Discussion with Dr. Shawn St. Peter and Dr. Todd Ponsky regarding evaluation and management of empyema.
Dr. Ponsky: Welcome to "Stay Current in Pediatric Surgery.” Today we’re going to be talking about empyema and with us we have Dr. Shawn St. Peter who I’m sure is very well known to all of you. Shawn is director of research at Children’s Mercy Hospital in Kansas City. He’s also the director of the Center of Prospective Trials and he’s the director of the pediatric surgery training program, and he’s director of the Surgery Scholars program, where they have general surgery residents coming to do research there. And, for those of you that don’t know, Shawn has really been the leader in the world, actually, I was going to say the country but probably no one comes close to really the work you’ve done, Shawn, in getting pediatric surgery on the map and doing real research, prospective trials. Before you came along we were doing a lot of case reports and experiential data but you’ve sort of gotten us going on doing real research and prospective trials there at Children’s Mercy hospital and you’re certainly who we call when we want to get a prospective trial going. Shawn, thank you for joining us today.
Dr. St. Peter: Thanks for having me, Todd.
Evaluation of patient with pleural effusion
Dr. Ponsky: The reason that we’re going to talk about empyema with you is that some of the work you’ve done has radically changed sort of the paradigm of how we manage empyema. I remember I was giving a lecture at the fellows course on empyema and I stood up there and my first slide starts talking about doing a VATS and everyone in the audience was shaking their heads at me saying, "You are old news man, we don’t do that stuff anymore.” I said, "What are you talking about?” And they said, "Well haven’t you seen the paper out of Kansas City where they showed the whole new management using TPA?,” so that was when I first found out about it, and over several years I’ve finally been convinced and we have switched over at our hospital and so we’re going to get deep into how we deal with these very common and complicated patients sometimes. Let me first start out with a patient who, let’s say it’s a 3 year old in the winter months. He comes in with symptoms of pneumonia and has a chest x-ray that even shows early pneumonia. He’s not in the intensive care unit, he’s on the floor, and he’s having some very mild respiratory illness and fevers. An x-ray shows evidence of an effusion. How do you manage that patient?
Dr. St. Peter: Well there’s several centers and authors who have advocated on not treating the effusion for the sake of the effusion, but only when it becomes symptomatic. Defining that can be a difficult thing and it takes some clinical acuity to figure out how much of this is being driven by their parenchymal disease versus their pleural disease. Typically, once it gets to be greater than 1/3 of the chest and you’re having severe respiratory symptoms it’s the typical logic that at that point when you have what you’d define as a moderate or a larger pleural effusion that they would clinically improve from aspirating that. And in a situation where you have an ultrasound that shows free-flowing fluid, and it’s large enough that you believe that it’s symptomatic and that they would benefit from tapping it, then we would start with a tap and that would answer the question of whether or not it looks like empyema in the form of frank pus. Now if your ultrasound shows that there’s solid material or septations, you’ve got to pin down that you have a clinically relevant pleural effusion that has solid material. Now we’re going to treat it like empyema and go down the VATS versus fibrinolysis pathway which we’ll discuss in a bit. If they have greater than 10,000 white blood cells on their tap, which was one of the entry criteria for our trial, of VATS versus fibrinolysis, they really do have an empyema. At the time that we were developing the trial, one of our infectious disease doctors recommended, it was Mary Anne Jackson that recommended that entry criteria, and we thought that might be a little too soft, but it turned out to be completely correct. When you get that tap and it’s 30,000 white cells, in the patients who were randomized to VATS, you put a scope in and it looks like any other case of empyema that you’ve done, so those patients really do have empyema.
Dr. Ponsky: Let me back up and clarify a few things that you said. First I want to talk about the 1/3 of the chest, and I know that’s somewhat arbitrary but maybe not.
