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Ultrasound staging of empyema. (A) Grade 1 effusion showing anechoic fluid. (B) Grade 2 effusion showing echoic fluid without septations. (C) Grade 3 effusion showing multiple thick septations. (D) Grade 4 effusion showing multiple septations with solid appearing components comprising more than one-third of the collection.
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The incidence of empyema in children is increasing worldwide. While there are emerging data for the best treatment options, there is little evidence to support the imaging modalities used to guide treatment, particularly with regard to the role of routine CT scanning. The aims of this study were to develop a radiological scoring system for paediatr...
Context in source publication
Context 1
... images were subsequently reviewed by two paediatric radiologists (AC, CMO) blinded to patient data. The effusions were graded according to their internal echostructure using a system based on that described by Kearney et al 15 but with the addition of an extra grade for highly septated effusions with significant solid components (grade 1, anechoic; grade 2, echoic fluid without septation; grade 3, septated effusion; grade 4, septations with solid appearing components comprising more than one-third of the effusion; see fig 1). Scores from both radiologists were used for analysis. ...
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PurposeTo evaluate the outcomes of patients who underwent thoracoscopic wedge resection without chest drain placement. Methods
The subjects of this retrospective study were 89 patients, who underwent thoracoscopic wedge resection at our hospital between January, 2013 and July, 2015. A total of 45 patients whose underlying condition did not meet the...
Background: Empyema is a well-known disease that significantly increases the morbidity and mortality
associated with pneumonia. There are a number of treatment modalities available but recently video assisted
thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly
in early stages. The aim of this st...
Citations
... In cases where pleural involvement has to be assessed, the timing of the acquisition after intravenous contrast injection should be longer for the better enhancement of pleural folds. Lastly, CT is the technique of choice in children with recurrent pneumonia to determine the cause of recurrent infections, such as aspirated foreign bodies or possible congenital lung abnormalities [10,[27][28][29]. ...
The most common acute infection and leading cause of death in children worldwide is pneumonia. Clinical and laboratory tests essentially diagnose community-acquired pneumonia (CAP). CAP can be caused by bacteria, viruses, or atypical microorganisms. Imaging is usually reserved for children who do not respond to treatment, need hospitalisation, or have hospital-acquired pneumonia. This review discusses the imaging findings for acute CAP complications and the diagnostic role of each imaging modality. Pleural effusion, empyema, necrotizing pneumonia, abscess, pneumatocele, pleural fistulas, and paediatric acute respiratory distress syndrome (PARDS) are acute CAP complications. When evaluating complicated CAP patients, chest radiography, lung ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) can be used, with each having their own pros and cons. Imaging is usually not needed for CAP diagnosis, but it is essential for complicated cases and follow-ups. Lung ultrasound can supplement chest radiography (CR), which starts the diagnostic algorithm. Contrast-enhanced computed tomography (CECT) is used for complex cases. Advances in MRI protocols make it a viable alternative for diagnosing CAP and its complications.
... Several studies suggest that pleural infection can occur spontaneously even in the absence of underlying lung consolidation. [16][17][18] This nding implies there is another route causing infection in the pleural space. Possible mechanisms include visceral pleural defects or stula formation, dispersion from the mediastinum, transdiaphragmatic infection, hematogenous spread, and trauma or iatrogenic injury. ...
Background:
Thoracic empyema is a serious infectious disease worldwide. Video-assisted thoracoscopic surgery is strongly recommended as a treatment, and pleural fluid and tissue cultures can be obtained intraoperatively. The combination of a pleural peels tissue culture and a pleural fluid culture improves the positive culture rate. We aimed to investigate the role of respiratory secretion cultures to determine the optimal management for improving surgical outcome.
Methods:
This retrospective study identified 1197 patients with phase II or III thoracic empyema from our institution. Patients who underwent decortication of the pleura from April 2011 to May 2022 with a positive pleural culture were included.
Results:
There were 225 empyema patients with either a positive pleural fluid culture or a positive pleural peel tissue culture. Of these, 76 patients had positive respiratory secretion culture findings during hospitalization. The most common species of pathogens were Pseudomonas aeruginosa (44%), Klebsiella pneumoniae (16%), and Staphylococcus aureus (10%) in the respiratory secretion cultures and Streptococcus spp. (38%), Klebsiella pneumoniae (12%), and Staphylococcus aureus (11%) in the pleural cultures. There were 30 patients who had a common pathogen in a respiratory secretion culture and in the pleural fluid/tissue culture. Poor outcome measures were found in these patients, including the longer use of antibiotics preoperatively (19.03 ± 37.66 days versus 9.59 ± 27.09 days, p = 0.006) and a higher mortality rate during hospitalization (40.0% versus 17.4%, p = 0.002).
