Pediatric emergency medicine trisk 4093 4093
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VATS allows for thoracoscopic debridement of the infected fibrinous peel that
encases the lung and prevents its full expansion. Under a general anesthetic, a
high-resolution camera placed within the pleural space via a small (1-cm) incision
between the ribs allows the removal of the purulent debris. The peel may be
removed under direct visualization with the aid of thoracoscopic instruments
placed through additional thoracoscopic incisions. A chest tube is then placed to
drain the pleural cavity and left in place for a period of days. Because sedation
approaching the depth of general anesthesia is needed for the placement of a chest
tube, many surgeons and infectious disease consultants recommend thoracoscopy
as the initial approach to a child with empyema. Studies suggest that while
outcomes may not vary significantly, early surgical intervention likely decreases
duration of IV antibiotics, days with a chest tube, and hospitalization. In centers
where a chest tube and fibrinolytic therapy is the initial treatment of choice,
patients who fail to improve clinically after a few days should progress to VATS.
Seldom is open thoracotomy now necessary to resolve empyema. It should be
remembered that VATS will aid in the resolution of the pleural space disease but
not necessarily the parenchymal disease which will need ongoing therapy.
Solid Lung and Pleural Lesions
A number of solitary lesions are benign, with the most common being
inflammatory pseudotumor and hamartoma, both of which may become quite
large and cause symptoms of respiratory distress, cough, airway obstruction, or
mediastinal compression. Solid lesions in the pleural space occur uncommonly in
children. A localized, pleural-based mass should suggest neoplasm, which may be
primary or metastatic. The most common primary lung tumors are bronchial
adenomas, and the most common metastatic lesions are Wilms tumor and
osteogenic sarcoma. They may encase the lung and produce restrictive lung
disease.
It is impossible to generalize the mode of presentation of such rare processes.
Focal lesions may be expected to be found in the investigation of symptoms
caused by local compression or erosion; because of the large functional
pulmonary reserve of children, restrictive lung disease caused by a diffuse
process is distinctly uncommon; or by serendipity. A full radiographic evaluation,
including a CT scan, should be obtained, admission to the hospital strongly
considered, and appropriate consultation sought. Focal lesions should be
considered malignant until proven otherwise; thus, operation for biopsy or
excision will likely be required.
LUNG LESIONS