Dr. St. Peter: It’s entirely arbitrary and there’s a pretty elaborate algorithm that was proposed by the folks in Seattle led by Ed Carter, he’s a pulmonologist. They had looked at calling it, small: less than a quarter, moderate: from a quarter to a half, large: greater than a half. That’s just one. But, even then, under each of those boxes you have the branch of symptomatic/asymptomatic. Tt’s not something that I’d want to be quoted on putting a number on, a percentage, or anything else. I think I would just stick with, it’s a large pleural effusion that you clinically think is making an impact on how they are doing right now. In the case of a free-flowing fluid collection I think your threshold can be a little bit lower for tapping it because you don’t lose a whole bunch for trying so if you tap it, and it is free fluid, and it looks clear, and it doesn’t make them better, you’ve answered the question. This is somebody who’s suffering from parenchymal disease and if they have a recurrence of the pleural effusion, you’ll have a higher threshold for treating it the next time around since you know it didn’t help them the first time you tapped them.
Dr. Ponsky: Again, obviously, for the listeners out there, we’re going to be getting into this new algorithm and I want you to explain the trial you’ve done and all that, and the algorithm, but just to start with I think this part is great to know. That you get the x-ray, you see a moderate to large effusion in a patient who’s symptomatic. Getting a tap is probably a good idea, not only for treatment but also for diagnosis to help guide you in what you’re going to be doing next with that patient. Is that right?
Dr. St. Peter: Yeah
Dr. Ponsky: Shawn, there was a number that you threw out and I want to make sure that I heard it correctly. The number of white blood cells in the effusion should be what?
Dr. St. Peter: 10,000
Dr. Ponsky: Greater than 10,000. Okay.
Dr. St. Peter: Yeah that’s what we define as an empyema as enrollment criteria for the trial. That doesn’t mean that that number is right. We haven’t studied that particular parameter, just that that’s what we used as a yes or no can they be in the study, and of the patients who had that criteria, who randomized to that, I can tell you that it looked like just a regular empyema once you put the scope in.
Treatment algorithm for empyema
Dr. Ponsky: Let’s say you have this patient, because it sounds like, study or not, these patients are going to get an x-ray that shows a large effusion and are going to get tapped. Tell me your algorithm and tell me about the study that you did to come up with this algorithm
Dr. St. Peter: If they have septations that are seen in the pleural space in somebody who has significant pleural space disease, or a parapnuemonic effusion, or a tap that shows greater than 10,000 white cells, now they’re defined as empyema and the study that we did is a randomized trial comparing primary VATS to primary fibrinolysis. At the time, there were several papers that said if you just go straight to fibrinolysis they’ll do better than chest tube alone. There were other papers that said if you just go straight to VATS, once you have a diagnosis of empyema you’ll do better than having a chest tube and waiting to see if that fails before going to VATS. What we didn’t know is VATS versus fibrinolysis at the time you make the diagnosis. The data seemed clear do chemical debridement, fibrinolysis, or mechanical debridement, VATS, as soon as you have a diagnosis, but the comparison between the two wasn’t known. We used our own retrospective data and we had a difference of over two days in the hospital in favor of VATS. We couldn’t really come forward with that data because they were managed by two completely different services. At the time, if you were having fibrinolysis in our hospital, you were going to IR and the pediatricians were managing your chest tube. The surgeons were managing their own chest tubes after VATS, so there’s a whole different clock and level of comfort for pulling the chest tubes of course, whether they’re on the medicine service or the surgery service.
Dr. Ponsky: This again argues why you need to be doing prospective trials
Dr. St. Peter: Yes, that’s kind of how it turned out as we designed the trial. The surgeons were under the assumption that VATS would win, and win by a landslide, which is kind of a funny thing. I think the public perception, I certainly hear this a lot, is that I have some strong bias to fibrinolysis and I’m biased and not approaching this as an unbiased, thoughtful person and it actually was entirely the opposite. My only bias was that I knew VATS was better than fibrinolysis. And it wasn’t until we started the randomized trial. And, another thing that comes up is the sample size. The reason the sample size was so small is because the difference was so big going into the trial design. It was designed fairly, we weren’t doing any gamesmanship for making it do-able, we were just taking the numbers that we had. And the numbers that we had were, on average, 2 days less in the hospital plus a small standard deviation. We were consistent, they were consistent, so that gave us a small sample size. And, once we started enrolling in the trial and all patients were managed on the surgery service with the exact same protocol, it was really powerful to see with your eyeballs exactly how these patients were doing. And it was towards the end of the study that one of the fellows asked me what I would do if my daughter came up with empyema, and I said I would do the fibrinolysis. I don’t think I’d enroll her in the trial because it really struck me that none of those kids got sicker. I didn’t even have the data yet, but I did know that sometimes you do a VATS and with the barotrauma to the good lung and beating up the bad lung, they fly pretty close to the tree tops sometimes after the operation. Nobody gets sicker with the fibrinolysis.