Conclusions:
The respiratory secretion culture plays an essential role in prediction of surgical outcome in bacterial empyema. Obtaining the respiratory secretion specimen promptly through proper methods helps to improve the survival of empyema patients.
... Several studies reveal that pleural infection can occur spontaneously even though there is no underlying lung consolidation. [16][17][18] This nding implies there is another route that causes the infection of the pleural space. Possible mechanisms include visceral pleural defects or stula formation, dispersion from the mediastinum, transdiaphragmatic infection, hematogenous spread, and trauma or iatrogenic injury. ...
Background:
Thoracic empyema is a serious infectious disease worldwide. Video-assisted thoracoscopic surgery is strongly recommended as a treatment, and pleural fluid and tissue cultures can be obtained intraoperatively. The combination of a pleural peels tissue culture and a pleural fluid culture improves the positive culture rate. We aimed to investigate the role of sputum cultures to determine the optimal management for improving surgical outcome.
Methods:
This retrospective study identified 1197 patients with phase II or III thoracic empyema from our institution. Patients who underwent decortication of the pleura from April 2011 to May 2022 with a positive pleural culture were included.
Results:
There were 225 empyema patients with either a positive pleural fluid culture or a positive pleural peel tissue culture. Of these, 76 patients had positive sputum culture findings during hospitalization. The most common species of pathogens were Pseudomonas aeruginosa (44%) and Klebsiella pneumoniae (16%) in the sputum cultures and Streptococcus spp. (20%) and Staphylococcus aureus(11%) in the pleural cultures. There were 30 patients who had a common pathogen in a sputum culture and in the pleural fluid/tissue culture. Poor outcome measures were found in these patients, including the longer use of antibiotics preoperatively (19.03±37.66 days versus 9.59±27.09 days, p=0.006) and a higher mortality rate during hospitalization (40.0% versus 17.4%, p=0.002).
Conclusions:
The sputum culture plays an essential role in diagnosis of bacterial empyema and in prediction of surgical outcome. Obtaining the sputum specimen promptly through proper methods helps to improve the survival of empyema patients.
... The effusion should be drained if it is excessive, localized, or the patient's condition progressively worsens (12,13). Although parapneumonic effusions are the most common in epidemiologic studies in the literature (14,15), such effusions usually regress with only antibiotherapy or simple aspiration, and there is no need for a permanent drainage catheter. ...
Objective: This study aimed to investigate the possible complications, outcomes and course of ultrasonography (USG)-guided percutaneous pleural effusion drainage (PEPED) treatment with underlying etiology of effusion in neonates and infants.
Material and Methods: In 31 patients aged 0-2 years hospitalized in the neonatal or pediatric intensive care unit, 45 catheters were inserted for USG-guided PEPED in a total of 40 sessions. Of these, a 6.3F 25 cm pigtail drainage catheter was inserted in 23 (57.5%) of our patients using the Seldinger method and in 17 (42.5%) using the trocar method. The sample fluid was biochemically classified as transudate, exudate, empyema and chylothorax. The duration of inserted catheter and type of fluid was studied along with etiological reasons for effusions.
Results: Of our 31 patients, 17 were male (54.8%) and 14 were female (45.2). The weeks of birth ranged from 25.1 to 41 weeks, with a mean of 35.55±4.22 weeks. The retention time of drainage catheters ranged from 1 to 18 days, with a mean of 6.5±4.02 days. We compared the retention time of inserted catheters between different preterm and mature groups. Besides, the various fluid characters in the postoperative patient group were compared in the context postoperative day period.
Conclusion: Catheter dwell time does not change with different levels of neonatal maturity. In neonates and infants with a history of surgery, the effusion transforms into chylothorax from hemothorax over time. Bedside USG-guided PEPED treatment for refractory pleural effusion in neonates and infants is highly safe and effective with low complication rates.
... In complicated childhood pneumonia, CT is far superior to chest radiographs in revealing pleural and parenchymal complications, which may require subsequent surgical intervention. CT has been shown to be the most sensitive and accurate modality, demonstrating pathology before it becomes evident on chest radiographs [6][7][8][9][10]. ...
Purpose
To investigate computed tomography (CT) features which predict lung resection in children with complicated community-acquired pneumonia.
Methods
A retrospective study of CT findings of patients with complicated pneumonia treated between January 2010 and December 2019. Fisher's exact test and ROC curves were used for statistical analysis.
Results
The study cohort consisted of 84 patients who underwent chest CT for complicated pneumonia. Lung resection was performed in 36 patients, 3 patients were treated by lung decortication, 45 patients were cured conservatively. Seven CT features were found statistically significant among the patients who underwent lung resection. 80.5% of patients from the resection group had two or more of these features on the initial CT scan, 64% had three or more. According to ROC analysis, simultaneous occurrence of multiple cavities equal to or greater than 3 cm and lung abscess predicted a pulmonary resection.
