# Empyema — GCMD Library living collection

Everything in the library about empyema — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 79 cited statements

## Episodes
### Medical Management
- [Empyema with Dr. Shawn St. Peter](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932) — podcast · 36:37 · [machine version](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932.md)
- [Empyema with Dr. Shawn St. Peter](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312) — podcast · 36:37 · [machine version](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312.md)

### In-Depth Reviews
- [Empyema and Pneumothorax: Update Course 2014](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646) — video · 31:32 · [machine version](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=0) Introduction and Dr. St. Peter's Background (Ep 3)
- [1:45](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=105) Initial Assessment and Diagnostic Approach (Ep 3)
- [7:39](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=459) Randomized Trial Results: VATS versus Fibrinolysis (Ep 3)
- [16:59](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1019) TPA Protocol and Supporting Evidence (Ep 3)
- [20:26](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1226) Practical Implementation and Monitoring (Ep 3)
- [23:46](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1426) Defining and Managing Fibrinolysis Failure (Ep 3)
- [29:11](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1751) Pulmonary Necrosis and Contraindications to Surgery (Ep 3)
- [34:27](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=2067) Pulmonary Abscess Management and Alternative Agents (Ep 3)
- [0:00](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=0) Empyema case presentation and initial management debate (Ep 1)
- [5:32](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=332) Evidence review: fibrinolytic therapy versus VATS (Ep 1)
- [10:49](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=649) Clinical decision-making: timing and patient selection (Ep 1)
- [15:06](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=906) Ultrasound limitations and intraparenchymal disease (Ep 1)
- [16:47](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1007) Spontaneous pneumothorax: small pneumothorax management (Ep 1)
- [20:50](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1250) Large pneumothorax and role of CT imaging (Ep 1)
- [24:14](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1454) VATS technique and pleurodesis strategies (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=0) Introduction and Guest Background (Ep 2)
- [1:45](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=105) Initial Assessment and Diagnostic Approach (Ep 2)
- [6:50](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=410) Randomized Trial Design and Results (Ep 2)
- [11:09](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=669) Antibiotic Duration Protocol (Ep 2)
- [15:08](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=908) Fibrinolysis Protocol and Supporting Evidence (Ep 2)
- [20:26](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1226) Sedation Considerations and Post-Treatment Monitoring (Ep 2)
- [23:46](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1426) Management of Treatment Failure (Ep 2)
- [29:21](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1761) Pulmonary Necrosis and Abscess Management (Ep 2)
- [34:27](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=2067) Alternative Fibrinolytic Agents and Closing (Ep 2)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Ultrasound has no disadvantage compared to CT for diagnosing empyema and identifying pleural stranding, and prospective studies show that placing ultrasound before CT decreases CT utilization without changing outcomes. — Shawn St. Peter (clinical) [Ep 3 · 15:16](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=916)
- Empyema is defined by pleural fluid with greater than 10,000 white blood cells, which was the enrollment criterion used in the randomized trial. — Shawn St. Peter (clinical) [Ep 3 · 6:50](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=410)
- When pleural fluid has >10,000 white cells and the patient undergoes VATS, the pleural space appearance is consistent with typical empyema. — Shawn St. Peter (clinical) [Ep 3 · 7:02](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=422)
- The randomized trial at Children's Mercy compared primary VATS to primary fibrinolysis and found no difference in length of stay, with a 16% failure rate in the fibrinolysis group. — Shawn St. Peter (clinical) [Ep 3 · 7:39](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=459)
- Great Ormond Street published a study of 60 patients using urokinase with 4-hour dwell time that found identical results: no difference in length of stay and a 1 in 6 (approximately 16%) failure rate. — Shawn St. Peter (clinical) [Ep 3 · 17:34](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1054)
