Acquired Lesions of the Lung and Pleura

Question 1

What is empyema?

Answer 1

Empyema is derived from the Greek word empyein which means to ‘put pus in’. In general medical care, it refers to purulence within the pleural space.

Question 2

What is the cause of empyema?

Answer 2

This occurs most commonly secondary to pneumonia; however, other sources such as infected hematoma or extension of mediastinal, retropharyngeal, or paravertebral infections.

Question 3

What are the stages of parapneumonic pleural effusion?

Answer 3

The exudative stage is a simple parapneumonic effusion which is clear and free flowing pleural fluid with a low white cell count.

The fibrinopurulent stage is a complicated parapneumonic effusion or empyema with septations and fibrin strands appear.

The most advanced state is termed the organization stage when a thick peel is present.

Question 4

Does Degree of Illness Progress with these stages?

Answer 4

No, patients may be quite systemically ill early in the course of severe pneumonia
but stabilize by the time thicker material develops.

Question 5

What are the Light Criteria?

Answer 5

As the stages advance, the chemistry of the parapneumonic fluid changes where glucose decreases, pH decreases and lactate dehydrogenase rises.

The Light criteria for complicated parapneumonic effusion include pH<7.2, lactate dehydrogenase>1000 units, glucose <40mg/dl or <25% blood glucose, Gram stain or culture positive and with loculations or septations proven with imaging.

Question 6

What is the best imaging to diagnose empyema?

Answer 6

US should be the first step to identify septations and loculations.

Sometimes it can help differentiate between parenchymal and pleural based processes.

CT with intravenous contrast can delineate the degree of necrotic lung and quantify pleural space disease which can be helpful if operative planning is being considered.

Question 7

How do you manage simple parapneumonic effusion?

Answer 7

If there is free-flowing effusion with no solid components or signs of frank pus, the intervention will depend on size and symptoms.

Symptoms precipitating intervention are generally poor feeding tolerance, tachypnea, and increasing oxygen requirements.

Drainage is then indicated by a chest tube.

This should be a tube that can be used to treat empyema if that were to evolve, or if empyema were diagnosed while placing the tube by the presence of frank pus.

This is generally a 12F chest tube (Thal-Quick Chest Tubes, Cook Critical Care, Bloomington, Indiana, USA).

Question 8

How is empyema managed?

Answer 8

The pleural space can be cleared of solid material surgically via the minimally invasive approach, video-assisted thoracoscopy (VATS), or chemically with fibrinolytic agents.

Three prospective, randomized trials have been conducted comparing fibrinolysis to VATS upon diagnosis of empyema in children, all of which found no difference in outcomes.

Since these patients can be treated without an operation, fibrinolysis is recommended as first line therapy.

Question 9

How is fibrinolysis performed?

Answer 9

The simple published algorithm is 4 mg of tissue plasminogen activator mixed into 40 ml of saline placed through the chest tube every 24 hours for 3 rounds.

Each round includes a dwell time of 1 hour by clamping the chest tube.

While this has been shown to be effective first line therapy, there are no good comparative studies with other regimen.

Question 10

What if the patient is still ill after fibrinolysis?

Answer 10

While VATS has been used after failure of fibrinolysis in the trials according to the protocols, however, surgeons should be cautious because the ongoing illness is most frequently to persistent pneumonia or parenchymal necrosis.

Therefore, being patient with either another round of fibrinolysis or observation with continued antibiotic therapy can result in the rare need for VATS.

Further ongoing illness should not be considered fever, but poor oral intake or oxygen requirements.

These patients should be imaged if further intervention is considered to define ongoing pleural disease versus parenchymal disease.

Question 11

What if the imaging shows pulmonary necrosis?

Answer 11

Don’t touch it.

Question 12

How do you treat a pulmonary abscess without empyema?

Answer 12

In general, an operation should be avoided as abscesses can be treated to resolution with antibiotics only as was the historical standard.

If the lesion is peripheral, not associated with airway connection then image guided drainage or catheter placement is feasible.

Question 13

What if the abscess has a solid appearing ball inside of it?

Answer 13

This is a fungal infection and it present a unique challenge.

Resection is usually necessary, by thoracoscopic wedge resection or lobectomy.

These are usually more central and not visible on the surface so wedge resection often requires wire localization.

Question 14

What is bronchiectasis?

Answer 14

Bronchiectasis s defined as a permanent dilatation of segmental airways.

This is not a pathophysiologic process, but architectural abnormalities resulting from any pathologic processes causing persistent pulmonary inflammation leading to the damage.

The damaged tissue includes muscle and connective tissues leading to narrowing and dilated segments of airway.