Conclusion
The combination of CT features which clearly predict lung resection are the simultaneous occurrence of multiple cavities ≥ 3 cm and lung abscess. The most common triple combination of CT signs in the resected group of patients were multiple cavities ≥ 3 cm, consolidation of lung tissue and pleural effusion < 3 cm.
... Literature emphasizes that intravenous contrast enhancement can be particularly helpful in young children who have poor natural tissue contrast, frequently enabling differentiation of pneumonia from atelectasis, effusion, empyema and adenopathy 7 . Further evidence that CT is unable to distinguish stages of pleural infection in pediatric population comes from study by Donnelly et al. 11 and Jaffe et al. 12 . In presented case, due to a few-hours duration of symptoms and performed CT scan without contrast, it was very difficult to estimate the stage of the disease. ...
Introduction. Empyema thoracis, defined as the accumulation of pus in the pleural space, is rare in neonatal population. There are limited data reported in the medical literature and there are still no treatment guidelines available for this age. Case report. We present a healthy term 12-day-old neonate with sepsis caused by methicillin-resistant Staphylococcus aureus (MRSA) and pneumonia associated with advanced stage empyema. The child was admitted to our hospital with a few-hours history of difficulty breathing and lethargy. At the admission, the child was cyanotic with desaturation, in severe respiratory distress, so it was intubated and started mechanical ventilation. Imaging tests were performed in emergency, therefore chest computed tomography (CT) scan was done without contrast. Suspected congenital pulmonary airway malformation (CPAM) with trapped air collections, significant mediastinal shift on CT scan and deterioration of the patient?s condition indicated urgent surgery. Intraoperatively, the diagnosis of stage 2 empyema was established, and decortication of thickened parietal and visceral pleura was performed. Afterwards the baby showed quick and progressive clinical improvement. Conclusion. The diagnosis and management of empyema in neonates may be a challenging one, especially in the case of unremarkably history, fulminant and rapid progression of the disease and incomplete imaging tests.
... 5,6,8 A prospective randomised trial comparing VATS and CDF for the management of children with empyema reported no association between ultrasound characteristics (fluid echogenicity or the presence of septations) and duration of hospitalisation. 15 There is currently insufficient data to determine whether ultrasound characteristics can predict treatment failure in primary CDF for paediatric complicated pneumonia. ...
... 18 The ultrasound characteristics selected in this study were based on criteria that have been used by other researchers to describe more organised effusions. [15][16][17] We refined previous variables seeking a more quantitative and objective measures of assessment, though this did not improve the utility of ultrasound to predict outcome. Despite efforts to standardise these criteria there remains a large subjective element in their description, as reflected by the variability in the kappa statistic. ...
Background: Parapneumonic effusions and empyema are the most frequent complication of paediatric pneumonia. Treatment options include chest drain and fibrinolytics (CDF) or thoracoscopic surgery. CDF is considered less invasive, more cost effective though with higher rates of reintervention. Pleural fluid characteristics on ultrasound may identify cases at increased risk of treatment failure with primary CDF. Methods: A retrospective cohort 2011-2018 of complicated pneumonia managed with primary CDF. Cases were reviewed using ultrasound criteria to describe pleural fluid. We compared ultrasound findings and treatment failure. Results: We report 137 cases with a median age 3.8 years and 43% female. Treatment failure occurred for 32/137 (23%) cases. The interobserver reliability was substantial for the number of septations (Kappa 0.72, 95% CI 0.6 to 0.8), moderate for the size of the largest locule (Kappa 0.55, 95% CI 0.4 to 0.7) and fair for the level of echogenicity (Kappa 0.22, 95%CI 0.1 to 0.3), pleural thickening (Kappa 0.28, 95% CI 0.2 to 0.4), maximum effusion depth (Kappa 0.37, 95%CI 0.2 to 0.5) and radiologist’s risk for reintervention (Kappa 0.32, 95% CI 0.2 to 0.5). Hyperechoic pleural fluid was associated with treatment failure, with cases nearly five times more likely than anechoic fluid to have a reintervention (OR 4.9 95%CI 1.7 to 14.2, p=0.04). Treatment failure was not associated with other variables. Conclusion: We did not find an association between ultrasound characteristics and treatment failure for complicated pneumonia managed with primary CDF. Inter-observer agreement of ultrasound findings was difficult despite more objective criteria.
... Therefore, it can be used as a guide during thoracentesis and GT insertion 12 . Thoracic computed tomography (CT) scan is conducted to obtain differential diagnosis including tumor and congenital airway malformations and to facilitate surgical planning for large pneumatoceles that are unresponsive to treatment , 13 . In addition, by appropriately identifying CT, LA, and NP, the duration, content and treatment type can be modified 13 . ...
