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Background: Discussions on the diagnostic and management of acquired pediatric lung pathology are usually published by large tertiary children's hospitals. It is likely that much of this pathology is actually seen and managed in nonacademic practices., Methods: A 10-year retrospective review of patients under 18-years of age, treated for lung abscesses or empyema was performed., Results: Nineteen empyema and four lung abscesses were included. Presenting symptoms, workup, and management are reviewed. A unique subset (n = 4) of atypical pulmonary pathology is described. A 14-year-old with a vaping history and a lung abscess misdiagnosed as an empyema. A 15-year-old with primary pulmonary Hodgkin's lymphoma presenting as a lung abscess and empyema. A 5-year-old with an empyema complicated by a bronchopleural fistula and a 21-year-old with autism and an acquired lung cyst., Conclusion: Our dilemmas, experiences, and strategies in managing complex lung disease are generalized to community-based practice., (© 2021 Wiley Periodicals LLC.)

BACKGROUND Bronchopleural fistula formation is a rare complication of lobectomy surgery, with a frequency reported ranging from 0.5% to 1%. A post-lobectomy bronchopleural fistula usually presents within 14 days of surgery. To our knowledge, it is extremely rare for a bronchopleural fistula to develop many years after an operation. CASE REPORT We present the case of a 55-year-old male smoker with history of a right lower lobe lobectomy 15 years prior who presented to the Emergency Department with complaints of worsening back pain, shortness of breath, and cough productive of sputum. He was found to have a right bronchopleural fistula with right-sided empyema. He was taken to the operating room a few days after initial admission for right thoracoscopic chest exploration, right chest debridement, right chest wall resection, and window procedure with creation of pleurocutaneous fistula. Ultimately, he required a right completion pneumonectomy and buttress of bronchial stump with transdiaphragmatic omental flap. CONCLUSIONS We diagnosed a rare case of post-lobectomy bronchopleural fistula complicated by an empyema that demonstrates bronchopleural fistulas can appear 15 years postoperatively and present with subacute clinical signs and symptoms.

Pleural disease is a problem of global significance which causes significant morbidity and mortality. Pleural disease is usually first suspected on chest x-ray but further imaging, often ultrasound, is usually required as part of the diagnostic work-up. Complex imaging with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT are less often performed but are routinely required in patients with mesothelioma and occasionally required in patients with pleural infection and other pleural diseases. Cross-sectional imaging may be used to suggest the diagnosis of pleural disease, quantify disease severity, guide biopsy, and even predict prognosis. This review will focus on the contributions of CT, MRI, and PET to the management of pleural disease with discussion of their relative strengths and weaknesses., (Copyright © 2010 Wiley-Liss, Inc.)

Post-pneumonectomy empyema is an uncommon but potentially life-threatening complication. It has a strong association with bronchopleural fistula, which acts as a continued source of infection into the thoracic cavity. Numerous risk factors have been identified and strategies formulated to minimize its occurrence. When bronchopleural fistula occurs, its treatment depends on several factors including extent of dehiscence, degree of pleural contamination and general condition of the patient. Early diagnosis and assessment with appropriate investigations, and aggressive therapeutic strategies are paramount in controlling sepsis, facilitating closure of fistula, and sterilization of the closed pleural space. Recent success with repeat debridement has made routine space obliteration not mandatory in management. The development of minimal-access interventions including video-assisted thoracic surgery, endoscopic application of tissue glue and stenting may be additional tools to complement conventional surgery in post-pneumonectomy empyema management.