Dr. Ponsky: I have to tell you, Shawn, after I did my first one, I walked in the next morning to the ICU, he was so sick that we transferred him to the ICU the night before, he was sitting up on the bed, smiling, gives me the thumbs up. I said, "Can I take a photograph?” This is a photographic memory of what it looks like, my first TPA patient. I found the same thing. I want to clarify something that you mentioned just to say it again: At least what we do know—before this trial even—is that chest tube alone is not adequate, correct?
Duration of antibiotic therapy
Dr. Ponsky: Now, Shawn, you had mentioned that, now, let’s say the patient has persistent fever but is doing respiratorily okay and are eating okay so you let them go home on I’m assuming IV, maybe even oral antibiotics, what’s the end-point there
Dr. St. Peter: That’s a really interesting question, because when we had worked on the community acquired pneumonia guidelines with the IDSA group the recommendation, and this is just infectious disease doctors saying, okay there is literally nothing out there so we’re going to have to just throw out a number that we think is reasonable and prudent and that was 10 days, which was a grade D recommendation based on nothing whatsoever. So, that got us to thinking: What are we doing in our own hospital? If we’re following these protocols, what happens once we’re done? And so, we looked at our own experience and found that we had a shocking average of 19 days of antibiotics after being afebrile. Now the recommendation from the IDSA guidelines was 10 days after being afebrile, but didn’t define the other criteria. So, we had an average of 25 days, with 19 being after afebrile, and 40% of the patients had complications from their antibiotic therapy, ranging from diarrhea to fungal superinfections. With that being the case, we clearly had a problem. We took the data and reviewed it with the rest of our infectious diseases group, and came up with a prospective protocol moving forward to try to truncate the antibiotic therapy. The protocol that we now use, we put into place last fall in order to measure our results prospectively. This isn’t something we can randomize around because we have no event rate. Historically, we have no recurrent empyema. You know once you get it treated, your chances of having another empyema is next to none because it’s typically a cement space, it’s typically gone. But with a zero event rate, there would be nothing to randomize around, so instead we just truncate the investment. In our case we said 7 days [of antibiotics] after meeting all of the following criteria: you completed your fibrinolysis, you’re off oxygen, and afebrile—at that point, 7 more days of antibiotics. Some people are afebrile before they even complete their fibrinolysis, that’s not part of their disease, so they have to at least complete the fibrinolysis. And, if they are afebrile and they completed their fibrinolysis, but they’re still requiring oxygen, that would be another criteria to not start the clock yet. Once all those 3 criteria are met, then they can start their 7 day course and they can go to orals if they’re a candidate. Sometimes you’re dealing with little babies who aren’t going to be taking the medicines and they just get a PICC line. But that’s a clinical decision, that’s not part of the algorithm. The point is, having an algorithm to guide the care so that it’s not a simple matter of just continuing the antibiotics for any subjective period of time, which is clearly what had happened in our past because we had protracted courses that were highly variable. There was clearly no thought going into, I mean, there was no systematic thought. There was a lot of thinking but it was a lot of different people coming up with different conclusions, as opposed to saying well let’s establish some hard criteria for stopping antibiotics.
Imaging for empyema
Dr. Ponsky: Let me hear how this all happens. Now you’ve got this patient: 3 years old, has a pneumonia, has an x-ray that shows a moderate to large effusion, he’s having an tachypnea, he’s on a little bit of oxygen, and I’m assuming then that you would get an ultrasound. Is that right?
Dr. St. Peter: Yeah that’s where it would start.
Dr. Ponsky: You get the ultrasound and not a CAT scan?