- A Spanish randomized trial of 100 patients using urokinase found no difference in length of stay and a 15% failure rate, consistent with prior studies. — Shawn St. Peter (clinical) [Ep 3 · 19:14](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1154)
- Three randomized trials totaling 200 patients all show the same results: no difference in length of stay between VATS and fibrinolysis, with 15-16% failure rate for fibrinolysis. — Shawn St. Peter (clinical) [Ep 3 · 19:14](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1154)
- In 100 consecutive patients treated with fibrinolysis after the trial, there was no difference in operative time or blood loss for patients who required subsequent VATS compared to primary VATS, contradicting concerns that fibrinolysis makes subsequent surgery more difficult. — Shawn St. Peter (clinical) [Ep 3 · 19:14](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1154)
- The TPA protocol is 4mg mixed in 40mL normal saline, instilled into a 12 French chest tube with 1-hour dwell time, repeated at 24 and 48 hours (three doses total over 48 hours). — Shawn St. Peter (clinical) [Ep 3 · 16:03](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=963)
- Patients do not get sicker with fibrinolysis, unlike VATS where barrel trauma to the good lung and manipulation of the bad lung can cause patients to 'fly pretty close to the treetop' postoperatively. — Shawn St. Peter (opinion) [Ep 3 · 9:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=580)
- Daily chest X-rays after fibrinolysis are not useful because the chest will look bad for quite a while even after completing treatment, and X-ray appearance does not help determine if fibrinolysis has failed. — Shawn St. Peter (clinical) [Ep 3 · 23:25](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1405)
- Failure of fibrinolysis should be defined by persistent clinical illness (oxygen requirement, poor feeding) at 3-4 days after treatment, not by fever alone, since fever may be due to parenchymal disease. — Shawn St. Peter (clinical) [Ep 3 · 23:57](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1437)
- A second round of fibrinolysis is only indicated when imaging shows a walled-off collection not in continuity with the initial chest tube placement; if the tube is well-positioned and there is persistent pleural disease in continuity with the tube, a second round is not recommended. — Shawn St. Peter (clinical) [Ep 3 · 26:42](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1602)
- Extensive pulmonary necrosis is an absolute contraindication to surgical intervention because manipulating necrotic lung risks protracted bronchopleural fistulas requiring Heimlich valves for months. — Shawn St. Peter (clinical) [Ep 3 · 26:53](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1613)
- Bronchopleural fistulas only occur when operating in a field of necrosis and debriding that necrosis; peripheral lung lesions heal without this complication. — Shawn St. Peter (clinical) [Ep 3 · 26:53](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1613)
- During VATS for failed fibrinolysis, if the lung appears necrotic (black, necrotic-appearing), it should be left alone and only the pleural space should be debrided. — Shawn St. Peter (clinical) [Ep 3 · 29:11](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1751)
- A patient with complete unilateral pulmonary necrosis who underwent needle biopsy died from exsanguination into the wound and bronchi, demonstrating that necrotic lung does not tolerate being touched. — Shawn St. Peter (clinical) [Ep 3 · 29:50](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1790)
- A 3-year-old with bilateral pulmonary necrosis requiring VV ECMO for almost a month survived without surgical intervention and left the hospital without oxygen, demonstrating that necrotic lung heals with conservative management. — Shawn St. Peter (clinical) [Ep 3 · 31:21](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1881)
- Well-defined peripheral pulmonary abscesses can be drained percutaneously with a drain left in place, but multifocal or complex abscesses should be managed conservatively like necrosis. — Shawn St. Peter (clinical) [Ep 3 · 32:06](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1926)
- At Children's Mercy, the average duration of antibiotics was 25 days total with 19 days after becoming afebrile, and 40% of patients had complications from antibiotic therapy including diarrhea and fungal superinfections. — Shawn St. Peter (clinical) [Ep 3 · 11:41](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=701)
- The current antibiotic protocol at Children's Mercy is 7 days after meeting three criteria: completed fibrinolysis, off oxygen, and afebrile. Antibiotics can be switched to oral if the patient is a candidate. — Shawn St. Peter (clinical) [Ep 3 · 13:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=780)