Objective: To assess the efficacy and the safety of a single-trocar technique for minimally invasive surgery of the chest in the management of multiple noncomplex thoracic diseases, a prospective study was performed and the results are presented., Methods: Between October 1998 and December 2001, 100 patients underwent video-assisted thoracic surgery through a single trocar. The patients were divided into 4 groups as follows: (1) benign, (2) malignant, (3) pleural effusion, and (4) empyema. The following data were analyzed: age, sex, forced vital capacity, forced expiratory volume in 1 second, percentage of the predicted forced expiratory volume in 1 second, type of anesthesia, anesthesia time, surgery time, intraoperative complications, morbidity, chest tube removal, hospital stay, and follow-up., Results: The patient population consisted of 64 men and 36 women with a mean age of 62 years (range 31-92 years). General anesthesia was used in 53 patients (25 double-lumen and 28 single-lumen tube) and local anesthesia and sedation in 47 patients. Talc pleurodesis was performed in 55 patients. Mean operative time was 65 +/- 37 minutes, 48 +/- 18 minutes for simple and 67 +/- 37 minutes (P =.004) for complex pleural effusion. Mean anesthesia time was 102 +/- 85 minutes. Chest tubes were removed after 5 +/- 2 days. Mean overall hospital stay was 6 +/- 3 days, 5 +/- 2 days for benign diseases, 7 +/- 3 days for malignant diseases, and 8 +/- 3 for empyema. Morbidity was present in 19 patients. Two patients had intraoperative bleeding; 1 required a mini-thoracotomy to control it. There was no hospital mortality. Three patients had wound infection, and no patient with malignant diseases had port site metastasis., Conclusion: Video-assisted thoracic surgery through a single trocar is simple, effective, and beneficial for all patients in the diagnosis and treatment of noncomplex diseases of the chest. Furthermore, with this newest type of technologically advanced instrumentation it is possible to carry out simple intrathoracic procedures without using additional ports.

Objective: To study the practicality and feasibility for a physician to diagnose and treat pleural diseases through thoracoscopy., Methods: To perform open thoracoscopy on 345 patients with a fibrobronchoscope or a hard thoracoscope under local anesthesia and evaluate the safety and tolerance of patients during the operation., Results: (1) Determination of etiology: in 92.7% (227/245 cases) of pleural effusion cases, 75.0% (69/92) of pneumothorax cases, etiologic causes have been determined and 8 cases of pleural tumors were diagnosed. (2) Therapeutic effectiveness: the response rate of malignant pleural effusions was 78.4% (80/102 cases), the cure rate of pneumothorax was 81.5% (75/92 cases) and for empyema, the cure rate was 92.9% (26/28 cases). (3) SAFETY: during operation the ECG, SaO(2), BP, R, P of 98 patients did not show important changes. In 345 patients, 4.3% (15/345) complained a fransceis cheot stiffin. 7% (24/345) showed sinus tachycardia., Conclusions: (1) Through thoracoscopy, we can observe the whole pleural cavity and can take biopsy specimen under direct observation. It is a good method to get the etiological diagnosis in cause-underdetermined pleural diseases. (2) It is effective and practical to treat difficult pleural effusion, the obstinate pneumothorax, or one that is not suitable for thoracic surgery. (3) It is safe and simple to apply the thoracoscopy under local anesthesia.

The pleural space is a potential space under normal physiologic circumstances. It envelops the lung, the mediastinum, the diaphragm and the chest wall. A thin film of pleural fluid provides lubrication for the two pleural layers; only 2-10 ml of pleural fluid is present in healthy people. For the purposes of this review, pleural abnormalities will be divided into pleural effusion, pneumothorax, and pleural calcification.

Radiologic imaging of the pleura has undergone dramatic changes in the past 5 years. This can be primarily attributed to the availability and better understanding of computed tomography and, to a lesser extent, ultrasonography. When used in the proper clinical-radiologic environment, abnormalities of the pleural space can be quickly identified, localized, and often diagnosed in a rapid efficient manner.

Nine cases of thoracic actinomycosis treated in the period 1966-1987 are reported. Three of the patients presented with a clinical picture of empyema and six were admitted for suspected primary pulmonary neoplasm. No case was correctly diagnosed preoperatively. The final diagnosis was based on direct microscopy (2) or culture (1) of drained pus in the empyema cases and on histologic examination of resected tissue in the others. In one case the correct diagnosis was missed when a palpable tumour mass was not extirpated at exploratory thoracotomy, and was made only when clinical deterioration necessitated a second operation. Good clinical results can be expected from surgical eradication of an intrathoracic focus of actinomycosis in conjunction with appropriate antibiotic therapy.