Dr. St. Peter: Right. There’s plenty of data to say that looking at empyema, trying to diagnose pleural disease, and identifying stranding, the ultrasound has no disadvantage to CT. And, there’s been one prospective study that put the ultrasound in front of the CT as an automatic protocol and they found that they decreased their CT utilization but didn’t change their outcomes—sort of like you find whenever you put ultrasound in front of CT for appendicitis. You just, you decrease your CT rates, but you don’t really change a whole lot else.
Dr. Ponsky: Now you get an ultrasound, and we talked about the fact that if it shows an effusion, free-flowing or not. Tell me what you do then.
Dr. St. Peter: Well, if it’s free-flowing that’s when you’d go to the tap and make a decision. If it shows that you’ve got septations and solid material within the pleural space and you think you have enough disease to warrant treatment in the pleural space, you’re on the empyema pathway. Then they would get typically a 12 French valved chest tube and 3 rounds of TPA. And what we had used in our initial protocol was 4 mg of TPA mixed into 40 mL of normal saline. Sometimes the pharmacy sends up the mix, sometimes just the powder, and we mix it right there. Then that’s put into the chest tube and allowed to sit for 1 hour with a clamp on the chest tube. A dwell time of 1 hour and then put it back to suction to get it back. That’s done at the time of diagnosis, at 24 and 48 hours. Three doses over the course of 48 hours and that’s that
Dr. Ponsky: Who puts in the TPA? The nurses or the physicians?
Dr. St. Peter: It’s the physicians. The surgery fellows do it. They typically teach the junior residents how to do it early on so that they don’t have to do it. If interventional radiology does it, then they’ve got nurse practitioners that come up to the floor to do it.
Dr. Ponsky: Okay. The 12 French catheter is placed, TPA is put in immediately. You don’t wait hours or days to put it in? You put it in right after you put in the catheter, and let it dwell for an hour, drain it, and then repeat that 24 hours later?
Dr. St. Peter: Right. And to get back to the data, you know, the trial that we did showed that there was no difference in length of stay and there was a 1 in 6 failure rate, so 16% in our study. And, at the time, just recently published out of Great Ormond Street by Sonnappa et. al., they had found the same thing. That there was no difference in length of stay and a 1 in 6 failure rate. They had more patients. They enrolled 60, so at this point, we had a lot more patients than just the 36 we randomized. We had effectively 100 patients randomized between us and Great Ormond Street, and their protocol was the exact same as ours except that they used urokinase instead of TPA. They had a 4-hour dwell time instead of a 1-hour dwell time, but otherwise the study was set up almost exactly the same. And, with both of those studies being that concurrent, and to agree completely across the board, not only was there no difference in length of stay, the actual raw days were very similar between our study and theirs. And, we found that the charges were higher with VATS, and so did they. And again, the difference was very similar. But, what came out of that, and the reason we moved forward with such confidence in our conclusion, was that now with those two studies together you can safely say that you’re not getting an advantage from an operation, when you’re comparing an operation to not an operation. The two aren’t of equal comparison by any means. Getting equal results without requiring an operation, then there’s no way you can recommend the operation. And, there’s really no way a parent would sign up for that. You’d say, well we can take you to the operating room and do this, or we cannot, and the results are the same, everyone’s going to say, let’s do the "not.” And then, just in the past couple months, I think it was in the fall, the paper came out of Spain, where they had done a randomized trial in 100 patients, also using urokinase, and they found the exact same thing. There was no difference in length of stay, and they had a 15% failure rate. Now with 3 randomized trials, all showing the exact same thing, and 200 patients randomized, I think we feel pretty good that that data is real and we don’t have an observation error because of the small sample size that we had in our study. And after we finished that study, then we carried on with that protocol in place, and after treating 100 consecutive patients, we reported that experience to the AEP. That’s now in the Journal of Pediatric Surgery, and in those 100 patients, the results were the same: that we had a 15% failure rate, and the length of stay was staying about the same. The interesting thing is that one of the concerns about fibrinolysis is that you’d make the subsequent operation harder and we didn’t find that to be true. There was no difference in operative time or blood loss in the patients who had a subsequent operation as opposed to a primary operation.
