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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


CLINICAL PEARLS AND PITFALLS
Airway and lung lesions are uncommon in children, but can present
with common respiratory symptoms and signs.
Chest radiographs are the initial diagnostic modality of choice, and
should be obtained promptly in patients with respiratory distress when
such lesions are suspected.
Patients with large cystic lesions or hyperinflation may develop air
trapping and worsened respiratory compromise if positive-pressure
ventilation is applied.
Prompt surgical consultation may be needed in cases of respiratory
distress caused by a lung lesion.

Current Evidence
Most lung lesions in children are congenital, with the majority comprised of
CPAMs, bronchogenic cysts, bronchopulmonary sequestrations (BPSs), and
congenital lobar emphysema (CLE). Many lesions are discovered prenatally and
are asymptomatic after birth, while some cause clear early signs of respiratory
distress or circulatory impairment. Complications associated with the abovementioned lesions include compression of critical structures, infection,
pneumothorax, or rarely, malignant degeneration; therefore surgical intervention
is frequently warranted in the care of children with lung lesions.

Goal of Treatment
Since patients with lung lesions typically present with respiratory symptoms and
even distress, prompt evaluation and treatment is critical. Familiarity with normal
variations and potential pathologic abnormalities is necessary to arriving at a
prompt diagnosis and delivering the appropriate treatment, as patients with spaceoccupying lung lesions may require quite different management than patients
with more common respiratory illnesses.

Cystic Lung Disorders—CPAM and BPS
Cystic lesions of the lung are congenital processes that can present with
pulmonary infection, a mass or tension effect causing respiratory distress, or an
abnormal chest radiograph in an otherwise asymptomatic patient. CPAM lesions
are the result of an overgrowth of bronchioles (Fig. 124.7 ) and an increase in
terminal respiratory structures and mucous cells lining the cyst walls. These
lesions are generally supplied solely by the pulmonary arterial system, and are


present in more than one lobe of the lung in up to 3% of cases. If a CPAM lesion
also receives systemic blood supply, which is a characteristic of BPS, it is termed
a hybrid lesion . The tissue within a CPAM does not function in normal gas
exchange but is connected with the tracheobronchial tree; therefore, these lesions
can lead to air trapping and recalcitrant pulmonary infections. Rarely, patients
may develop malignant degeneration within the lesion (pleuropulmonary
blastoma, rhabdomyosarcoma).

FIGURE 124.7 Congenital pulmonary airway malformation in a 12-month-old girl with
recurrent episodes of left-sided pneumonia of the lower lobe.

BPSs arise from an accessory bronchopulmonary bud of the foregut.
Histologically, they consist of pulmonary tissue; however, they are not connected

with the normal bronchial tree or pulmonary vessels (and hence, the pulmonary
tissue is “sequestered”). Occasionally, sequestrations have a connection with the
esophagus or stomach, because of their foregut derivation. They have a systemic
rather than pulmonary blood supply. A sequestration is described as intralobar if
it is contained within the normal pleura, or extralobar if it has its own pleural


investment and is separated from the normal lung parenchyma. Sequelae of BPS
can be respiratory, with symptoms of respiratory distress or feeding intolerance,
or circulatory, in which substantial arteriovenous shunting can occur within the
sequestered lobe, leading to high-output cardiac failure. Case reports of
associations between BPS and diaphragmatic abnormalities have been described.
Clinical Recognition
Recurrent respiratory infections often lead to a chest radiograph, which
demonstrates an abnormal lesion. These lesions can appear as hyperaerated
segments of lung, lung containing air–fluid levels in the instance of CPAM (Fig.
124.7 ), or as solid masses in BPS. As mentioned, clinical findings may be
identical to those of a lobar pneumonia. Occasionally, a lesion is discovered in
older patients in the setting of recurrent lobar pneumonia or after an empyema
fails to recover with appropriate management.
Management
Chest radiographs in the PA, lateral, and decubitus positions should be obtained
to evaluate any areas with air–fluid levels. Patients with significant respiratory
symptoms, fever, or significant abnormality on chest film should be admitted for
further evaluation and treatment. When a CPAM or BPS is suspected, a CT scan
with IV contrast (ideally, a CT angiogram) should be obtained to better delineate
the lesion and to identify any possible systemic blood supply. Because the blood
supply may arise from below the diaphragm in up to 20% of cases of BPS, the
scan should include both the chest and the upper abdomen. Arteriography is
seldom necessary with currently available imaging techniques. The CT scan will

likely exclude other conditions that may present similarly, such as a
diaphragmatic hernia, postpneumonic pneumatoceles, or esophageal duplication.
In the setting of infection, any pathogens identified in the sputum should be
treated with appropriate antibiotics. After control of superimposed infection, the
lesion should be resected to prevent recurrent infection. Attempted aspiration of
the cystic lesions or placement of a chest tube is to be avoided because it may
lead to spread of infection into the pleural space.
Surgical resection is indicated for all identified CPAM and BPS lesions. For
young, asymptomatic patients, resection can occur electively. For patients who
present with infection, resection is typically deferred until 6 to 8 weeks after the
resolution of the infection, as resection during the acute phase of inflammation is
associated with a higher rate of complications. Resection can be accomplished