- Recurrent empyema after successful treatment is extremely rare because the pleural space is typically obliterated (cemented space), making randomized trials of antibiotic duration unfeasible due to zero event rate. — Shawn St. Peter (clinical) [Ep 3 · 13:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=780)
- In the United States, TPA is the only available fibrinolytic agent for empyema since urokinase is not available and streptokinase has come off the market. — Shawn St. Peter (clinical) [Ep 3 · 34:27](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=2067)
- A randomized trial in adults suggested more rapid clearance by adding DNase to fibrinolytic therapy, but DNase is not approved for intrapleural use and requires an IND for pediatric study. — Shawn St. Peter (clinical) [Ep 3 · 34:37](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=2077)
- Mary Anne Jackson, an infectious disease physician, recommended the >10,000 white cell entry criterion for the trial, which initially seemed too soft but proved completely correct. — Shawn St. Peter (clinical) [Ep 3 · 4:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=280)
- When comparing an operation to a non-operative approach, if results are equal, there is no way to recommend the operation and no parent would choose surgery when outcomes are the same. — Shawn St. Peter (opinion) [Ep 3 · 18:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1100)
- Placing a 12 French chest tube under ultrasound guidance is less invasive and faster than placing a PICC line, taking less than a minute. — Shawn St. Peter (clinical) [Ep 3 · 21:06](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1266)
- In older children who are not severely tachypneic, chest tube placement can be performed with local anesthetic alone without sedation. — Shawn St. Peter (clinical) [Ep 3 · 22:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=1340)
- Stage 2 empyema is defined by loculated pleural effusion with greater than 100,000 white cells — Dan Ostlie (clinical) [Ep 1 · 3:51](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=231)
- Once stage 2 empyema is present, antibiotics alone are insufficient and intervention is needed to remove fibrinous exudate — Dan Ostlie (clinical) [Ep 1 · 3:51](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=231)
- The Kansas City trial using TPA showed length of stay 6.8 days, cost $11.6K, 7.5% complication rate, and 15% failure rate — Dan Ostlie (clinical) [Ep 1 · 7:09](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=429)
- Both fibrinolytic trials demonstrate 85% success rate, meaning 15% of patients require subsequent surgical intervention — Dan Ostlie (clinical) [Ep 1 · 8:14](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=494)
- In the Kansas City VATS cohort, 2 children required oscillator support and 1 developed renal failure requiring hemodialysis; no such complications occurred in the TPA arm — Dan Ostlie (clinical) [Ep 1 · 11:30](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=690)
- Post-operative illness after empyema VATS is primarily due to underlying pneumonia rather than residual pleural disease — Arnie (clinical) [Ep 1 · 9:09](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=549)
- Percutaneous Seldinger-type chest tubes can be placed at bedside under local anesthesia with minimal sedation in approximately 2 minutes (clinical) [Ep 1 · 13:40](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=820)
- Ultrasound can sometimes fail to distinguish intraparenchymal necrotic lung from pleural effusion, requiring CT for accurate diagnosis — Dan Ostlie (clinical) [Ep 1 · 15:47](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=947)
- Intraparenchymal lung necrosis requires antibiotic therapy only and does not need surgical intervention — Arnie (clinical) [Ep 1 · 16:04](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=964)
- Oxygen supplementation for small pneumothorax is standard practice though its efficacy is uncertain (opinion) [Ep 1 · 17:26](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1046)
- Simple aspiration of pneumothorax may seal a tiny hole or relieve symptoms, but risks creating a larger pneumothorax if a needle is used (clinical) [Ep 1 · 18:17](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1097)
- Spontaneous pneumothorax is rare in children under 16 years old and predominantly occurs in teenagers approaching adulthood — Todd Ponsky (epidemiological) [Ep 1 · 20:50](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1250)
- Nearly all teenage patients with spontaneous pneumothorax have apical blebs visible on imaging — Arnie (clinical) [Ep 1 · 21:17](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1277)
- Patients with spontaneous pneumothorax typically have asthenic body habitus with thin chest capacity — Todd Ponsky (clinical) [Ep 1 · 21:57](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1317)
