Empyema with Dr. Shawn St. Peter

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.

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.

Chest tube alone for empyema is not adequate treatment.

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.

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.

The current antibiotic protocol is 7 days after meeting all three criteria: completed fibrinolysis, off oxygen, and afebrile.

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.

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).

The randomized trial comparing primary VATS to primary fibrinolysis showed no difference in length of stay between the two groups.

The failure rate for fibrinolysis in the Kansas City randomized trial was 1 in 6 (approximately 16%).

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.

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.

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.

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.

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.

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.

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.

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.

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.

Patients with extensive pulmonary necrosis should not undergo operative intervention because you risk hurting them much more than helping by manipulating the lung.

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.

During VATS for empyema, if the lung looks necrotic, the principle is to leave the lung alone and clean out the pleural space only.

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.

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.

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.

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.

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.

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.