Complicated Pneumonias: Why So Complicated

1. Complicated Pneumonias:Why So Complicated? Eric D. Zee Bay Area Pediatric Pulmonary California Pacific Medical Center Children�s Hospital & Research Center Oakland 12 November 2010

2. Complicated versus uncomplicated pneumonias Controversies Imaging Approaches and management Role of Vaccines Necrotizing pneumonias and post infectious pneumatoceles Case study Overview

3. Infective pleural effusions Lung abscess Necrotizing pneumonia

4. Excess liquid caused by disequilibrium of filtration (formation) and absorption (removal) Increased filtration with normal or impaired absorption Normal filtration with impaired absorption Addition of exogenous fluid (intravenous fluid or peritoneal fluid) Pleural Fluid

5. Infection and inflammation damages vascular endothelium and promotes capillary leak Inflammation also promotes increased local blood flow Net liquid and protein transudation Pleural Fluid

6. Fluid in the pleural space secondary to pneumonia Parapneumonic effusion Exudative: high LDH, high protein, low glucose, low pH Empyema Pleural Fluid

7. Staphylococcus aureus in infants less than 2 years Streptococcus pneumoniae most common community acquired Haemophilus influenzae less since vaccine Pseudomonas aeruginosa less commom Anaerobes (Fusobacterium and Bacteroides) rare Organisms

8. S pneumo consistent through the years Since 2000, increased incidence of MSSA, MRSA, Fusobacterium, Pseudomonas and S milleri Organisms

9. Three phases: Exudative stage: low wbc counts Fibrinopurulent stage: more wbc, fibrin, start of loculations Organizational stage : fibrous pleural peel Infective pleural effusion

10. Differing definitions: Uncomplicated: No pleural fluid or necrotic lung versus Exudative stage Complicated: Presence of pleural fluid versus Fibrinopurluent and organizational stages Complicated Versus Uncomplicated Pneumonias

11. Imaging modalities? No consensus on appropriate treatment Surgery way Pediatric way No �trapped lung syndrome� in children unlike adults No restrictive or obstructive lung sequelae Controversy Abounds

12. Plain films (roentgenogram) Upright and decubitus films Easy, readily available, infiltrate and fluid easy to see Intrapleural pathology and parenchymal disease drawbacks Ultrasound Estimate size of effusion Loculations and pleural thickening easy to see Imaging

13. Computed tomography Able to estimate size pleural fluid Detailed information on anatomy and location of disease (parenchymal versus pleural) MRI Detect loculations Differentiates between inflammatory and non inflammatory changes Logistical and availability disadvantages in pediatrics Imaging

14. CT radiation risk is real Ultrasound superior in resolution pleural fluid and loculations CT chest is useful in determining parenchymal disease, necrosis, pneumatocele, abscess CT no additional clinical information not already seen on ultrasound Ultrasound versus CT

15. More emphasis on staging effusions Purulence and fibrin may inhibit simple drainage, small caliber chest tubes Avoid complications and salvage procedures Meta-analysis: operative versus non-operative therapy Non-operative: antibiotics and simple chest tube Operative: VATS, thoracotomy, fibrinolysis The Surgery Way

16. Non-operative therapy: 20 days Fibrinolysis: 10 days VATS: 10 days Failure rate non-operative therapy: 23.6% Length of Stay

17. Although primary operative therapy decreases LOS and failure rate, >76% resolve without surgery. Step-wise approach possible but many favor initial surgery to decrease LOS and morbidity. VATS cost-effective in centers where chest tubes placed in OR. The Surgery Way

18. Better than thoracotomy Not superior than fibrinolysis Consider if clinical symptoms for compressive effects VATS

19. Seattle Children�s Hospital: conservative management Half treated with antibiotics alone Retrospective study: Small effusions: <10mm or <� thorax Large effusions:>10mm or >1/4 thorax Larger effusions required pleural drainage The Pediatric Way Seattle children�s recommended conservative management; they found retrospectively half of cases required antibiotics alone, although these were associated with small effusions.Seattle children�s recommended conservative management; they found retrospectively half of cases required antibiotics alone, although these were associated with small effusions.

20. Pleural interventions Chest tube Chest tube with fibrinolytics VATS No consensus VATS versus fibrinolytics is more efficacious Pleural intervention if clinically ill or CXR shows mediastinal shift The Pediatric Way

21. 28% children with initial simple chest tube required VATS Seattle advocates initial VATS intervention Seattle less experience with fibrinolytics Antibiotics: IV Ceftriaxone and Clindamycin Vancomycin IV if child critically ill Less emphasis on staging effusions The Pediatric Way

22. Mortality and long-term morbidity very low Pleural intervention directed at decreasing short-term morbidity and LOS Surgery papers advocate early intervention LOS with antibiotics alone comparable at 7 days Chest tubes alone may increase LOS Those with chest tubes may take longer time to eventual VATS Length of Stay

23. Children usually do well with antibiotics alone Unusual to require intervention Drainage possible via airways Invasive intervention (needle aspiration, bronchoscopy, wedge resection or lobectomy) Clinical deterioration Mediastinal shift Airway compression Lung Abscesses

24. Increasing incidence since 2000 Increasing detection? Computed tomography readily available Antibiotics able to sterilize pleural fluid Resulting inflammatory reaction Some advocate surgical resection but controversy remains Necrotizing Pneumonia

25. Query increase in S pneumo complicated pneumonias with PCV 7 Studies from Salt Lake City, Alberta and US National database: increased incidence empyema Query serotype replacement: non-vaccine serotypes 5 and 19A more prevalent Query increased MRSA Role of Vaccines