Dr. Ponsky: Okay, I want to address some semantics just because this used to be my argument, and I’ve heard others say the same. I believe that at Kansas City, you do a lot of this at the bedside. But I know that there are some institutions that put in these catheters in the operating room if they need sedation, or if they don’t have sedation available at the patient’s bedside or in a sedation unit. Then they would say, "Okay, you’re going to the operating room. You’re giving sedation either way. One is you put in a trocar, and the other one is you put in a catheter. Is there really that much difference between the two?”
Dr. St. Peter: I completely empathize with institutions which are going to require what is considered a general anesthetic. We had a baby, during the trial, and now it seems we never have this situation because our sedation team is good. But they wouldn’t sedate on the floor because it was a baby and sick. We went to the operating room, but we didn’t intubate and use positive pressure ventilation. We did sedate and then slipped in the 12 French valved chest tube and then they go down that course. I empathize with the logic: go ahead and put in one port, do a limited debridement, and then leave the chest tube. The downside, now that I’ve thought about that more, is that you’re nullifying some of your advantages. You’re still creating that mechanical debridement and you’re going to kick up their serum response and you’re putting them on the ventilator with positive pressure ventilation to the other lung. You still end up going down that pathway. If I’m in a situation that we’re going to have to go to the operating room, I’m going to employ an anesthesiologist. I’m going to ask that we don’t intubate, and I’m going to put in the needle-guided 12 French valve, which is really innocuous. I think it’s less of a to-do than just putting in a PICC line, because the amount of time it takes knocking around to get a PICC line in when you can literally do this in less than a minute.
Dr. Ponsky: Right. And I think that’s a helpful argument on doing the fibrinolysis, and the argument about doing the sedation at bedside. The hard part is that at our hospital and others, when they’re sick enough that they need this done, they’re usually pretty tachypneic, they’re usually pretty sick and they usually don’t qualify for bedside or sedation unit sedation
Dr. St. Peter: In an older kid, we won’t even bother with the sedation. We just, and we’ve done this several times, say we’re going to inject this with local anesthetic. It’s going to burn for a second, and then that will be that.
Post-procedure chest x-ray
Dr. Ponsky: I think we’ve got the algorithm pretty clear, but one of the things I wanted to understand, do you need to get a chest x-ray every day?
Dr. St. Peter: No, and it’s not going to change anything. It’s going to look pretty bad for quite a while, even after you finish a course, I don’t think it’s terribly helpful in discerning whether or not you’re a candidate for VATS after what you would consider a failed fibrinolysis. The chest x-ray is not going to look that different, so it’s not entirely useful.
Determining failure of therapy
Dr. Ponsky: Alright. So now you’ve given your 3rddoes of TPA, you let it drain after that hour, and you wait 24 hours. I’m assuming and you get a chest x-ray at this time?
Dr. St. Peter: No, no I wouldn’t.
Dr. Ponsky: Okay. What do you do then? Now you just look at the patient?
Dr. St. Peter: Now it’s just strictly clinical observation and we did not specifically set a failure criteria, but what we practiced was 3-4 days in the study. The Great Ormond Street did define that as 4 days of continuing fevers was going to be their criteria for failure. Since we’ve completed the trial, and this came out a little bit in our paper on the 100 consecutive patients, we’ve become more patient with fevers. We’ve realized that they’re going to continue on their antibiotic therapy anyway, regardless, because of their parenchymal disease at the start of the whole process. With that being the case, the fever shouldn’t be the determining factor for considering that. It would be not being able to get out of the hospital, requiring oxygen, not eating well. In other words, they’re still sick. Those are the patients that we would begin to consider a failure. Typically, after about 4 days we start to think about it. At 4 plus days, if they’re still sick, then we start with imaging the pleural space and start with an ultrasound. If you see that you have pleural space disease, then you’ll be a candidate for VATS. The question frequently comes up, what about a second round of fibrinolysis? If there’s nothing to explain why the first round failed, then a second round isn’t indicated. If the tube is in the right spot, there is still all this pleural space disease that’s in continuity with where your tube is, then I wouldn’t recommend the second round. What we do, when we do recommend a second round, is when you see that your chest tube is not putting out much, it’s effectively walled-off, and you see you have a big collection somewhere else in the chest, we would pull that tube, put in an image-guided tube into the walled-off collection that’s not in continuity with the space that seems to have been cleared out by your initial tube, and then do a second round of fibrinolysis because you’ve got a temporal explanation for failure that’s regional as opposed to you see a very similar looking empyema but your fibrinolysis didn’t work. That doesn’t happen very often. Most of the patients in the situation where they have severe pleural space disease after fibrinolysis and they still are clinically ill after 4-5 days, would go to VATS.