- CT imaging for pneumothorax allows visualization of blebs and assessment of the contralateral lung (clinical) [Ep 1 · 22:36](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1356)
- Before the era of VATS, the standard was to wait for a second pneumothorax before performing anterior thoracotomy for bleb resection and pleural abrasion — Dan Ostlie (clinical) [Ep 1 · 24:25](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1465)
- Current practice is more aggressive, with many surgeons performing VATS on first pneumothorax rather than waiting for recurrence — Todd Ponsky (clinical) [Ep 1 · 24:44](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1484)
- Standard VATS technique for pneumothorax includes apical wedge resection and mechanical pleurodesis by roughing the pleura with a scratch pad — Todd Ponsky (clinical) [Ep 1 · 26:12](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1572)
- Talc pleurodesis distributes uniformly throughout the chest during thoracoscopy but creates dense adhesions that make future thoracic surgery extremely difficult, sometimes requiring retropleural approach — Todd Ponsky (clinical) [Ep 1 · 27:02](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1622)
- Mechanical pleurodesis is considered adequate when small blood vessels become prominent on the pleural surface — Dan Ostlie (clinical) [Ep 1 · 28:15](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1695)
- Some surgeons perform mechanical pleurodesis on both visceral and parietal pleura, though this may increase air leak risk — Todd Ponsky (clinical) [Ep 1 · 27:02](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1622)
- A study of 350 patients undergoing lung procedures (not specifically pneumothorax) showed no complications when chest tubes were omitted post-operatively — Todd Ponsky (clinical) [Ep 1 · 29:20](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1760)
- Reliable post-operative nursing surveillance is essential when omitting chest tubes after pneumothorax surgery to detect early re-accumulation — Todd Ponsky (clinical) [Ep 1 · 29:20](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1760)
- Ultrasound has no disadvantage compared to CT for diagnosing empyema and identifying pleural stranding, and prospective studies show that placing ultrasound before CT decreases CT utilization without changing outcomes. — Shawn St. Peter (clinical) [Ep 2 · 15:16](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=916)
- Greater than 10,000 white blood cells in pleural fluid tap was used as the empyema definition and enrollment criterion for the randomized trial, and patients meeting this criterion who were randomized to VATS had findings consistent with typical empyema on thoracoscopy. — Shawn St. Peter (clinical) [Ep 2 · 7:02](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=422)
- The randomized trial comparing primary VATS to primary fibrinolysis showed no difference in length of stay between the two groups. — Shawn St. Peter (clinical) [Ep 2 · 17:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1040)
- The failure rate for fibrinolysis in the Kansas City randomized trial was 1 in 6 (approximately 16%). — Shawn St. Peter (clinical) [Ep 2 · 17:50](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1070)
- In 100 consecutive patients treated with fibrinolysis after the randomized trial, the results remained consistent with a 15% failure rate and similar length of stay. — Shawn St. Peter (clinical) [Ep 2 · 20:10](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1210)
- There was no difference in operative time or blood loss in patients who underwent VATS after failed fibrinolysis compared to those who had primary VATS. — Shawn St. Peter (clinical) [Ep 2 · 20:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1240)
- When you are not getting an advantage from an operation compared to not doing an operation, and the results are equal, there is no way to recommend the operation. — Shawn St. Peter (opinion) [Ep 2 · 19:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1140)
- The fibrinolysis protocol uses 4 mg of TPA mixed into 40 mL of normal saline, instilled into the chest tube with a one-hour dwell time, administered at time of diagnosis, 24 hours, and 48 hours (three doses over 48 hours). — Shawn St. Peter (clinical) [Ep 2 · 16:59](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1019)
- Historical antibiotic practice at Children's Mercy showed an average of 25 days total antibiotics with 19 days after becoming afebrile, and 40% of patients had complications from antibiotic therapy ranging from diarrhea to fungal superinfections. — Shawn St. Peter (epidemiological) [Ep 2 · 11:41](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=701)
- The current antibiotic protocol is 7 days after meeting all three criteria: completed fibrinolysis, off oxygen, and afebrile. — Shawn St. Peter (clinical) [Ep 2 · 13:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=820)