... Thoracic computed tomography (CT) scan is conducted to obtain differential diagnosis including tumor and congenital airway malformations and to facilitate surgical planning for large pneumatoceles that are unresponsive to treatment , 13 . In addition, by appropriately identifying CT, LA, and NP, the duration, content and treatment type can be modified 13 . ...
Introduction:Community-acquired pneumonia(CAP) in children has tended to decrease in recent years with effective vaccination and treatments.However,the frequency of complicated community-acquired pneumonia (CCAP) is gradually increasing.By determining risk factors for the development of CCAP,new approaches for early diagnosis and effective treatment can be determined. Method: Records of 113 patients who were hospitalized due to CAP and CCAP between January 2017 and December 2017 were examined.Demographic characteristics of the patients,comorbid diseases,admission symptoms,physical examination findings,laboratory and imaging results, treatments, hospital stay and treatment response were recorded. Pleural effusion,if empyema developed in patients with CCAP,thoracentesis and/or chest tube insertion,fibrinolytic therapy,and the need for additional surgical intervention were investigated. Results:Our patients had a mean age of 3.6 ± 2.2, 60(53%) were female and 53(47%) were male.93 (82.3%) of the patients were diagnosed with CAP and 18(15.9%) were diagnosed with CCAP.Detection of pleural effusion at the admission of patients in multivariate logistic regression[(OR (95% CI),4.24 (1.77-10.16), p <0.001)] respiratory distress(tachypnea and retraction)[(OR (95% CI) 3.04 (1.30-7.130) ),p <0.001)] and hypoxia (92% and less saO2 measured by pulse oximeter) at admission [(OR (95% CI),: 5.247 (1.58-9.46),p <0.001)] were identified as independent risk factors for diagnosis of CCAP. Discussion:Hypoxia,respiratory distress and imaging pleural effusion are important distinguishing findings for development of complications in patients admitted for CAP. Determining the etiology of CCAPs and early diagnosis and treatment approaches can be established, and protection measures can be taken. With future prospective studies, the causes of CCAP can be determined and preventive measures and new treatment approaches can be developed
... Generally, no additional information is added by the use of chest computed tomography (CT) [43]. Compared to US, CT does not offer elements for a more precise prognosis [44] and for a more effective management [45]. To reduce radiation exposure, it is generally recommended that CT is used only when neither chest X-ray nor US are sufficient to definitively clarify the true characteristics of CAP. ...
Introduction
In the last decades, the large use of several effective vaccines has dramatically reduced the incidence of community acquired pneumonia (CAP) in infants and children. Moreover, the availability of new antibiotics effective against emerging resistant strains of bacteria has greatly improved the early and long-term prognosis of this disease.
Areas covered
The aim of this manuscript is to evaluate the burden of complicated CAP in pediatric age and to discuss its appropriate management.
Expert opinion
Complicated CAP remains a problem for children in industrialized and developing countries. A larger use of lung ultrasonography (US) as first diagnostic approach could significantly improve early identification of cases at higher risk of complications. Difficult to solve, is the problem of the use of an antibiotic therapy able to assure adequate control in all the CAP cases, including those at high risk of or with already established complications. All these findings reveal that control of the incidence of complicated CAP remains difficult and will not be significantly changed in the next few years. Any attempt to improve complicated CAP management must be made. Consensus documents on better definition of the use of corticosteroids, fibrinolytic agents and interventional procedures (including surgery) can allow us to reach this goal.
... US is a valuable imaging modality in children, particularly because of its lack of ionizing radiation. Furthermore, thoracic US is more sensitive than chest X-ray detecting small volumes of pleural effusion and is better than computed tomography in detecting thin pleural septations [15,16]. Knowledge of the typical presentations of pleural disease will help radiologists to better characterise pleural pathologies and to avoid diagnostic pitfalls. ...
Ultrasound (US) is an ideal diagnostic tool for paediatric patients owning to its high spatial and temporal resolution, real-time imaging, and lack of ionizing radiation and bedside availability. The lack of superficial adipose tissue and favorable acoustic windows in children makes US the first line of investigation for the evaluation of pleural and chest wall abnormali-ties. Lung parenchyma was previously thought to be inaccessible to ultrasound due to the presence of the air and bony thorax. The change in attitude and growing awareness of the diagnostic possibilities has led to lung ultrasound (LUS) being accepted as a valuable point of care method. In addition, the application of LUS has widened with improvements in technology such as higher resolution transducers, harmonic imaging and contrast-enhanced ultrasound. In the current World Federation of Societies for Ultrasound in Medicine and Biology (WFUMB) paper series the topic will be introduced, the technical requirements explained and the use of ultrasound in the lung and pleura in pediatric patients are discussed.
