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Summary

This on-demand teaching session is relevant for medical professionals interested in pediatric surgery, specifically empyema in children. The session, held by Doctor Kirsty Pedersen, offers a comprehensive overview of empyema, discussing its classification, causes, pathogenesis, and management. In addition to the standard three-stage process of pathogenesis, the presentation also brings attention to a precollection stage consisting of pleuritis and inflammation. Attendees can gain insights into primary investigations for empyema, like blood tests and fluid chemistry, with an appraisal of how light criteria are utilized to define a complicated parapneumonic effusion. The session addresses managing this condition in South Africa. Medical professionals interested in expanding their knowledge on pediatric conditions like empyema should not miss this informative session.
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Description

This is an invited talk on "Empyema thoracis in children" by Mr. Dakshesh Parik, Birmingham, UK, as a part of the Zoom academic meeting of the Department of Paediatric Surgery in East London, South Africa. This video is for health care professionals ONLY and NOT for the general public.

Learning objectives

1. Understand and explain the definition of empyema, including how it falls under parapneumonic effusions. 2. Recognize the classification system for empyema and identify the key characteristics of each class. 3. Identify the common causes of parapneumonic effusions that can evolve into empyema. 4. Understand the pathogenesis of empyema, specifically the three stages of formation. 5. Learn how to investigate suspected cases of empyema, including the use of blood tests, fluid chemistry, and the application of Light's criteria to diagnose complicated parapneumonic effusion or empyema.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello. Hi, Kie. Hi. Uh, do you just want to, uh, share a screen and check that it works. Well. Uh, kine that, uh, that table. Um, have you, are you going to, um, that table? I just thought was a bit too busy. That was the only comment from my, um, my information. No problem. I'm not gonna say much about it. I'm just saying a sentence. I just wanted to have it there so people could see. Ok. Ok. But then, uh, p point out to whatever you want to point out whatever information you want to point out. Sure I will do. Thank you. Ok. That's fine. Kay. And, um, uh, are those x-rays on your presentation? What Doctor Sonia is going to talk about? Are they on, uh, at, at the end of your presentation? Kirsty? No, I have a second one separate for her. This one? Oh, ok. Ok. Yeah. Ok. And so you will project it and she will, is going to talk. Is that correct? Yes, she did. Just send me a message now to say they just finishing in theater. So I'll just check with her. I'll just check that she has drawing when I finish? Ok. Ok. That's fine. You do, you do not know much about those patients, do you in case she cannot? No. Ok. No, unfortunately not. No, that, that's fine. That's fine. I don't think it'll matter too much she said, I mean, yeah, I don't think it matter too much if she doesn't, if she's not able to drive. Uh, that's fine. Kirsty. We'll just see if she, by the time you are about to finish, we will know if she joined us then, then otherwise I just invite, uh, Mister Pa to, to come in. Sure. Otherwise Kia, how is, uh, studies going on? Um, they're going all right. Thanks for, ok. It's a bit hard to study in between work, but it's, it's ok. Yeah, I had, I had pretty much finished my preparation for the last time. So, yes, there's not much to do except for revised papers. Oh, absolutely. Yeah, absolutely. I can only really do last week. Um, ok. Uh, uh, Kirsty, um, I'll try and remember, but remind me on Monday when I'm back that, uh, your trainees can also become a member of Associations of Surgeons of South Africa, EA. And, uh, it is free and, um, the useful part for you people is that they regularly conduct tutorials for primary and intermediate examination. Oh, ok. Ok. I have, II was aware of one of the other. So U CT also does some p correct. I think I, it could be the same U CT tutorial. But, uh, but I try to remember but if you haven't, I set up, uh, an email only to come to you people on Monday or so. But if you haven't received my email, uh, then no, but you will be on leave next week. Am I correct? Yeah, I won't be, unfortunately, you won't be here Monday. Ok. Ok. No, that's fine cause, yeah, I will, uh, just keep it in mind when you come back from leave, if you haven't received my email. Sure. How good did send us the link to those U CT one, a while ago when we started a study, right? But I just want all of our staff to register for that as a website and uh so the juniors who are preparing for the primary and the intermediate, they can at least be aware of those tutorials. Sure. Problem the urethra. Ok. About you. Hello doctor. Good afternoon. You need to unmute yourself. Just a new to yourself. Yeah. Ok. Is it? Ok. No, that's perfect. Uh Do you want to just try and uh share your screen and we can just go through one or two of your slides? Ok. W where, where do I share? Um you need to, you need to keep that presentation open on your PC. Yeah. And then right at the bottom there is this green, um, sort of arrow share screen. Oops I in the powerpoint or in the, no, no um uh on your uh uh PC or your ipad uh share, share the screen. OK. Yeah. Yeah, I got it. And you just click on that. Yeah. And uh then it will open windows. Uh which window and then you need to click on that powerpoint presentation uh desktop. Oh, sure. It is open. I don't know what happened. Oh, actually I keep my video off because I am sharing my office with our son. Ok. Ok. You can keep it on or off. It's up to you. I'm trying to um uh share the screen. So no problem. You just need to click on that share screen tab and then click on the powerpoint. Hm. Uh No, it's a one. Ok. Microsoft powerpoint. Yes. Yeah. Is, is your powerpoint presentation open? Yeah, it is open. Uh I've made it smaller but it's not opening. No, it's uh if you click on that green, green up going arrow here screen, it should open windows, those windows for you. No. Yeah, it's not doping now. You just need to click it. Um I can see um you as well as uh my powerpoint but it's not going into your um share screen thing. So. Ok. What something I'm doing wrong. Uh What you can do so long. Maybe just email it to me. I have, I have e-mailed you, uh, have you, when did you do it? Yeah, a few, a few days ago back when you asked me to send your e email presentation? Oh, and I had sent it to you. I check it now, I check it. Uh II will ask my son whether he can, he can uh share the screen. Yes, yes, please. And uh just hang on and don't stress. We will wait for you. Yeah. OK. She has this heart point presentation inside the inside this you shared this uh I tried to share the screen to show my power presentation. Where is it? Which