Dr. Ponsky: And clinically ill is having trouble with oxygenation or feeding, but not fever?
Dr. St. Peter: Right.
Dr. Ponsky: Is there a patient who should not go to VATS after an apparent failure of fibrinolysis?
Dr. St. Peter: Yeah, the patient who has extensive pulmonary necrosis. Sometimes you get an ultrasound and it’s not too terribly impressive, but they’re quite ill. Then you can move to a CT and if you see extensive pulmonary necrosis, then those are the patients that I think you risk hurting a lot more than helping by manipulating a lung at all. We have all seen those patients from experience when primary surgery was the way to manage empyema that ended up with these really protracted courses of bronco-pleural fistulas and ended up with those Heimlich valves for months on end. The only way that you can get into that bad of a situation is if you’re getting into the proximal lung—peripheral lung lesions heal. And that’s only going to happen if you’re operating in the field of necrosis and debriding that necrosis, so that’s somebody that we would not touch and just continue antibiotic therapy in perpetuity.
Dr. Ponsky: I want to make sure I understand this correctly. You have a patient that is qualified to get fibrinolysis, you do the fibrinolysis and after they’re still ill. You get a repeat ultrasound which shows fluid. Do you always get a CAT scan first, or only if you don’t see fluid? So that if you see fluid you go to VATS, but if you don’t see fluid you get a CAT scan?
Dr. St. Peter: If you don’t see fluid you may want to get a CAT scan to further figure out what’s going on. Even though you typically see an abscess if it has an air fluid level, you might find a peripheral well-formed abscess that doesn’t have an air fluid level on the CT. That’s sort of a judgement call. The patient who doesn’t need a CT is one who gets an ultrasound and it looks just like your first ultrasound did, where you have fluid, septation, and you’ve got room. Even if you have some parenchymal necrosis in that circumstance, you have a pleural space to work on, so you are still going to follow the basic principles of a VATS, which is leaving the lung alone and cleaning out that pleural space. But, if you see that the pleural space is unimpressive, and it’s not adding up with the clinical picture, that’s when you may want to go onto a CT scan to figure out what’s going on.
Dr. Ponsky: If you do the VATS and the lung looks really nasty: black lung that looks necrotic, do you touch it or leave it alone
Dr. St. Peter: Leave it alone.
Dr. Ponsky: Okay. And if the patient who didn’t have much pleural fluid gets a CAT scan and sees pulmonary necrosis but he’s ill, on the ventilator, and is having super high fevers and a high white count, and is very sick but doesn’t have much pleural fluid, but has necrotic lung. Would you still sit tight on that patient?
Dr. St. Peter: Absolutely. There was a patient that had complete pulmonary necrosis. Now, severe chest wall abnormality, multiple other problems, so there was one hemithorax that was very small to begin with and one that was normal size. And the small side ended up with this diffuse necrosis. It just looked on CT like there was no viable lung there at all. And, the patient was persistently ill. The surgical recommendation was absolutely don’t touch it. We talked with our cardiac surgeons, we all looked at it, we agreed that you could try to do an intrapericardial pneumonectomy and it would still be incredibly risky, but that would be the last step after many months of antibiotics. We started down this many months of antibiotics pathway and it was the suggestion to get a needle biopsy to try to help identify the bug at a more peripheral level. With the needle biopsy, that patient died. Exsanguinated out of the wound and into the bronchi and so I think that patient drowned more than exsanguinated, but the point was that lung does not tolerate being touched in that situation.
Dr. Ponsky: One other situation that we’ve seen, is that sometimes it’s so bad, the lung disease, the parenchymal disease, that they’re actually, as you said, drowning, not on blood but on pu. They just cannot keep up with the secretions and then sometimes some believe that’s an indication to go in.