- Once empyema is treated, the chance of having another empyema is next to none because it is typically a cemented space, resulting in a zero historical event rate for recurrence. — Shawn St. Peter (clinical) [Ep 2 · 13:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=780)
- Patients with fibrinolysis never got sicker during treatment, whereas patients undergoing VATS sometimes fly pretty close to the treetop after the operation due to barotrauma to the good lung and manipulation of the bad lung. — Shawn St. Peter (clinical) [Ep 2 · 10:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=640)
- Failure of fibrinolysis should be defined by persistent clinical illness (requiring oxygen or not eating well) rather than fever alone, typically assessed at 3-4 days after completing treatment. — Shawn St. Peter (clinical) [Ep 2 · 25:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1540)
- A second round of fibrinolysis is indicated only when there is a temporal and regional explanation for failure, such as a walled-off collection not in continuity with the initial chest tube location. — Shawn St. Peter (clinical) [Ep 2 · 25:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1520)
- Patients with extensive pulmonary necrosis should not undergo operative intervention because you risk hurting them much more than helping by manipulating the lung. — Shawn St. Peter (clinical) [Ep 2 · 26:53](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1613)
- Protracted courses with bronchopleural fistulas and Heimlich valves for months only occur when operating in a field of necrosis and debriding that necrosis, getting into the proximal lung rather than peripheral lesions which heal. — Shawn St. Peter (clinical) [Ep 2 · 27:30](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1650)
- During VATS for empyema, if the lung looks necrotic, the principle is to leave the lung alone and clean out the pleural space only. — Shawn St. Peter (clinical) [Ep 2 · 29:21](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1761)
- A patient with complete pulmonary necrosis who underwent needle biopsy died by exsanguinating out of the wound and into the bronchi, demonstrating that necrotic lung does not tolerate being touched. — Shawn St. Peter (clinical) [Ep 2 · 30:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1840)
- A 3-year-old patient with bilateral pulmonary necrosis stayed on VV ECMO for almost a month with CT showing hardly any viable lung on either side, did not undergo surgery, came off ECMO and did fine, and would not have survived if anyone had tried to operate. — Shawn St. Peter (clinical) [Ep 2 · 31:21](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1881)
- Necrotic lung heals remarkably well without surgical intervention, as demonstrated by a patient with no viable lung on either side after two weeks of ECMO who left the hospital without oxygen. — Shawn St. Peter (clinical) [Ep 2 · 33:57](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=2037)
- A well-defined peripheral pulmonary abscess can be drained if it is well out into the lung parenchyma with a thick rind, ensuring you are getting into abscess and not airway. — Shawn St. Peter (clinical) [Ep 2 · 32:54](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1974)
- Multifocal abscesses and complex abscesses can be treated like necrosis by being patient, and even fields of abscesses in patients with underlying disease will typically heal up. — Shawn St. Peter (clinical) [Ep 2 · 32:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1940)
- Chest tube alone for empyema is not adequate treatment. — Shawn St. Peter (clinical) [Ep 2 · 11:09](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=669)
- Chest X-rays after completing fibrinolysis are not terribly useful because they will look pretty bad for quite a while and are not helpful in discerning whether a patient is a candidate for VATS after failed fibrinolysis. — Shawn St. Peter (clinical) [Ep 2 · 23:25](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1405)
- Available fibrinolytic agents worldwide are urokinase or TPA, and since urokinase is not available in the US after streptokinase came off the market, TPA is the only option in the United States. — Shawn St. Peter (clinical) [Ep 2 · 34:27](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=2067)
- For older children, chest tube placement can be done with local anesthetic injection alone without sedation, as it can be completed in less than a minute. — Shawn St. Peter (clinical) [Ep 2 · 22:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1360)
- When sedation is required for chest tube placement, it can be done in the operating room without intubation or positive pressure ventilation using a needle-guided 12-French chest tube, which is less involved than placing a PICC line. — Shawn St. Peter (clinical) [Ep 2 · 21:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1300)