one is it? Uh it, it should be ba basically will it be in des or I don't know what you said? It's on a des where? Ok. Is that it? Yeah. Uh Well, I why does it say unknown? I don't know where you saved it so I can't help you. It's up here look uh it's on a desktop. So yeah, I don't know where it is. It's on a icloud desktop. Say for example Microsoft Google try mm lashes ca can you please email me the presentation once again? I don't seem to find it. So maybe you can just email it to me and I can project it done. You just he's more so team so you see so switch off your camera in the morning and I on there. Ok. Yeah. Ok. Ok. Yeah. Yes. Ok. Yeah, you too. No sweet. Ok. Mhm. Ok. Thank you, sir. 60. Ok. Ok. Ok. Uh Good afternoon everyone. Uh sorry for the technical glitches, but uh but they, they are part and parcel and probably like the spice of these zoom meetings. Um It's my pleasure to welcome you all uh to this meeting um of the Department of pediatric Surgery. Um and uh today, um uh doctor Kirsty Pedersen, who is our medical officer is going to talk about sis in Children. And um we are really very honored to have Mister DSHS far as our invited guest today. Um Duh claims that he is a retired consultant, pediatric surgeon. Um but uh but he finds out a reason to try and come and assist either his colleagues or his patients in Greater Birmingham area. Um When I looked at CV, uh it was very pleasing for me to know that he trained where I trained in Mumbai. Um not in the same institute though. And I trained four or five years after him and subsequently he trained in Liverpool. And he also did a fellowship from Glasgow where both doctors and I have strong connection dshs is deeply involved in teaching and training and mentoring throughout his career. And he continues to do that even post retirement. And this includes local and overseas training and young consultants during this period of COVID. The has been or is a principal editor of two books on th pediatric thoracic surgery. One is a new or a recent one TX in thoracic surgery and a second one which I am proud to have that I own a copy, copy which I've given to the library is almost like the Bible of pediatric thoracic surgery. He has given over 100 invited lectures and has more than 100 publications and he says that he just waiting for the COVID nonsense to over uh to be over so that he can enjoy his retirement and do what he loves outside medicine that is to travel, to do photography and to enjoy sports from all faculties. So, duh, we are really very honored to have you today as our invited guest. So um I'm going to stop sharing now and I'm going to invite uh doctor Kirsty Pedersen to give her talk about Pima Thoracis in Children. K, we have audience not only from our country but as far as New York, Caribbeans, Pakistan um and including our colleagues from East London, some retired, some working and also from Queenstown. So please go ahead. Thank you, Kirsty. Thanks, bro. Uh Sorry, as I've mentioned, I'll be speaking about emphysema. I'll look briefly at the definition, classification causes and then set on pathogenesis and management and then have a brief overview of how we manage it in South Africa. So, empyema falls under parapneumonic effusions. This is collection of fluid in the pleural space and empyema is then defined as an accumulation of pus in the pleural space. They can be classified according to the system into classes of 1 to 7. Um Class six is a simple empyema where Frank pass is present and a single locule or free flowing pass. And class seven is a complex empyema with Frank pass present and multiple locus causes of para manic effusions include so from adjacent infection, a reaction to a subphrenic abscess, extension of infection from the media spin or retropharyngeal or paravertebral infections, infection, post thoracic surgery or trauma. A collection can form after intrathoracic esophageal perforation or it can be relating to neoplastic process. This fluid can then become infected. Um So the pathogenesis of the empyema forming is described in three stages by most sources. A few of the sources. However, add a full stage, which is a precollection stage, which consists of pruritis and inflammation. Stage. One is exudative stage where it is a simple parapneumonic effusion. This is clear, free flowing pleural fluid and the fluid is often sterile winter in stage two is the fibropurulent stage. This is a complicated parapneumonic effusion also known as empyema. The fluid has been invaded by infective organisms. This causes deposition of febrin and purulent material in the pleural space. There are septations and fibrin stones with start forming and it results in the development of loculations of purulent fluid. In stage three is the organization stage. This is where this thick fibrinous peel is established. It can in the lung and cause restrictive lung disease. So, investigations in these patients, um primary investigations would be your blood test where you do infection markers and a blood culture. Then the fluid from the pleural space can be tapped and sent for fluid chemistry. Looking at the fluid, you use light criteria to define a complicated parapneumonic effusion or empyema. This is defined by a PH less than 7.2 LDH, more than 1000 units glucose, less than 40 or less than 25% of the blood glucose at the time of the tap, a grain stain or culture positive on the fluid and then loculations or septations. As seen on imaging. The imaging options um should start initially with an X ray. So chest X ray will show a consolidation. It can sometimes be difficult to distinguish between parenchymal and pleural disease. On X ray, X rays can show a blanking of the costophrenic angle, a fluid meniscus and then movement of the fluid on lateral decubitus. If they um if it's stage six, so simple pneumonic or if it doesn't move, then you think of a complex parapneumonic effusion on ultrasound, ultrasound is insensitive for diagnosing loculated fluid. It can be used to guide the drainage and catheter placement. It can reliably differentiate between parenchymal and pleural based disease and is thought to be superior to CT scan in diagnosing emphysema and it also has less radiation risk to the child CT scan thus should be reserved for complicated cases or preoperative planning. So, management um consists of antibiotics, debridement and drainage. So when we look at antibiotics, um high IV. Anti dose antibiotics are used in a small effusion which is less than 10 millimeters on a lateral decubitus chest X ray or less than one quarter of the hemothorax. These can be treated with oral antibiotics and as outpatients. If the patient is stable, large effusions will require 10 to 14 days of IV. Antibiotics and uncomplicated empyema or antibiotics can be continued for 1 to 4 weeks after discharge. The most common organisms that are cultured from the pleural pus in patients with emphysema are streptococcus pneumoniae, staphylococcus, aureus, and haemophilus influenza fluid cultures and blood cultures can often come back without