleural fluid (class I) without pleural adhesions. Pleural inflammatory infiltrate was found in rats that received the bacteria but had no fluid at necropsy (class 0). One control rat, although with no clinical signs of disease or pleural fluid, had signs of pleural and pulmonary infection at necropsy. We conclude that empyema may be induced in rats by the inoculation of Staphylococcus aureus by means of thoracentesis with pleural pressure monitoring. The highest amount of pleural fluid was observed 3 days after bacterial inoculation.     

Paediatric complicated pneumonia: Diagnosis and management of empyema

Pneumonia can be complicated by an empyema, progressing from an exudative effusion, to a fibrinopurulent stage with loculations, and then organized with a thick fibrinous peel. The predominant causative organisms are Streptococcus pneumoniae, Staphyloccocus aureus (including methicillin-resistant S aureus) and Streptococcus pyogenes. Recently, an increased incidence of paediatric complicated pneumonia has been reported. For diagnostic imaging, a chest radiograph followed by a chest ultrasound is preferred. Computed tomography chest scans, with associated radiation, should not be routinely used. Antibiotic coverage should treat the most common causative organisms. Additional invasive or surgical management is recommended to reduce the duration of illness in cases not promptly responding to antibiotics or with significant respiratory compromise. Choice of management should be guided by best evidence and local expertise. Video-assisted thorascopic surgery or insertion of a small-bore percutaneous chest tube with instillation of fibrinolytics are the best current options.     

Lung Perforation by Chest Tubes in the Neonate

In 272 consecutive neonatal autopsies in one institution, 70 patients had had intercostal drainage tubes inserted to treat air leak secondary to pulmonary disease. In 9 of these cases, one or more chest tubes penetrated lung parenchyma. The majority of these occurred in infants less than 36 weeks' gestation with hyaline membrane disease and its sequelae. Laceration of lung parenchyma most commonly occurred when tubes were inserted on the left side at 5 days or later and when multiple tubes were inserted.     

Management of thoracic empyema in childhood: does the pleural thickening matter?

AIMS: To determine the clinical course and long term outcome of empyema treated without decortication. METHODS: Fourteen consecutive admissions to one hospital were studied; radiological resolution and lung function were subsequently followed. The children were aged 2-14 years. All were treated with intravenous antibiotics and chest drain only. RESULTS: All patients had extensive pleural thickening evident on chest x ray examination at the time of discharge, which resolved entirely over a period of 2-16 months. Lung function was measured in 13 children, and showed no evidence of restrictive or obstructive deficit: mean (SD) values as per cent predicted for height were: forced expiratory volume in one second (FEV1) 107.5 (9.6), forced vital capacity (FVC) 95.5 (8.8), total lung capacity (TLC) 98.6 (20.7). Individual children all had values in the normal range (80-120 per cent predicted). CONCLUSION: Results suggest that decortication is not necessary in children to prevent long term problems with pleural thickening, and should be undertaken on the basis of the clinical picture (failure of fever resolution), rather than radiological appearance.     

Cardiac tamponade in a preterm neonate secondary to a chest tube

In a preterm infant, chest tubes were inserted for treatment of bilateral pneumothoraces. Hemorrhagic pericardial effusion with cardiac tamponade developed, probably resulting from traumatic injury by the left chest tube. The infant survived due to timely diagnostic and therapeutic intervention. No recurrence of pericardial effusion was seen and follow-up showed normal psychomotor development.