- Performing limited debridement with VATS when general anesthesia is required nullifies some advantages of fibrinolysis because mechanical debridement kicks up the serum response and positive pressure ventilation affects the other lung. — Shawn St. Peter (opinion) [Ep 2 · 21:06](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1266)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- The IDSA community-acquired pneumonia guidelines recommend 10 days of antibiotics after becoming afebrile, but this is a grade D recommendation based on no data. — Shawn St. Peter summarizing a resource [Ep 3 · 11:20](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=680)
- Ted Carter and colleagues from Seattle proposed an algorithm for pleural effusions categorizing them as small (<25%), moderate (25-50%), or large (>50%), with symptomatic versus asymptomatic branches under each category. — Shawn St. Peter summarizing a resource [Ep 3 · 5:10](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-312?t=310)
- A meta-analysis of 170 patients showed primary VATS (M3 arm) had better outcomes than chest tube with fibrinolytic followed by delayed thoracoscopy/thoracotomy, but the VATS cases were concentrated in later years creating temporal bias — Dan Ostlie summarizing the discussion [Ep 1 · 5:32](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=332)
- A trial of 60 patients comparing urokinase versus saline with small versus large drains showed small tube with urokinase performed better than other combinations, with no operations required — Dan Ostlie summarizing the discussion [Ep 1 · 7:09](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=429)
- The London (Great Ormond Street) trial using urokinase showed length of stay 6 days, cost 13 (units unclear), 9% complication rate, and 16% failure rate — Dan Ostlie summarizing the discussion [Ep 1 · 7:09](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=429)
- Length of stay is identical between TPA and VATS groups even though TPA numbers include intention-to-treat analysis with all failures who required subsequent VATS — Todd Ponsky summarizing the discussion [Ep 1 · 10:10](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=610)
- A 5–10% apical pneumothorax in a minimally symptomatic patient should be observed with oxygen supplementation — Todd Ponsky summarizing the discussion [Ep 1 · 17:08](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1028)
- 2001 Adelphi consensus guidelines stated there was no role for simple aspiration in pneumothorax management — Dan Ostlie summarizing a resource [Ep 1 · 19:50](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1190)
- 2010 British Thoracic Society guidelines recommend simple aspiration as first-line therapy for pneumothorax — Dan Ostlie summarizing a resource [Ep 1 · 19:50](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1190)
- A Cochrane review (2007) with one RCT comparing manual aspiration versus chest tube in patients aged 16 and older showed 59% immediate success rate with aspiration, 50% avoided hospitalization, and no difference in overall hospital stay or recurrence rate — Dan Ostlie summarizing the discussion [Ep 1 · 19:50](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1190)
- In adult thoracic surgery practice, the standard approach is to treat the symptomatic side with blebs and monitor the contralateral side, intervening only if a second pneumothorax develops — Arnie summarizing the discussion [Ep 1 · 23:38](https://qa.library.globalcastmd.com/watch/empyema-and-pneumothorax-update-course-2014-646?t=1418)
- The Great Ormond Street study by Sannapa et al enrolled 60 patients and found the same results as the Kansas City trial: no difference in length of stay and a 1 in 6 failure rate, using urokinase with a 4-hour dwell time. — Shawn St. Peter summarizing a resource [Ep 2 · 18:10](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1090)
- A Spanish randomized trial of 100 patients using urokinase found no difference in length of stay and a 15% failure rate, consistent with the other two trials. — Shawn St. Peter summarizing a resource [Ep 2 · 19:40](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=1180)
- The IDSA community-acquired pneumonia guidelines recommended 10 days of antibiotics after becoming afebrile, which was a grade D recommendation based on no data whatsoever. — Shawn St. Peter summarizing a resource [Ep 2 · 12:00](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=720)
- A randomized trial in adults suggested more rapid clearance by adding Dornase (DNase) to fibrinolytic therapy, but it is not approved for intrapleural use in the US and requires an IND for study. — Shawn St. Peter summarizing a resource [Ep 2 · 34:50](https://qa.library.globalcastmd.com/watch/empyema-with-dr-shawn-st-peter-932?t=2090)

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