growth of an organism due to the Children being on antibiotics for the pneumonia. Preceding protocol is to start broad and then narrow down your antibodies of choice as cultures or the clinical picture directs. Literature suggests you start with cefotaxime or cefTRIAXone and then to add clindamycin or vancomycin. If M RSA is suspected um in patients with T BTB, um empyema is much more rare than a simple TB pleural effusion. But if it is suspected, then TB treatment should be started. Um drainage of the fluid should be decided on patients symptoms, the size of the collection and response to antibiotic treatment. So single thor thoracocentesis can be helpful in draining small collections of fluid as well as in collecting a sample of fluid for culture. If multiple thoracentesis is needed, it is then advisable to rather insert an intercostal tube or drain. The indications for a chest tube will be an opacity, larger than half of the hemithorax with more than 10 millimeters on natural decubitus X ray for a child that's in respiratory distress. And if the fluid is consistent with emphysema on investigation, the insertion of a chest tube should be considered also if a patient fails to respond despite 48 to 72 hours of antibiotic therapy. Um looking at debridement in these Children, there are two types of debridement that can be done. One is chemical and the other is operative um in treating of empyema, adding debridement agents to chest tube placement, prove superior to chest tube drainage alone. Um The chemical debridement is with fibrinolytics, namely urokinase or streptokinase or tissue plasminogen activator. All three of these fibrinolytics have similar effectiveness. The oxy ribonuclease is a lytic agent that can be added to treatment. This enhances the effectiveness of the fibrinolytics by debriding. The fal space operative development is done via va video assisted thoracoscopic surgery. Current literature does suggest to give IV antibiotics insert a chest tube and give three doses of fibrinolytics if this fails to have a clinical response, um then to repeat imaging and operate if there is persistent disease. Other indications for operative intervention include empyema with significant lung vas, bronchopleural fistula with pyopneumothorax or a secondary empyema. Both chemical debridement and operative debridement. The outcomes for patients. Yes, ma'am sorry, just, just uh sorry for interruption. Um Some attendees are saying that the slides are not progressing and um sell had just advised we restart the meeting. Sell. Can you unmute yourself and please give your advice? No, no problem. Um Thanks. So I was saying that can restart the Zoom meeting, not the whole presentation. The person who's having issues with the video can just log out and log in again. Um It might help because we can see the slides progressing. Well, only those people who are having problem. Yes, they can just leave the meeting and rejoin it should be able to help. Ok, so those people like Kevin do, Kevin wait who are having problems just maybe exit the meeting and reenter the meeting. We will continue the meeting. Um uh In the meantime, thanks. Hello, sorry, Kirsty, you can proceed. Sure, pro um sorry. So just to finish on that debridement is chemical operative. Um and both chemical debridement and operative debridement have shown to have similar outcomes for patients. Then I thought I found two studies that were done in South Africa that I thought would I would share. Um So the first study was conducted at hospital in Joburg. The objective was to describe the etiology and management of emphysema in a setting of high HIV and tuberculosis prevalence. Um A retrospective descriptive study was undertaken between 2012 to 2016, 65 patients were included in the study. So the findings were the commonest cause was streptococcus pneumoniae followed by staphylococcus aureus, which is similar to the global findings. And then my mycobacterium tuberculosis accounted for 10 to 14% of cases. Um although fibrinolytics or early surgery are recommended by literature and neither practice was very common in this setting. The median duration of hospital stay was 18 days. All of the Children received antibiotic therapy. 91% of the Children required pleural drainage. Fibrinolytics were only documented in 9% of patients despite 91% requiring drainage and 12% had a thoracotomy open and 10% had video assisted thoracoscopic surgery or vats. And then they found a high proportion of the HIV infected Children with emphysema who initiated on TB treatment, um possibly incorrectly. So this just highlights again the challenge that we face in managing TB and HIV per infection in our country which are then often complicated with empyema. Sorry, I don't know what's written. Um A second study. Con sorry Puff in one second. That's true. Sorry, sorry for that. Um A second study conducted at Red Cross Children's Hospital in Cape Town. Looked at the impact of fibrinolytics in the treatment of Children with empyema. A prospective observational study of Children with empyema was done between 2006 and 2011 in their hospital intrapur tissue placement activ was administered according to a standard protocol. This was introduced in 2009. So midway through the time that they looked outcomes in the Children that were treated with CPA. After 2009 were compared with a historical co who was not treated with um fibrinolytics who would have met the treatment criteria. So, in total, they looked at 100 and 42 Children with empyema. 59 in the pre FB lytic group and 52 who received fibrinolytics. 95% of the Children had a test, chest tube inserted. 38% were not treated with fibrinolytics and required surgery compared with 9% of those who were treated with fibrinolytics. So there was a big um improvement. So they concluded that intrapleural TPA resulted in a fourfold reduction in surgery and that fibrinolytics should be used for the management of emphysema in Children in South Africa. This is especially important as thoracic surgeons are a scarce resource. The prevalence of TB was also again, nearly 10% which highlighted the importance of TB as an unrecognized cause of empyema in our setting. So, just to conclude for emphysema, um parapneumonic effusions are very common in Children with pneumonia. Up to 50 to 70% of Children who have pneumonia will um develop an effusion. These become complicated by infection and can form emphysema, chest X ray and ultrasound are the cornerstones of investigation. The commonest organisms to think of is streptococcus and staph aureus in South Africa. TB should also be considered a conation path should be followed when managing a case of parapneumonic effusion in Children as the severity of the case and the progress of the disease can usually dictate. The approach. Primary management should be consist of antibiotics, drainage and fibrinolysis. Operative drainage should be reserved for those cases who do not respond or complicate further with other lung pathology requiring surgery. Um However, this view is currently under review. Um