Decreased epithelial and mucociliary integrity results in poor airway clearance leading to predisposition for further infections.

Question 15

Why does the pediatric surgeon care about bronchiectasis?

Answer 15

Children with cystic fibrosis can develop bronchiectasis resulting in a lobar pneumonia that can’t be cleared with protracted medical management requiring a lobectomy.

These are difficult cases due to inflammation, lymphadenopathy and a bulky solid lobe that will not decompress.

Question 16

What is chylothorax?

Answer 16

Chylothorax is a chylous effusion or the presence of lymphatic fluid within the pleural space.

Chyle typically demonstrates a total fat content greater than 400 mg/dL, tri- glycerides greater than 200 mg/dL, or a specific gravity greater than 1.012. It usu- ally contains >90% lymphocytes and chylomicrons.

Question 17

How is chylothorax managed?

Answer 17

First level is fat restricted diet rich in medium-chain fatty acids.

The next level of management would be nothing by mouth and total parenteral nutrition.

Finally, if no resolution, thoracic duct ligation.

As many as 80% of patients respond to conservative management.

Question 18

An otherwise healthy 3-year-old male presented to the hospital 7 days ago with a diagnosis of right lower lobe pneumonia. He has been treated with intravenous antibiotics and continues to have a fever. The patient is on room air. An ultrasound is performed which shows a pleural effusion that layers in the decubitus position. What is the most appropriate management at this point?

A chest physiotherapy and extending the coverage of the antibiotics

B thoracoscopic debridement and pleurodesis

C continue to observe and complete 14 days of intravenous antibiotics

D thoracostomy tube placement

E thoracotomy and debridement of empyema

Answer 18

D

Primary therapy for empyema is the administration of high-dose intravenous antibiotics. However, failure to respond to the initial treatment such as the presence of persistent fevers requires effective drainage of the pleural space. Fluid that layers in the decubitus position may be treated with chest tube drainage alone. loculated fluid collections may not be sufficiently drained in such a way, and the optimal management of these patients is still debated. This patient probably has an empyema in its exudative phase given the fact that there are no loculations on ultrasound. Thoracoscopy or thoracotomy is not indicated at this time, and postural drainage alone has not shown to be effective in treating empyema. If fevers persist despite 7 days of antibiotic treatment, it is unlikely that the empyema will resolve by extending coverage or treatment time.

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Question 19

The most common pathogen affecting the lungs in children under 1 year of age with cystic fibrosis is:

A Staphylococcus aureus
B Streptococcus pneumoniae
C Haemophilus influenzae
D pseudomonas
E anaerobes.

Answer 19

D

Cystic fibrosis is the most common autosomal recessive disease affecting Caucasians and occurs in approximately 1 in 3500 live births. In the first decade of life, the most common organism isolated from cystic fibrosis patients is S. aureus, followed by H. influenzae. However, pseudomonas is usually the first pathogen isolated in children younger than 1 year of age, and over 80% are infected with this organism by 18 years of age. Sodium is also thought to facilitate increased bacterial binding to the airway mucosa, particularly pseudomonas. Clinically, pseudomonas is the most important pathogen in cystic fibrosis, since it also produces exotoxins that contribute to its virulence, increasing the viscosity of secretions and further impairing ciliary transport.

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Question 20

Which of the following statements is true regarding bronchiectasis in children?

A Localised damage to the elastic fibres of the bronchi in association with oedema and inflammation, result in the saccular phase of bronchiectasis.

B The digital clubbing associated with this disease is usually irreversible.

C Surgical resection is indicated once the diagnosis is made.

D Patients with tuberculosis usually present with bilateral lung involvement.

E Saccular bronchiectasis is considered an irreversible condition.

Answer 20

E

Bronchiectasis is the irreversible dilatation of the airways secondary to the inflammatory destruction of bronchial and peribronchial tissue. The pathogenesis of bronchiectasis follows three progressive stages. Initially, the ciliary epithelium is replaced with cuboidal squamous epithelium. In the next stage, called cylindrical bronchiectasis, there is localised damage to the elastic tissue of the airway in addition to oedema and inflammation. The last, irreversible stage is called saccular bronchiectasis, and the damage involves the muscle and cartilage layers of the airways, with neovascularisation between pulmonary and bronchial arteries in the areas of saccular dilatation. up to 50% may have digital clubbing, which is reversible after appropriate treatment. The mainstay of treatment is medical. However, there are surgical indications such as localised disease with severe and debilitating symptoms, massive haemoptysis from localised disease, resectable disease in the context of failure to thrive, and resectable disease in an area of recurrent lower respiratory tract infections. lastly, patients with pulmonary tuberculosis tend to have unilateral involvement.