Dr. St. Peter: We had a gal last winter that was 3 years old and went onto VV ECMO because of bilateral pulmonary necrosis, that is severe necrotizing pneumonia on both sides. She already had chest tubes on both sides not putting anything out. It was not pleural disease. She stayed on ECMO for almost a month. The CT showed hardly any viable lung on either side. And, we did not operate, we did not touch that lung. She came off ECMO and did fine. I’m convinced that she wouldn’t have survived if anyone tried to operate on that lung on either side.
Dr. Ponsky: We talked about necrosis. What about pulmonary abscess. How do you manage those in Kansas City?
Dr. St. Peter: Well it’s been reported in a handful of reports that a well-defined peripheral abscess can be drained and we would follow that same line of thinking. But, in general, multifocal abscesses, complex abscesses, can be treated like necrosis, just sit tight. Even fields of abscesses in patients with underlying disease will typically heal up by just being patient.
Dr. Ponsky: Okay, so do you recommend any maneuvers to help drain the abscess, postural drainage or anything like that, or just time
Dr. St. Peter: Again, those things have been reported, but I think you just have to look at the clinical situation to see if it’s a proximal enough lesion that you think postural drainage would help. If it’s well-seated in the parenchyma, it’s kind of far-fetched to think that that’s going to make a difference.
Dr. Ponsky: So you would ever place a drain into a pulmonary abscess?
Dr. St. Peter: Yeah, so that has been reported for a well-defined peripheral lesion, but I think those two criteria would have to be pretty clear. I would like to see that it’s well-out into the lung parenchyma and it’s got a thick line to it so you know you’re not going to be getting into airway, you’re going to just be getting into abscess.
Dr. Ponsky: Okay. When that would be drained, would you leave a catheter or just aspirate the fluid?
Dr. St. Peter: The situation that we’ve had where we’ve gone that IR pathway we have left the drain, took it out, and treated it like any other abscess.
Dr. Ponsky: And they didn’t get a bronchial pleural fistula?
Dr. St. Peter: No, not that I’ve had.
Resection for pulmonary necrosis
Dr. Ponsky: Good. I have a few quick questions for you. Number one, for these patients that have this pulmonary necrosis, they get better, and they’re doing okay, have you ever gone back to resect the lung later?
Dr. St. Peter: No. That’s been the remarkable thing is that that lung heals. It really is a remarkable thing. And the extreme example that I gave, really everyone on our team felt that there was no chance for survival after two weeks of ECMO and no viable lung on either side, and that kid left the hospital without oxygen, so the lung does figure it out .
Agents for fibrinolysis
Dr. Ponsky: Amazing. You talk about TPA, and you did mention urokinase in Europe. What other options do we have in the United States or worldwide?
Dr. St. Peter: Worldwide, at this point, with streptokinase coming off the market, is urokinase or TPA. Since urokinase isn’t available in the U.S. it’s just TPA. There was a randomized trial done in adults that suggested you could get more rapid clearance by adding dornase or DNase to the mix, so we looked at trying to start a randomized trial here. It’s not approved for intrapleural use, so we got a IND and once it becomes an IND, you require funding in order to get that, so that’s a study we haven’t started yet.
Dr. Ponsky: What’s IND?
Dr. St. Peter: Investigational Drugs.
Dr. Ponsky: Okay.
Dr. St. Peter: You have to get a clearance. We now are in a position that we would still like to do that study, but without something changing in the FDA in the near future, we’ll have to think of some other way to manage it. Now apparently you can just go ahead and start using it clinically and that’s a consideration.
Dr. Ponsky: Well, Shawn, this has been very helpful for me. It answers all of the questions that I had. Was there something that I didn’t bring up or mention that you wanted to touch on?
Dr. St. Peter: No, that feels pretty thorough.
Dr. Ponsky: Okay. Well Shawn thank you for taking a big chunk of time out of your day and I think we’re going to be calling on you again for other subsequent topics but I appreciate the work you’re doing and all the clinical trials and getting us up to speed on the new standards of care, so thanks for joining us today.
Dr. Ponsky: We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen to Stay Current in Pediatric Surgery by subscribing on the iTunes store or by downloading the GlobalCastMD podcast app. Please send questions or comments to us at firstname.lastname@example.org. We’ll see you next time.