One study previously done which included over 3000 Children concluded that although national trends favored chest tube and rinos, primary vats are associated with a shorter hospital stay and a shorter PP ICU stay as well as a low requirement for ventilation. They suggest that further study should aim to risk stratify Children who may suffer from a protracted course of disease with a goal to offer primary vats to the subset of Children and return them to normal life more quickly. Overall, the prognosis for these Children with emphysema is good. Most studies show resolution of the chest x-ray changes within 3 to 6 months after completing therapy. Those were my references. Thank you. Thank you, Kirsty. Um uh You can, I think uh present those uh uh interesting x-rays of the patients which Doctor Sonia Van Ray, uh Thoracic surgeon will, will talk about. So now, uh Doctor Terson is going to project some images and I invite Doctor Sonia Van Ray who is uh a thoracic surgeon who works in our hospital and she primarily nowadays deals with uh these thoracic problems. So uh in next like 5 to 7 minutes, she's going to present a couple of patients before I invite Mister Dus to, to give his advice and his talk. Ok, Kirsty, go ahead. Uh, hi Sonny. You just need to unm yourself in the bottom left hand corner. Sonia. Can you talk Allisonia? Yes. Can you hear me? Yes. Yes. Yeah. Ok. Good. Right. Ok. Um, so with the patients we see are maybe somewhat different from the European patients and the problem is that most of the patients I see present a little bit late. Um I think this new care stream view system unfortunately has sort of mixed up some of the X rays um which I only realized after I had given you the names. So this child was thi a mentally retired, a child who fell from a tree and had a big hemothorax. But due to previous chest infection, it was loculated. So we only, I think saw the child a few days only after the initial trauma. So um just continue to the next x-rays if you can just sort of slide through them all. Um So uh drains were put in by other people and then because it was loculated, I think a CT scan was done. We tried to drain that specific space, which also didn't really help because by this time, it was uh the fibrin deposits were thick on the lungs. So it didn't expand well, unfortunately, for four weeks, there was no space in pets IC and no surgical space. So he had a decortication only four weeks after the initial procedure, but he is recovered well and the lung is now well expanded a after the procedure. Yeah, I don't know where that X ray comes from. So they, they're just not in the totally but uh the child was last week at the clinic and the lung as well expanded, the child is active. So we can go to the next child, which is a small baby who presented to, to the pediatricians with the staphylococcal pneumonia with the pine pneumothorax, um responded well to its acute situation by insertion of a drain. And um it was a very sensitive staph and it had responded to cloxacillin, but it's now left with a residual sort of uh oh all kinds of things in the chest there. That is uh um you know, it was better at one stage, but it's now worsened again. Um The, the child is not running a temperature and I think the fibrin deposits and also once again, in our situation for alys is, is a bit complex and also cannot be done in such a small child with the ICU bed is not really available. So, um we going to, we, we want to decorticate the child because this is a rather complex pleural space. Um And I, unfortunately, the old PAX was down because what I wanted to show was some, well now adults who were treated as empyemas that Cida Kiwani more than 20 years ago announced it was calcified sort of contracted chest since it was not completely drained. And um you know, sometimes when the pleura is thickened, one should go and strip out that pleura to get the lung in the chest to expand properly. Because once that chest rings up and cannot develop in the child, it is, it's really not good. So II just request please for the Children if there is any problem with the X ray not looking normal to refer them to me that I can just follow them up. And if the that chest should contract to rather early, do something about it. And uh yeah, and in our situation, well, except that we can't really do the va equip don't have vs equipment, the means to do it. It's uh these are very, very complex and they advance when we see them and vacs will not really be possible. So I just asked for early early referral and early insertion of drains and, and for please for regular review, which I'm prepared to do. So, that is that is my whole story. OK? Because we want to save lung in, in our society. And the other problem that we have is we see quite a number of ruptured cysts into the pleural space and you don't see the water Lily or anything anymore because it has become uh a total empyema and the membrane has mostly dissolved. So that is another thing that we often have to think about. Ok. Yeah, thank you, Sonia. Thank you very much. Thank you. Yeah, you have highlighted our problems that unfortunately we get patients referred uh not early, which we would like to quite late. And uh our problems are complicated by problems like HIV and TB and, and uh things like that. So Kirsty, uh if you can uh stop sharing, I will now invite Mister Pa to share his screen and then then give his talk. Uh No, uh Thank you very much for waiting patiently. Uh Now we are ready to listen to your talk and, and your advice. So please go ahead and, and uh you can start your talk. Can you hear me now? I can hear you nicely and we can see your presentation also. You can go ahead. That's great. It's worked out well. Then eventually after going on and off, on and off. Hi. Hello, everyone. Um uh I will, this is my, this was my talk which I gave to Adult uh European Society of Thoracic Surgeons uh in Vienna and II thought it will be the same talk which will be useful because it's a mixture of um the audience was mixed and I thought maybe it's easier rather than me uh doing an entirely new talk. So this was given to um in, in October 2017. So my main work was in Birmingham Children's Hospital. Um And I, I'm sure Kirsty must have said various things about um empyema um which is accumulation of uh infective rate. Um which uh we described increasing incidence in UK first in Lancet in 1997 and then subsequently, many other authors reported increased incidents around the world in western countries. And in spite of having seven well and pneumococcal vaccination um ha has not reduced the empyema um amongst the uh western world. Um and the studies from USA suggest that it, it has increased even further than um it was before. Um however, the incidence of um pneumonia has fallen. So maybe as the time goes by, it might reduce, but time will tell. Um So as uh somebody said, um postpneumonic pima is the commonest. Um and a secondary pima are related to trauma surgery is a visual injury, subchronic abscess hydrated or uh infected uh cam. Um but they, they