Sonography was performed in 40 patients with pleural shadowing of uncertain origin in order to complement conventional x-ray examination. Where the findings were not clear-cut, computer tomography was performed subsequently and the diagnosis ascertained by biopsy or operation. Fluid-containing pleural lesions, such as encysted effusions and empyemas, pericardial cysts and one echinococcus cyst were identified by sonography from their appearance and biopsy was performed; computer tomography adds little additional information in these conditions. Solid pleural masses, on the other hand, can be more accurately defined by computer tomography. This shows the entire pleura, including small areas of calcification. Density measurements are able to differentiate various tissues, and particularly fat.

There are four factors that govern fluid movement to or from the pleural space: hydrostatic pressure, colloid osmotic pressure, filtration coefficient, and lymphatic function. When any of these factors are altered, fluid accumulates within the pleural space. Congestive heart failure, pancreatitis, neoplasia, hypoalbuminemia, and pulmonary thromboembolism can evoke pleural effusions by altering normal fluid transport mechanisms. This approach to pleural effusion helps to explain fluid accumulation. Chylothorax, hemothorax, and empyema are also covered in the article.

Lactate concentrations in the pleural fluid of 50 patients were determined by the Monotest Lactate Kit. Lactate values were found higher in bacterial pleural infections than in cases of hydrothorax. Elevated levels were also found in most cases of histologically confirmed cases of pleural neoplasms and in some cases of non-bacterial pleuritis exsudativa . The highest levels were found in cases of empyema, but there was considerable overlapping between the groups. Pleural lactate thus appears to have little diagnostic value in the differential diagnosis between empyema and non-bacterial pleural effusions.

Eleven of 48 (23%) patients diagnosed as having lung abscess or empyema presented diagnostic problems in the localization of infected material. All 11 patients were found eventually to have empyemas, all but one of which was complicated by bronchopleural fistulas. Difficulty in distinguishing abscess from empyema on a chest roentgenogram delayed diagnostic and therapeutic thoracentesis from 1 to 12 days. Pleural effusions were noted in all but one of the patients who did not initially have a bronchopleural fistula. In addition, once the bronchopleural fistula became established, the extension of the air-fluid level to the chest wall, the tapered borders of the air-fluid pocket, and the extension of the lesion across fissure lines were noted, in retrospect, to be suggestive of pleural localization. Delay in the evacuation of empyema fluid can lead to chronic complications and increased morbidity. Early identification and treatment of pleural effusions may avoid these diagnostic and therapeutic problems.

Thoracoscopy was originally devised for diagnostic purposes but has subsequently come to have several therapeutic applications as well. This report reviews our experience with 13 patients in whom thoracoscopy was used in a therapeutic capacity. In three patients intrapleural foreign bodies (segments of polyethylene catheters) were removed endoscopically. In two patients open postpneumonectomy empyema cavities were explored and debrided thoracoscopically. In the remaining eight patients thoracoscopy was used to facilitate chemical pleurodesis in the treatment of effusions or pneumothoraces, after resectable disease had first been ruled out. Our conclusions are as follows: (1) Thoracoscopy can serve therapeutic as well as diagnostic functions. (2) Excellent exposure can be obtained during general anesthesia by use of one-lung ventilation. (3) Thoracoscopy is a safe, simple, and effective means of removing intrapleural foreign bodies. (4) Thoracoscopy allows chemical pleurodesis to be applied selectively to patients who will not require future thoracotomy; i.e., those with proved incurable malignant disease or with recurrent pneumothoraces without gross abnormalities of the pulmonary parenchyma. (5) Chemical pleurodesis is facilitated by this technique, which assures uniform exposure of all pleural surfaces to the sclerosing agent. (6) Pleurodesis is less painful when the sclerosing agent is introduced during general anesthesia. (7) Thoracoscopy allows safe, complete, visually guided débridement of open postpneumonectomy empyema cavities.

Modern real-time gray scale ultrasonography has contributed new diagnostic and therapeutic information in patients with diseases of the lungs and pleura. This article will discuss the ways in which ultrasound is most clinically useful in patients with thoracic disease.