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Question 21

A 4-year-old male patient with cystic fibrosis presents to the emergency department with massive haemoptysis. After sedation and intubation the patient is resuscitated with intravenous fluids and his vital signs remain stable. There is still active bloody discharge through the endotracheal tube. What is the most appropriate next step in management?

A angiography and embolisation of the bleeding bronchial vessel

B thoracotomy in the operating room with lobectomy

C clinical observation in the intensive care unit

D intravenous vasopressin drip

E emergency room thoracotomy and damage control surgery

Answer 21

A

massive haemoptysis is defined in children as the expectoration of at least 240 ml of blood in 24 hours or recurrent episodes involving substantial amounts of blood (>100 ml/day) over days to weeks.

It occurs in approximately 1% of patients with cystic fibrosis and is more frequent in those patients with severe lung disease.

The pathogenesis is related to the enlargement and tortuosity of the bronchial arteries and the multiple anastomoses that form between these vessels and the pulmonary arteries.

Several treatments have been proposed such as vasopressin drips, endobronchial balloon tamponade and topical alpha agonists without encouraging success.

However, bronchial artery embolisation has emerged as a highly successful non-surgical intervention for the short-term control of haemoptysis.

Several series have demonstrated that this technique is safe and effective for the control of massive haemoptysis.

Clinical observation would not be appropriate in this patient given the evidence of ongoing massive haemoptysis.

Surgery with lobectomy may be life-saving for patients who fail embolisation, or those who present with haemodynamic instability due to fulminant haemoptysis.

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Question 22

A 3-year-old female patient developed a right upper lobe pneumatocele secondary to S. aureus pneumonia. There is no associated pneumothorax or pleural effusion. What is the next most appropriate step in management?

A thoracoscopic marsupialisation of the cyst

B right upper lobectomy

C clinical observation

D percutaneous drainage of the cyst

E bronchoscopy and transbronchial drainage of the cyst

Answer 22

C

Pneumatoceles are small, thin-walled structures consisting of single or multiple cysts within an air-lined cavity secondary to alveolar and bronchiolar necrosis.

These abnormalities are seen frequently as a consequence of infection by S. aureus and group A Streptococcus.

Complications of pneumatoceles such as pneumothorax or empyema usually require surgical intervention. However, non-complicated pneumatoceles often resolve spontaneously.

Follow-up chest radiographs are required until the resolution of the pneumatocele, and computed tomography may be useful in difficult situations. In uncomplicated cases, there is usually no residual pulmonary disease.

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Question 23

Which one of the following statements is true regarding empyema in children?

A Anaerobes are the most common isolated organisms in empyema.

B Thoracostomy and fibrinolytics have shown to be equally as effective as thoracoscopic debridement in the treatment of empyema.

C The diagnosis is confirmed by an elevated glucose and a pH < 7 in the pleural fluid.

D The fibrinopurulent phase results in a thick pleural ‘peel’ which is usually refractory to antibiotic treatment.

E Fibrinolytic therapy is usually reserved for the organising phase of empyema.

Answer 23

B

An empyema is the accumulation of purulent fluid in the pleural cavity secondary to different disease processes such as pneumonia, trauma, neoplasms, intrathoracic oesophageal perforation, or surgeries on the chest.

Close to 30% of children with pneumonia will develop an empyema. Currently, the most common organisms in childhood empyema are S. pneumoniae, S. aureus and H. influenzae.

The diagnosis is confirmed by analysis of the pleural fluid, which shows a pH of less than 7 and a glucose level less than 40 mg/dl. Empyema exhibits three characteristic stages: (1) an exudative stage when the fluid is thin and of low cellular content; (2) a fibrinopurulent stage during which large numbers of polymorphonuclear cells and fibrin are deposited in the pleural space, progressively impairing lung expansion and leading to the formation of fluid loculations; and (3) a fibrotic and organising empyema during which a thick peel forms around the pleural surface, entrapping the lung.

Patients who present with loculations during the second stage usually cannot be managed with chest tube alone. A randomised prospective trial showed no difference in outcomes or hospital stay when these patients are treated with thoracoscopic debridement or thoracostomy tube and fibrinolysis.

Currently, the recommendation is to place a chest tube and treat with tissue plasminogen activator for 3 days and reserve the thoracoscopy or thoracotomy for refractory cases.

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Question 24

Spontaneous pneumothorax occurs frequently in patients with cystic fibrosis. The recurrence rate after a first episode treated with thoracostomy tube is:

A 5%–10%
B 20%–30%
C <5%
D 40%–60%
E 75%.