are called secondary and um has highlighted um pathological stages which you might have described as 12 and three is never a uniform and you will not see uh in a single stages as you will see in a clinical practice. Uh and empyema is always a continuum. So basically, you will see a combination of all three stages in 11 case and you will never see entirely exudative stage, entirely fibropurulent stage and entirely organization stage. However, very, very late stages you will see organized like um um uh thoracic surgeon described that it is uh a calcified uh situation. Clinical features or symptoms are uh standard and related to the respiratory compromise. You will see and, and that depends on extent of the lumbar consolidation and rapidity with which the pus accumulates within the pleural space. So the acuteness of symptoms will depend on these two factors. However, the clinical presentation has various other factors which are tired of uh a situation which is uh host immunity. So if the host immunity is low, um and the organization is more powerful, uh then you will get a severe uh presentation of empyema. Um And if you have inadequate management, then you will have a chronic uh or subacute presentation, which is um uh prolonged pain situation and you will have a late referral and as uh discussion was went on, then there you have a two modality of imaging, ultrasound and CT scan. Uh we tend to do CT scan in almost all cases, but uh um ultrasound is uh um available at bedside and done primarily by many uh respiratory physicians uh before referral. Uh and it shows uh confirms the diagnosis, uh shows you loculation, thickness of uh fluid and pus in the pleural cavity and also can guide chest drain placement depending upon where the loculations are. And, and that has been done by the respiratory physicians who uh um insert the fibromy agents through a pic catheter. However, ct scan can exclude the lung pathology, which is not possible on ultrasound can identify o population as for ultrasound as well. Thickness of the uh C can be i thickness of fluid can be done by attenuation value within the um uh pleural fluid. And that you can say thicker or, or um uh or less thick and accordingly, you can judge or tailor your treatment. We had had seven Children with empyema like presentation, um which uh turned out to be tumors as you will see in this one. And I'll, I'll talk to you about it later. It's reported in 2006 in pediatric Surgery International. Um So, um value of CT scan as you can see that you can see the necrotic uh lung in this um area which uh you will not be able to see it on ultrasound alone, um, infected hydrated CT, which was already mentioned um before. Um And you can see the liver hydrated disease. So it, it probably uh that distinguish the problem. We had this case from uh Zambia, which came across um to Holland and he was studying in um in a rugby school uh because the father was working in a W um and uh he came to us uh with this uh condition which we never see. Um, we can see the infected um uh infected cam, um multiple uh lung abscesses which you will not see. Otherwise this girl was anorexic and uh throwing up um by putting the fingers in the throat and was aspirating. So she had uh multiple lung abscesses which you would not not have identified um and bilateral and PMA. So it's very difficult to identify if you just do an ultrasound on basis of um um um ultrasound alone. So important part of management principle of Pima is achieve early diagnosis. That is if you want to get good results, um achieve adequate drainage, which is whether you will do um fibrotic agents or thoracoscopy or thoracotomy. Important thing is to achieve adequate drainage, but at the same time, monitor your progress. Um So if you, whatever management you employed strategy, you must monitor the progress uh of the treatment employed and so that you can achieve full expansion of lung. Um This is the most important part of environmental management, whatever treatment you will do, whether you do full circle um from Hippocratic time for uh or now you have to have a complete drainage of complete drainage of fluid from the ural cavity. So um you, as you discussed intra agent, we, we, we were um um part of that study. Um And um you can achieve a good result if you identify the hyma early. Um um our strategy was always primary surgical intervention with the A S. Um um But um you can have failure of um uh inter fibrolytic and if you identify that and you can refer it, refer to a thoracic surgeons for uh vats or thoracotomy depending upon the stage of um empyema. But however, you will have to do a surgical intervention if you have a persistent sepsis and collection, a late presentation with pleural peel and tap lung complex empyema with significant lung pathology, which I'll come to you later. And pyopneumothorax with broncho fistula, you cannot do it with um VA S alone. You will have to do a thoracotomy. Um We uh presented to BSA couple of times our audit on VA S um once in 2008 and another time in 2000 and uh 19 for VA of uh Department of Emp. Uh This is in uh respect to what uh study which we had with RCT with vats with fibrolytic agent at that time was in a 16.6% va s failure. So, in with, with that, in mind, we conducted our audit to see what um outcome we had. Um and we had 100 and 22 Children in our study. Eight had a primary thoracotomy for rop fistula and were excluded from the study. Um And we had 100 and 14 Children with uh had a pure vats, age onset of symptoms, uh operating time, um duration of chest drainage was only four days and say stays was seven with range of 4 to 36 days depending upon um the situation. Um We had eight treatment failures, uh five converted to thoracotomy um due to failure to progress and release of trip tongue on table, we could not release the trapped uh lung uh and therefore converted to open. Uh And three had recurrences um uh following uh inadequate thoracoscopy by other surgeons because we had seven surgeons doing the thoracoscopy. So it's, it's difficult to maintain the same uniform outcome. Um We have few complication but all were managed conservatively. So during that time, uh we had about 8 to 10 series published. Uh and our series showed that uh we had uh 2.6% failure of uh or conversion rate. Uh length of stay was uh seven days. Um And um um uh total chest pain drainage about four days. So compared with others, which is the commonest one was canel, which is comparatively similar to us, but they had one death. Um And the length of postop stay was not specified and length of chest tube drainage was nine days. So, in conclusion, uh this is very important. VA department has a better outcome than recently reported randomized controlled trial. Va is effective primary treatment for empyema in experienced hands. So this is important, you do need to have a little bit of experience but it's not difficult to learn. Um debridement by VA S is is if you can do a thoracoscopy, this is uh a very simple thing to do or relatively simple thing to do complication