Rajiv Gandhi University of Health Sciences Karnataka



|RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, |

|BANGALORE |

|ANNEXURE-II |

|PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION |

|1. |Name of candidate and address |DR.PRASAD N.A. |

| | |S/O N .S. ASHOK KUMAR |

| | |14/25, “ARPANA”, 7TH MAIN ROAD, |

| | |8TH CROSS,SHAKAMBARI NAGAR, |

| | |J P NAGAR 1ST PHASE, |

| | |BANGALORE--560078. |

| | |KARNATAKA. |

|2. |Name of institution |J.S.S.MEDICAL COLLEGE, |

| | |MYSORE, KARNATAKA. |

|3. |Course of study & subject |M.D (PEDIATRICS) |

|4. |Date of admission to course |31-05-08. |

|5. |Title of topic | |

| | | |

| | |CLINICO-BACTERIOLOGICAL PROFILE AND OUTCOME OF EMPYEMA THORACIS IN CHILDREN |

| | |BETWEEN |

| | |0-15 YEARS OF AGE IN |

| | |J.S.S. HOSPITAL, MYSORE. |

| | | |

| | |

|6. |6.1 Need for study:- |

| |Childhood empyema is an important complication of bacterial pneumonia. Although the incidence of serious morbidity with |

| |childhood pneumonia has decreased over time, empyema as a complication of pneumonia continues to be an important clinical |

| |problem. It is estimated that 0.6% of childhood pneumonia’s progress to empyema , affecting 3.3 per 1,00,000 |

| |children(4,12).Due to delay in seeking medical opinion, poor facilities for culture and indiscriminate use of antibiotics, |

| |it is very difficult to isolate the causative microorganism. Empyemas are significant cause of morbidity , but not |

| |mortality in children, as it is rare for children to have an underlying lung disease 4. |

| |Optimal management of empyema in children, especially the duration of parenteral antibiotics and role of surgery is |

| |controversial. Treatment options include antibiotics alone or in combination with chest tube drainage, intrapleural |

| |fibrinolytics, VATS (Video assisted thoracoscopic surgery) , and open decortication based on the stages of empyema. Very |

| |few studies are available regarding optimal management of empyema in children. Variation in management of empyema is due to|

| |lack of randomized controlled trials12. The current treatment method for children is based on previous physician experience|

| |and local biases, as well as the availability of trained personnel and equipment 12. |

| |Hence there is a need to know the clinico-bacteriological profile in our set up and also to optimize the management |

| |strategies for empyema. |

| |6.2 Brief review of literature:- |

| |Empyema Thoracis is defined as presence of pus or micro organism in the pleural fluid. It should be differentiated from |

| |uncomplicated parapneumonic effusion. The diagnosis of empyema in this study is made according to International |

| |Classification of Diseases -10 code (ICD-10 CODE J869) 9 with atleast one of the following criteria: |

| |i)Thoracocentesis with microbial growth from pleural fluid. |

| |ii)Thoracocentesis with no microbial growth from pleural fluid but with elevated LDH and cell count, low pH and glucose. |

| |iii)Ultrasound or other diagnostic imaging evidence of pleural fluid assessed by radiologist as empyema. |

| |iv)Diagnosis at the time of thoracic surgery. |

| |Clinical signs vary 3 depending on age of the patient, stage of empyema and type of prior antibiotic therapy. A high index|

| |of suspicion and appreciation of factors predisposing to empyema , facilitates recognition. |

| |Common symptoms(are- |

| |i)fever(>38.5 C) |

| |ii)cough |

| |iii) tachypnoea (75/min,1-10yrs(40/min,>10yrs(30/min) |

| |iv)pleuritic chest pain. |

| |On examination signs 9 are- |

| |i)Focal chest wall erythema, swelling and decreased movements on the affected side. |

| |ii)Mediastinal shift. |

| |iii)Dullness on percussion. |

| |iv)Diminished breath sounds, pleural rub. |

| |v)Bronchophony and aegophony above pleural effusion. |

| | |

| |More than half of patients with empyema develop it as a complication of pneumonia 3. Staphylococcus aureus and |

| |Streptococcus pneumoniae are the commonest causative organisms 2,3,7,9,of which S.aureus is the commonest organism in |

| |developing countries 2,6,10,11. Streptococcus pyogenes, Haemophilus influenzae, Pseudomonas aeruginosa, Klebsiella |

| |aerogenes, Mycobacterium tuberculosis(TB) are the other aerobic bacteria causing empyema 2,4,10. Mycoplasma pneumoniae is |

| |accounted for 19% of cases in one series of study12. |

| |Entamoeba histolytica may cause empyema if a subdiaphragmatic abscess bursts into pleural cavity 3.Empyema is also caused |

| |secondary to rupture of retropharyngeal abscess, lung abscess, abscessed mediastinal lymph node, paravertebral abscess, |

