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 to 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