Figure 102-22. Video-assisted thoracoscopic treatment of complicated empyema in children. A: Chest radiograph of a 2-year-old

child presenting with pneumonia and pleural effusion. B: Computerized tomography demonstrates complicated pneumonia with

loculated empyema. C: Video endoscopic view of organized empyema debris. D: “Decortication” procedure includes removal of all

loculated, organized debris from the hemithorax. All surfaces of the visceral and parietal pleura are accessible using video

endoscopic techniques. E: Immediate postoperative chest x-ray shows the expected residual parenchymal lung disease. F: One

month later, the chest radiograph findings have resolved.

With a small amount of fluid, the empyema may resolve with antibiotics alone. When the collection

becomes larger, the treatment is drainage of the collection. Several trials have compared fibrinolytics to

video-assisted thoracoscopy (VATS). Both VATS and chest tube with fibrinolytics have been shown to be

2939

effective with a systematic review demonstrating no superiority of VATS.157 Other studies have

demonstrated improvement after VATS.158,159

Pneumothorax

Spontaneous pneumothorax is relatively uncommon. The etiology seems to be lung connective tissue

changes predisposing to leaks into the pleural space. This occurs in approximately 2.6 per 100,000

population of children requiring hospitalization in the United States in 2000. It has been suggested that

blebs are associated with the disease. The presentation is usually with chest pain and shortness of breath

but may also be associated with cough. The pain may be pleuritic in nature. Diagnosis is best confirmed

with chest radiograph.160 Chest CT has been utilized for identification of blebs but a negative

examination does not predict freedom from recurrence.161

Treatment of pneumothorax depends on the patient. Observation with or without high flow oxygen is

appropriate for the relatively asymptomatic patient. Chest tube placement is the next stage of

treatment. For recurrent pneumothoraces, intrapleural sclerosing agents such as talc can be used. VATS

with bleb resection and pleurodesis has also been described with good results.162

Chylothorax

Chylothorax which is the accumulation of chyle in the pleural space is a rare cause of effusion in

children but is the most common cause of effusion in the neonate.163 Chylothorax is associated with

pulmonary lymphangiomas and lymphangiectasia. Chylothorax may also be a manifestation of Down,

Turner, and Noonan syndromes. Chylothorax may occur due to trauma to the thoracic duct either

iatrogenic or noniatrogenic due to blunt trauma. Malignancy and granulomatous diseases may cause

obstruction of the thoracic duct leading to chylothorax.

The initial symptoms are related to accumulation of fluid in the pleural space with dyspnea, cough,

and chest discomfort. Pleuritic pain and fever are rare. Diagnosis is by chest radiograph combined with

findings on thoracentesis. The fluid is usually milky in appearance with triglycerides greater than 1.1

mmol/L, total cell count greater than 1,000 cells per microliter, and lymphocyte predominance greater

than 80%.164

Management consists of expansion of the lung with thoracentesis or tube thoracostomy. Minimization

of lymph flow is managed by either parenteral nutrition of diet manipulation using only dietary

medium-chain fatty acids. Long-term, this can lead to life-threatening immunologic problems. Surgical

management is then employed. Thoracic duct ligation can be performed either via thoracotomy or

thoracoscopic approach. This may require the administration of cream via a nasogastric tube in the

hours before surgery. If this fails, pleurectomy and pleurodesis or pleuroperitoneal shunting may be

employed.

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