| |iotrogenic introduction of organisms, chest trauma 3. |

| |Anaerobes are more common after 6 yrs of age. Bacteroides species, Fusobacterium species, Clostridium perfringens, |

| |Peptostreptococcus are few of the anaerobes causing empyema. Aspergillus fumigatus, Candida albicans are fungi which can |

| |cause empyema 3. |

| |Study done by S K Satpathy, C K Behra, et al shows that chest tube drainage is a safe primary method for management of |

| |empyema 7. |

| |Study done by K S Wong, Y .C. Huang, et al shows that early VATS reduced the duration of hospital stay when compared with |

| |salvage VATS in empyema 8. |

| |Study done by Omer Satici, Serdar Onat shows that multiple therapeutic approaches should be used depending on the stage of|

| |empyema 11. |

| |Study done by Harsh Grewal, Richard J. Jackson, et al shows that early VATS is a better option in management of empyema |

| |13. |

| | |

| | |

| | |

| |6.3 Objectives of study:- |

| |To study the clinico-bacteriological profile and outcome of empyema in children between 0-15 yrs of age in JSS Hospital, |

| |Mysore. |

| |2. Secondary objective is to know the efficacy of VATS in empyema. |

| | |

| |MATERIALS AND METHODS: |

| |7.1 Source of data: |

| |Children admitted to J.S.S. Hospital, Mysore ,with the diagnosis of empyema in the age group between 0 to 15 years , |

| |fulfilling Inclusion criteria. |

| | |

| |Inclusion criteria: |

| |i)Children between 0-15yrs of age, with diagnosis of empyema according to ICD-10 code J869. |

| |Exclusion criteria: |

| |i) Children more than 15 yrs of age. |

| | |

| |STUDY DESIGN:- |

| |Prospective study. |

| |SAMPLE SIZE:- |

| |30 |

| |7.2 Methods of collection of data:- |

| |Patients diagnosed to have Empyema admitted to the Department of Paediatrics, JSS Hospital, Mysore, in the age group of 0-15|

| |years will be studied. Informed parental consent will be taken. A standardized case report form will be developed to collect|

| |data on demographic, duration of prior antibiotic use, clinical , diagnostic, treatment and outcome measures of all these |

| |cases. |

| |In all cases basic investigations, chest x-ray, pleural fluid analysis , |

| |culture & sensitivity ,blood culture & sensitivity, ultrasonography of chest will be done . CT scan of chest will be done in|

| |cases with radiological suspicion of multiloculation or nonimprovement following therapy. |

| |Pleural fluid is collected with aseptic precautions by thoracocentesis or during the time of insertion of intercostal tube |

| |for drainage in a sterile culture bottle and sent for cell type and count, pH (by pH paper) , glucose(by glucose oxidase |

| |method), LDH levels (by Colorimetric Wroblewski/UVmethod), Gram’s stain, AFB stain, Culture and sensitivity. In relevant |

| |cases ADA(Adenosine Deaminase) levels, anaerobic (Robertson’s Cooked Meat media) and fungal culture(Sabourad’s Dextrose |

| |agar/KOH) is done. |

| |All cases except multiloculated cases will be managed with chest tube drainage (CTD) in combination with intravenous |

| |antibiotics and supportive treatment like maintainence of oxygen saturation,hydration and nutrition. Multi-loculated cases |

| |will be treated with VATS/Thoracotomy with decortication depending on stage of empyema. Efficacy of VATS in empyema is |

| |studied. |

| | |

| | |

| |Follow up will be done at the end of first month after discharge on OPD basis to study the outcome. Outcome of empyema will |

| |be in terms of clinical and radiological clearance with respect to different modalities of treatment used. PFT (Pulmonary |

| |function test) is also performed in children of age group of >6yrs . |

| | |

| |STATISTICAL ANALYSIS:- |

| |1) Chi square test |

| |2) Data analysis will be done with appropriate application of statistical methods. |

| | |

| |7.3 Investigation required :- |

| |a) Haematological—Haemoglobin ,Total count, CRP, |

| |Differential count, ESR, Platelet count, Blood culture & sensitivity, Serum Electrolytes , Sputum for AFB(if available), |

| |Mantoux Test. |

| |b)Pleural fluid analysis-- Pleural fluid for pH ,cell type and count, glucose, LDH levels, Culture & sensitivity, Gram’s |

| |stain, AFB stain . |

| |ADA levels , Anaerobic & Fungal culture(in relevant cases). |

| |c)Radiological-- Chest X-ray PA view, Ultrasound scan of chest , CT Scan of chest (only in relevant cases). |

| | |

| |7.4 Has ethical committee clearance been obtained in case of 7.3 |

| |Yes. |

| | |

| |8. List of references: |

| |1. K M Eastham , R Freeman , J Clark ,et al Clinical features , aetiology and outcome of |