rate is low hospital stay has significantly reduced uh longer when treatment was delayed. So if, if the treatment was uh referral was late, the hospital stay was longer. Uh V is achieved adequate drainage, full expansion of lung with minimal morbidity and no mortality. Complex exam, Pima should be recognized and managed appropriately to reduce the morbidity. And this is what I mean by complex empyema, empyema associated with significant lung pathology such as lung abscess or bilateral disease or trauma. I define that as complex empyema. So pneumothorax or necrotic pneumonia, lung abscess, infected lung lesion or parasitic lesions. Um panic trauma or blunt injury, uh unfollowed by infection or sort of hemothorax, getting infected, sub abscess and rupture, bilateral empyema and infected postlobectomy space. So these uh cases are considered as um complex hyma and has to be treated probably with open thoracotomy. So, if you have associated lung abscess, um you can treat um empyema as it is not open the lung abscess as such and uh treat with appropriate IV antibiotics. And that should resolve the um lung abscess with conservative management in most instances, um necrotizing pneumonia with spontaneous broncho fistula and this is what you, which I mean, but there is um a significant necro necrotizing pneumonia and it has leaked out spontaneously to cause uh pneumothorax. And in this case, we tend to do mini thy drain the empyema adequately, decorticate, parietal and visceral and insert um S digitation flap, which I have described and published in the literature. And this is my description of digitation flap, which I'll show it to you how it is done. Yes. So why we prefer cirrhosis and why we have done cirrhotic digitation flap is because every digitation of cirrhosis anterior has independent nerve supply and blood supply. Um So, um and it is part of uh lateral omy incision. So you don't have to take a separate incision. Uh raising this muscle, uh raising this muscle flap or digitation from the anterior incision. Anterior incision is very easy. Um because it's uh you just raise up from a peri periosteum. Uh And it comes out if you don't damage the lateral uh um thoracic nerve and uh you know, blood supply coming from the side. Um and it does not cause long term disability and I'll show you with the results of that. So this is, this flap was described by me in 2004. So, we, we uh analyzed the efficacy of our digitation flap. Um And we had 20 Children um between 4010 with uh P pneumothorax. Clinical resolution was achieved within two days. Uh chest drain uh was removed. Uh seven days, median 5 to 15 days, hospital stay was nine days and no reintervention. Uh lung resection or lung resection was required. So, it preserved the lung parenchyma. Uh and long term follow up showed full resolution um and no skeletal deformity. So that is one of our case, as you can see in post um uh CIA digitation flap, complete expansion and no scoliosis or anything like that. So, these are the cases. So if you see this case, uh who had um large um empyema with a lumbar, uh the whole lung consolidation, um had um pigtail catheter inserted by respiratory physicians in the periphery. Um and subsequently developed a pyopneumothorax with pict catheter inside you. Um You can see the CT scan with the um necrotic pneumonia and the pict catheter inside you on table. You can see there was a hissing sound with the necrotic pneumonia with um, uh bubbling of air coming out from, from the lung. We inserted the se center digitation flap onto the um, fistula and suture, the lung parenchyma around very loosely and, and that is the outcome POSTOP. So you can achieve good result after just a simple intervention but taking care not to damage the steroid anterior while you're doing a lateral. Thy another case, um, um was a large consolidation of pneumonia in a child which was admitted to it. And you can see the, just about see the um, chest tube, uh and the tube ventilated. And this child had also called a Pict catheter. Very small one you can see here, um, and was managed in it with a pict catheter and, and a, and a fibrillin, um, uh with uh IV uh IV given through the center line. Um, and as the time went by, uh they had done a CT also with no improvement. Um and you can see the necrotic lung um by the time they called us, um and child had developed bilateral lesions uh with overflow infections on the opposite side and a pneumothorax on the same side, um and developed a significant pneumothorax within hours. Then the tension pneumothorax with more time by the time they couldn't maintain the um ventilation. And therefore, they inserted three chest tubes which were bubbling away like nobody's business. Um and they could not maintain the oxygen saturation. So, uh we intervened in emergency uh and um inserted the C digitation flap onto the fistula. And that is the outcome. This is a real outcome. This child is doing exceedingly well now. So you, you know, you can improve um by early intervention um and um outcome can definitely improve. So that is me. Thank you for listening. Any questions? A uh thank you very much. I mean, I haven't read uh your recent publications. So th this uh cerus anterior uh flap was quite, quite uh uh ii it was very exciting new knowledge for me. So thank you for that. And um uh I always uh have appreciated and still appreciate your humility and modesty because uh I mean, you are one of the pioneers of pediatric thoracic surgery, not only in the UK, but throughout the world. And uh you really uh you never show off what you have already achieved. Now, I'm going to invite, there are other um uh sort of, uh, senior people who are attending the meeting. So I'm going to invite, uh, one by one. Some of them. Uh, the first one is, uh, Professor Larry Headley. Uh, you may know him. Dush, he, yeah, he is retired. Uh, but, uh, he's still, he's quite involved and, and he, uh, enjoys attending our meetings. So pro please give me a call. Yeah. Do, thank you very much. It's always lovely to listen to an expert talking about the field in which he is an expert um on your list of complex pima. Um I didn't see the word tuberculosis does, does TB associated with an, make it into a complex that's more likely to need a thoracotomy. Uh We don't see TB uh as commonly as you guys do. I think. Um in my experience in 25 years, we have seen uh MDR um about three times uh which came from um um infectious disease place and we had to do a lobectomy. But uh hyma infection wise, we have seen only two cases of TB with pleural effusion. Um But um uh no, I II haven't seen II cannot include TB. Um because uh unless you get a secondary infected TB uh pleural effusion, usually it's a very serious pleural fluid and uh and that tends, tends to control the tuber plus infection within the lung because it collapses the lung. And that's my personal exper uh that because you have a plumbed or closure or lung collapse, the, the TB, within the lung tends to um um uh remain uh within the cavity and then that tends to um uh I, if you give a