Empyema and Pneumothorax: Update Course 2014
With Dr. Dan Ostlie · hosted by Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Stage 2 empyema is defined by loculated pleural effusion with greater than 100,000 white cells
Once stage 2 empyema is present, antibiotics alone are insufficient and intervention is needed to remove fibrinous exudate
The Kansas City trial using TPA showed length of stay 6.8 days, cost $11.6K, 7.5% complication rate, and 15% failure rate
Both fibrinolytic trials demonstrate 85% success rate, meaning 15% of patients require subsequent surgical intervention
Post-operative illness after empyema VATS is primarily due to underlying pneumonia rather than residual pleural disease
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
Percutaneous Seldinger-type chest tubes can be placed at bedside under local anesthesia with minimal sedation in approximately 2 minutes
Ultrasound can sometimes fail to distinguish intraparenchymal necrotic lung from pleural effusion, requiring CT for accurate diagnosis
Intraparenchymal lung necrosis requires antibiotic therapy only and does not need surgical intervention
Oxygen supplementation for small pneumothorax is standard practice though its efficacy is uncertain
Simple aspiration of pneumothorax may seal a tiny hole or relieve symptoms, but risks creating a larger pneumothorax if a needle is used
Spontaneous pneumothorax is rare in children under 16 years old and predominantly occurs in teenagers approaching adulthood
Nearly all teenage patients with spontaneous pneumothorax have apical blebs visible on imaging
Patients with spontaneous pneumothorax typically have asthenic body habitus with thin chest capacity
CT imaging for pneumothorax allows visualization of blebs and assessment of the contralateral lung
Before the era of VATS, the standard was to wait for a second pneumothorax before performing anterior thoracotomy for bleb resection and pleural abrasion
Current practice is more aggressive, with many surgeons performing VATS on first pneumothorax rather than waiting for recurrence
Standard VATS technique for pneumothorax includes apical wedge resection and mechanical pleurodesis by roughing the pleura with a scratch pad
Talc pleurodesis distributes uniformly throughout the chest during thoracoscopy but creates dense adhesions that make future thoracic surgery extremely difficult, sometimes requiring retropleural approach
Some surgeons perform mechanical pleurodesis on both visceral and parietal pleura, though this may increase air leak risk
Mechanical pleurodesis is considered adequate when small blood vessels become prominent on the pleural surface
A study of 350 patients undergoing lung procedures (not specifically pneumothorax) showed no complications when chest tubes were omitted post-operatively
Reliable post-operative nursing surveillance is essential when omitting chest tubes after pneumothorax surgery to detect early re-accumulation
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
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
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
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
A 5–10% apical pneumothorax in a minimally symptomatic patient should be observed with oxygen supplementation
2001 Adelphi consensus guidelines stated there was no role for simple aspiration in pneumothorax management
2010 British Thoracic Society guidelines recommend simple aspiration as first-line therapy for pneumothorax
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
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