| |Empyema in children in noth east of England. Thorax 2004; 59:522-525. |

| |A K Baranwal , M Singh , R K Marwaha , L Kumar Empyema Thoracis ;A 10 year comparative review of hospitalized children from|

| |south Asia.Arch Dis Child 2003;88:1009-1014. |

| |Meenu Singh, Saroj Kumar Singh, Sujith Kumar Choudry Management of Empyema Thoracis in Children.Indian Pediatrics Feb 2002; |

| |39:145-157. |

| |I M Balfour-Lynn, E Abrahamson, G Cohen, S King, D Parikh, A H Thomson, et al BTS guidelines for management of pleural |

| |infection in children. Thorax 2005; 60(suppl1):il-2l. |

| |Amar A. Shah , Anirudh V. Shah , Raju C Shah, et al Thoracoscopy in management of Empyema Thoracis in children . Indian |

| |Pediatrics2002; 39:957-961. |

| |Tasnee Chonmaitree , Keith R.Powell , Parapneumonic Pleural Effusion and Empyema in Children: Review of a 19-Year |

| |Experience1962-1980,Clin Pediat(Phila)1983; 22:414 . |

| |S K Satpathy, C .K.Behra and P. Nanda Outcome of Parapneumonic Empyema, Indian Journal of Pediatrics, Volume 72-March,2005.|

| |KS. Wong, T.Y.Lin, L.Y.Chang, et al Scoring system for Empyema Thoracis and help in management, Indian Journal of |

| |Pediatrics, Volume 72-December,2005 |

| |Joanne M. Langley, James D. Kellner, Nataly Solomon, et al Empyema associated with community acquired pneumonia: A |

| | Pediatric Investigator’s Collobarative Study on Infections in Canada, BMC Infectious Diseases 2008, 8:129. |

| |M .Zampoli, H J.Zar , Empyema and parapneumonic effusions in children: an update, South African Journal of Child Health , |

| |October 2007 ,Vol.1 No.3 :121-128. |

| |Cemal Ozcelik, Serdar Onat, Omer Satici, et al Management of Postpneumonic Empyemas in children, European Journal of |

| |Cardiothoracic Surgery 25(2004): 1072-1078. |

| |Yea Huei Shen, Kao Pin Hwang, et al Complicated Parapneumonic effusion and Empyema in children, Journal of Microbiology |

| |,Immunology and infection 2006;39: 483-488. |

| |Harsh Grewal, Richard J.Jackson, et al Early VATS in Management of Empyema, Pediatrics 1999;103;e63. |

| |S Oak, S Parelkar, R Agarwal, et al Experience with VATS for Empyema in Children, Journal of Indian Association of Pediatric|

| |Surgery; Vol 8 (Oct-Dec 2003). |

| |Andreas H. Meir, Arun Raghavan, Lawrence Moss, et al Rational Treatment of Empyema in Children, Arch Surg.2000;135:907-912. |

| |Susan King , Anne Thomson, Radiological perspectives in Empyema ,British Medical Bulletin 2002; 61:203-214. |

| |Samatha Sonappa, Gordon Cohen, Catherine M. Owens, et al Comparision of Urokinase and VATS for treatment of Childhood |

| |Empyema , Ame J Respir Crit Care Med Vol174.pp221-227,2006. |

|9. |Signature of the candidate | |

|10. |Remarks of the guide |Empyema is the commonest life threatening complication of pneumonia. Management|

| | |strategy needs to be optimized depending on stage of empyema in our geographic |

| | |region. This study will throw light on optimal management of empyema in |

| | |relation to VATS. |

| | | |

|11. |11.1 Guide and Head of the Department |DR.NARAYANAPPA .D |

| | |M.B.B.S, M.D |

| | |PROFESSOR & HOD, |

| | |DEPARTMENT OF PEDIATRICS, |

| |11.2 Signature |J.S.S.HOSPITAL, MYSORE. |

| | | |

| |11.3 Co-guide |DR.ANIL KUMAR M.G |

| | |M.B.B.S, M.S, M Ch(PEDIATRIC SURGERY) |

| | |ASSOCIATE PROFESSOR, |

| | |DEPARTMENT OF SURGERY, |

| | |J.S.S HOSPITAL,MYSORE. |

| | | |

| |11.4 Signature | |

| | | |

| |11.5 Head of the Department |DR.NARAYANAPPA .D |

| | |M.B.B.S, M.D |

| | |PROFESSOR & HOD, |

| | |DEPARTMENT OF PEDIATRICS, |

| | |J.S.S.HOSPITAL, MYSORE. |

| |11.6 Signature | |

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|12. |12.1 Remarks of the chairman & principal | |

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| |12.2 Signature | |

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