Answer 24

D

Primary spontaneous pneumothorax is defined as a pneumothorax occurring secondary to apical blebs without evidence of other lung pathology. on the other hand, secondary spontaneous pneumothoraces occur in the context of underlying lung disease, such as cystic fibrosis.

A pneumothorax less than 15% can usually be treated with observation alone; however, larger pneumothoraces need drainage initially. Adolescents with spontaneous pneumothorax have been reported to have a recurrence rate of 40%–60%.

The indications for surgical management include recurrence, persistent air leak, bilateral disease, and possibly the presence of large blebs.

The recurrence rate after thoracoscopy with bleb resection and pleurodesis ranges from 2% to 10%.

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Question 25

What is the appropriate initial management of lung abscesses in children?

A percutaneous drainage and antibiotics
B thoracoscopic drainage and antibiotics
C antibiotics only
D antibiotics and postural or bronchoscopic drainage
E wedge resection of the affected area

Answer 25

D

Appropriate intravenous antibiotic therapy combined with postural or bronchoscopic drainage is the initial approach to lung abscesses in children.

Percutaneous drainage would be the next step in case of treatment failure.

Bacterial organisms recovered from most cases have been susceptible to penicillin.

most isolates include both aerobic and anaerobic flora. S. aureus is the most common organism found. Improved results can usually be achieved with a combination of ampicillin and metronidazole or clindamycin.

Patients who fail therapy may be immunocompromised or have fungal isolates and often require pulmonary resection.

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Question 26

Which of the following statements regarding the thoracic duct is true?

A It enters the chest through the oesophageal hiatus.

B It crosses the midline from left to right at the level of the fifth thoracic vertebra.

C It ascends posterior to the aortic arch towards the neck.

D Anatomical variations are rare.

E At the level of the diaphragm, it is located in the left chest.

Answer 26

C

The thoracic duct originates in the abdomen at the cisterna chyli located over the second lumbar vertebra.

The duct travels into the chest through the aortic hiatus and then passes upward into the posterior mediastinum via the right chest.

It then crosses the midline towards the left at the level of the fifth thoracic vertebra.

It ascends posterior to the aortic arch and into the posterior neck where it drains at the junction of the subclavian and internal jugular veins.

many variations are present in the entire ductal system, and the typical course of the thoracic duct is present in approximately 50% of individuals.

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Question 27

Which is the correct progression of treatment steps for a chylothorax?

A chest drainage, octreotide, dietary modification and surgical ligation of the thoracic duct

B dietary modification, postural drainage, octreotide and thoracoscopic pleurodesis

C surgical intervention and chest-tube drainage, octreotide, nil by mouth and TPN until resolution

D chest drainage, dietary modification, TPN, octreotide, and surgical ligation of the thoracic duct

E octreotide, pleura-peritoneal shunt, dietary modification, and surgical ligation of the thoracic duct

Answer 27

D

The initial approach to a chylothorax is thoracentesis. It is used for diagnosis and may also be sufficient to relieve spontaneous chylothorax. In addition, tube drainage allows quantification of the daily output and promotes pulmonary re-expansion, which may enhance healing.

The next step in management is dietary modification. Between 80% and 90% of all fat absorbed from the gut is transported by the thoracic duct as chylomicrons. Short- and medium-chain fatty acids are transported directly into the portal circulation. Thus, feeding restricted to medium- or short-chain triglycerides theoretically results in reduced lymph flow in the thoracic duct and may enhance spontaneous healing of a thoracic duct leak.

Recently, octreotide has been found useful in several reports. octreotide can be given subcutaneously every 8 hours, starting at a dose of 10–20 mg/kg/day. If non-operative management is effective, external intake should be reinstituted first with medium-chain triglycerides, followed by an age-appropriate diet after 2 weeks.

If drainage persists after 2–3 weeks, despite the above treatment steps, ligation of the thoracic duct on the side of the effusion may be necessary.

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Question 28

Which of the following is not an indication for surgical intervention in children with tuberculosis?

A cavitary disease with massive haemoptysis

B cavitary disease with continued positive sputum cultures after 6 months of therapy

C compression of the airway refractory to antibiotics and steroids

D solitary and peripheral lobar caseous nodule

E entrapped lobe with associated empyema

Answer 28

D

First-line therapy for patients with pulmonary tuberculosis consists of multidrug antibiotic therapy for at least 6 months.

In otherwise healthy children who are compliant with the antibiotic therapy, a cure rate close to 100% is be expected.