antituberculous treatment improve the outcome, but uh we haven't seen so II cannot be expert in TB. So I'm sorry, II wouldn't say the TB is our, I won't include that as a in, in my personal experience anyway, you may be able to because you see very complex TB. Yeah, 11 of, one of the lovely things about retirement is that uh we can say, you know, we'll ask Sonia but forget. Thank you very much indeed for uh for your contribution today. Um Thank you, provide um Sonia. Do you have any more comments before I invite comments from our other consultants? It, it it's just that TB is a very real and very huge problem for us and to manage those lungs is very problematic. Um Yeah, because often it's associated with HIV with malnutrition. So the these problems are very complex for, for us to manage and all of the most of them like in adulthood, they manage this very long term problems and they attend our clinic on regular basis until the space is clean and then some kind of the thoracoplasty etcetera is done uh which is very challenging. Um The surgery, everything about them is very challenging. So yes, it's, it's, it's what the problem you highlight. It's about early treatment and that's where vats, etcetera and proper drainage at an early, early stage comes in. And that is why get, get somebody involved who, who, who, who will place drains correctly and not little pigtail catheters that are not going to work. So, um, yes, that is all I can ask. And TD for us is a very, very real problem problem. I understand. I understand. Yes. Yes. Yes. Thank you. Sonia. And, uh, Sonia had advised me and I had personally invited at least a dozen pediatricians to attend this talk because uh I don't know whether I can say that I was relieved to see that even in the UK, uh pediatricians do not refer patients to pediatric surgeons well in time. And uh this is where uh uh what sort of Sonia has been advocating and we are trying to uh trying to influence, trying to tell our pediatric colleagues that uh this thing as soon as you suspect you rather uh get a pediatric surgeon to see sooner rather than later. And uh that doesn't seem to be happening. Uh So anyway, I think we will just have to keep uh uh conveying to our pediatric colleagues that please refer these patients as soon as possible. Now I'm going, yeah, that's in UK, we have a huge respiratory physicians, a pediatric respiratory respiratory physician's body. And um uh even I must have given at least 203 100 talks around the around the place and and people do have referred me earlier and earlier. Uh however, um it, it is, it, it is an ongoing um struggle and uh once you come out of the um practice, uh people go back to where they were and, and they tend to listen to their bosses who, who tend to put a pigtail catheter. So it is difficult, but as long as they recognize um failures and refer you after the failure, that also is a bonus. Um because then also we can get, get the child better earlier by uh intervention. Yes, I'm sure you, you have handed over the to, to some other competent colleagues, but uh thank you for that. Uh Now I'll invite Doctor Sello Maa. Doctor Mataya is a consultant, pediatric surgeon and he has actually mentored Christy Pedersen for this talk. So sell please your your comments. Uh Thanks. Well, uh thanks everyone for, for your contribution. We definitely are learning from hearing from everyone's uh experience. Um And what I'm gathering as well is an early referral is definitely always better than delayed. But unfortunately, um it seems it's not just a third world um population or issue difficult challenge where we get delayed referrals because as Sony is mentioning um by the time we get any child with any pathology, it's usually 34 weeks down the line. Once the child has stayed at the periphery and they've tried with the antibiotics and changed antibiotics and started TB treatment and they see TB treatment is not working and then they refer the child, um, saying that OK TB treatment is not working. We think it's a resistant TB or something along those lines. Um, so I think, um, from everyone's perspective, knowing early referral actually helps in the long run for um, the better outcome of the child is, um, or rather beneficial. And that, that also goes in part with how it kind of um changes. I think the management, which I'm up for correction. Um from Sonia in that, with, with the earlier presentations you could consider uh that. Um but with where we are, unfortunately, on the anesthetic side, they only have a da certain size shoe. I think it's a 28 size to do um single lung ventilation. And even if they, they do that, that's only literally, I think for a child who's 30 kg or above eight years old. So it's for more older pediatric group. And even if you were to consider just doing a bronchial blocker, which in our setting, unfortunately, we don't have that means that you can't, you can attempt, but it makes um doing any vats um a bit challenging. Um when you, when you haven't actually um tried to isolate um the lung. But I think going forward, the important thing is that um early identification um from the pediatricians and early referral to the ped surgeons and the cardiothoracic cardiothoracic surgeons would definitely alleviate um um the burden we're having now and even using fibrinolytics, um as it's the problem with delayed referral. I think that's where it comes, where you can't initiate it necessarily early. And I think also with um not ignorance but lack of insight into knowing that fibrinolytics can be used in lung empyema and not only just the chest drain, um would go a long way and once you've identified, it's empyema, you put a drain in and maybe even do fibrinolytic early on because literature suggest that. But in reality, um we have to adjust how we treat our patients according to the pathology according to the delay in presentation and not treat them as an empyema and class them all as how empyema present in certain parts of the country or certain parts of the world and treat it individually. So individualized uh treatment per patient where um we can't put them in the same um box or in the same thing altogether. Um But yeah, I think that's my five cents. Pro Thanks. Thank you. Thank you. Um We don't isolate our lungs. We have a bilateral uh ventilate both the sides. At the same time, we have never isolated an empyema ever. So, uh there is no need to isolate the lung. That's all I can say. Oh, thank you. Do that. That's uh important clarification for us. Um I will now invite Doctor Majola Doo Majola is uh our consultant, pediatric surgeon. Also does uh like the other Doctor Macha and man does thoracoscopic work. So Doctor Majola, any comments? Hi, thank you for uh I think has just sort of um run through all most of what II wanted to, to, to say. But what I just wanted to ask doctor uh our, our guests when it comes to the, as uh Doctor Van Ri mentioned that they sometimes get uh deformity of the lung or the chest because of contractions. Um How do then they go about releasing that lung? Do you really cut out