Surgery for tuberculosis in children is indicated to treat complications and reduce bacillary load. Examples include refractory bronchial obstruction, cavitary lesions with either massive haemoptysis or persistent positive cultures after 6 months of treatment, and associated empyema.

Actual pulmonary resection should be avoided whenever possible given its morbidity in these patients.

Surgical intervention can be very challenging because of the degree of intrathoracic scarring from chronic infection.

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Question 29

Which of the following statements is true regarding chylothorax?

A Spontaneous chylothorax in the neonatal period is more likely to resolve than postoperative chylothorax.

B This condition rarely causes malnutrition given that the protein content of chyle is low.

C Chemical pleurodesis is usually effective as first-line therapy.

D Prematurity is a risk factor for the development of chylothorax.

E The diagnosis is made by a pleural triglyceride level of greater than 40 mg/dL.

Answer 29

A

one of the most common causes of pleural effusion in the newborn period is spontaneous chylothorax. It can sometimes be related to traumatic vaginal deliveries; however, most of the time its aetiology is unclear.

Compared with postoperative or neoplastic chylothorax, spontaneous chylothorax in the neonate is more likely to heal with conservative treatment.

The chyle contained in the thoracic duct carries three-quarters of the ingested fat from the intestine to the systemic circulation.

The fat content of chyle varies from 0.4 to 4.0 g/dl.

The total protein content of thoracic duct lymph is also high and persistent leaks can cause severe malnutrition. In addition, the thoracic duct carries white blood cells such as lymphocytes and eosinophils.

loss of lymphocytes through a thoracic duct fistula may lead to immunosuppression.

Initial treatment with pleurodesis is not effective given the high fluid circulation, preventing the formation of adhesions.

Finally, a triglyceride level of greater than 110 mg/dl is considered diagnostic of chylothorax.

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Question 30

The three most common organisms that cause empyema in children are:

A S. aureus, H. influenzae and anaerobes

B S. pneumoniae, S. aureus and atypical mycobacteria

C H. influenzae, S. pneumoniae and pseudomonas

D S. aureus, S. pneumoniae and H. influenzae

E S. pneumoniae, atypical mycobacteria and H. influenzae.

Answer 30

D

Currently, the most common organisms in childhood empyema are S. pneumoniae, S. aureus and H. influenzae.

Although pneumococcal species were considered the most common organisms associated with thoracic empyemas, the introduction of penicillin and the pneumococcal vaccine has resulted in S. aureus now being the predominant pathogen.

Pseudomonas can be a cause of thoracic empyema, mainly in cystic fibrosis patients. other causative organisms include Bacteroides spp. and mycobacteria.

Tuberculous empyema is associated with a high bacterial load within the pleural space.

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Question 31

Which is not a surgical indication in patients with cystic fibrosis?

A massive haemoptysis

B persistent productive cough with cultures positive for pseudomonas

C end-stage lung disease

D recurrent pneumothorax

E refractory localised bronchiectasis

Answer 31

B

Pulmonary complications of cystic fibrosis, such as localised bronchiectasis, massive haemoptysis, and pneumothorax require surgical intervention.

lung transplantation remains the ultimate resort for patients with end-stage pulmonary disease.

Bilateral, sequential lung transplantation is the preferred approach for children with cystic fibrosis.

Although long-term survival is still a problem for most patients, 1- and 2-year survival rates between 65% and 85% have been reported.

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Question 32

Which of the following statements is true regarding chronic interstitial lung disease?

A It is characterised by an obstructive pattern on spirometry.

B It is usually caused by an infectious process.

C Refractory disease commonly mandates surgical resection.

D If tissue diagnosis is needed, a percutaneous core biopsy is indicated.

E Corticosteroids are indicated once infectious causes are ruled out.

Answer 32

E

Chronic interstitial lung disease may result from both infectious and noninfectious causes. The precise pathophysiology is poorly understood, but current evidence suggests that its aetiology is related to an intense inflammatory reaction at the level of the interstitial and perialveolar tissues.

It is characterised by a restrictive lung physiology and abnormal gas exchange. usually paediatric surgeons are asked to confirm the diagnosis by lung biopsy.

The current recommendation for tissue specimen is at least a 1 cm 3 sample from anywhere in the lung except for the lingula and the right middle lobe, unless there is obvious radiographic disease in specific locations.

The right middle lobe and the lingula often show disproportionate histological changes and might confuse the clinical picture.

A core biopsy is not recommended. Surgical resection (e.g. lobectomy) can result in further deterioration and is not indicated.

Steroids are the most commonly used agent once infectious causes have been excluded, followed by hydroxychloroquine, cyclosporine and methotrexate.

In severe cases, extracorporeal membrane oxygenation might be necessary.

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