the whole pleura covering the lung or do you cut out part of it? Um I just want the technicalities of how they do it. Um Is for me, is it um II tend to remove as much as possible except for the mediational pleura. So I, we tend to decorticate visceral pleura um As much as we can um not the medias side because you can damage a lot of structures. Uh So I if you can um decorticate uh visceral uh pleura on the side, on the periphery, uh as much as you can um uh the more you do, the better it is leaving the meal pleura. So then you can achieve a reasonable uh lung expansion that is during decortication. Yeah. Yes. Th thank you, Doctor Doctor Mola. Any other comments or questions? No problem. Thank you. And I'll invite Doctor Mann, our other consultant, pediatric surgeon to make any comments or questions Yoda All right. Yes, thank you. And thanks to Doctor Park for his uh wealth of knowledge. It's really um it's great to, to get your expertise on, on the subject. And thanks to Sonia who gave uh you know, a picture of what we are experiencing in our setting, which I think is really important, especially, um you know, there's a lot of uh places with the similar resources to us and similar difficulties. And I just wanna highlight to the, our juniors and the pedia pediatric surgeons um who are watching is that we tend to see a lot of the secondary empyema. And if I can use a double negative, it's not uncommon to have these uh complications with uh the surgeries that we do do. So. Um I know from our, my limited experience as a consultant, we've seen a few esophageal perforations, um central lines leaking into uh the thoracic cavity and uh complications of thoracotomies for esophageal atresia is resulting in um empyemas and my experience and my uh uh advice to the juniors would be and I think, II think I echo Sonia's um sentiments that early surgery is really important in these kids and they uh I'm talking about more neonates, but um especially with the very septic uh neonates, I think early surgery, it can be life saving. So what we do is thoracotomies, I think that is somewhere in our future, but especially with these kids, they tend to be quite um severe or uh complicated. So I would opt for an early thoracotomy and I think that's been working so far for us. So I just wanted to give our experience. Thanks and thank you, soda. Um Yes, you have highlighted uh like secondary employment due to esophageal injuries and, and complications of central line, which I'm glad about. And uh uh if, if I want to put it very simply, I mean, um to teach uh a medical student, empyema is an abscess in the thoracic cavity. So once an abscess is formed, we need to drain it, we need to drain it adequately. And obviously, we need to give antibiotics. And obviously here because lung is involved, we need to make sure that the lung is expanded properly. So I think that that uh those are very, very important messages uh given by all of you consultants, Mister Pa uh Sonia, uh all of us. Uh I see Doctor Y Cit who is a consultant at Red Cross is with us. You trained in Johannesburg now working in Cape Town. Any comments, anything different done in Joburg or in Cape Town? Hi. Hello, Doctor Gitner. Um And thank you so much that I can be part of this talk, even though I'm not part of the institution, it's great that knowledge is, is shared this way. Um If I think about my experience at wits um at um Baraga Hospital, there were no cardiothoracic surgeons. So these patients were referred to us and um usually to, to Derek who did these and I would say that the approach while the the referral was very delayed. So the patients were usually very ill with a lot of lung damage already. And the approach was quite um aggressive in terms of decortication, like a large area of, of pleura always had to be removed. And then at um Charlotte Mauke Hospital, um we there was actually a department of, of Cardiothoracic. So I didn't see um any of those during my rotations there. Um And at Red Cross, I still haven't had any personal experience, but it seems to be kind of um a multidisciplinary share um between the Department of Cardiothoracic um pulmonology and um pediatric surgery. And there is, I think the third month of every month there is a multidisciplinary clinic where um these patients are discussed, but I don't really have experience of it. I just, I have an awareness of it. Th thank you. Uh Thank you for sharing your experience. I think we are coming towards the end of the meeting. So I'm going to request uh Dush maybe to just give a final concluding remark, take home message for all the colleagues from South Africa USA Caribbeans, Pakistan. Uh please your final words, duh. And thank you again very much for joining us and I will certainly rope you in for any other thoracic uh talks uh in the, in the next year. Or year after that. So please your final comments. Duh. Oh, it's very good. Even I tend to revise my thing before I give you a talk because I haven't uh, talked about this condition for a while now because since I'm retired, so it's great to revise it again, uh and reenter the situation. But I think it's, it's very good. One of your trainee is in Birmingham at, at the minute doing a uh consultant job. W oh, from, I think, uh is she from Red Cross? Um, I'm sure Red Cross. Yes, Anne Marie. And yeah, so she's with us um in Birmingham Children's Hospital. Yes. II haven't um um been with her at all because I had retired. Um I'm going to go back to work to help with the COVID-19 cases uh waiting list. But other than that, I'm off the thoracic work altogether. But no, it's nice. I learned a little bit about TB, which I have lost touch with. Um um, but yeah, TB is something which uh I definitely had worked when I was in India uh with um uh we had a ATB hospital and my uh consultant used to take me over there to help with the TB cases, but that's long, long time ago. And as I said, I've forgotten um management of TB as such. So sorry about that. But I think overall even for it is educational and um as long as uh we have said number of people, early diagnosis, early referral and early management will improve the lung expansion and the overall outcome. Thank you very much. Thank you. Thank you. Do have a good evening and uh good to see you maybe next year or year after that. Certainly. And yeah, whenever you wish, yeah, I wish I I'm happy to join if you, if, if it is something which I can contribute. Ok. No, no, great. No. thank you. We will certainly keep that in mind and thank you everybody uh for attending and for being patient with our technical issues next week. Uh The Doctor Julie, our registerr is going to talk about um uh hypoglycemic um uh hyperin mimic hypoglycemia in newborn. And uh and uh uh uh and, and uh doctor uh Nira Patel from, from Johannesburg will be the invited guest. So you will get invitation for the meeting next week and uh e everywhere th thank you for joining again and, and have a good day wherever you are. Bye-bye now, all the best. Bye-bye.

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