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Key Points

  1. The most common condition related to lung infection requiring surgical intervention in a hospitalized child is empyema resulting from a complication of community-acquired pneumonia.

  2. Most children with empyema can be successfully treated by following an algorithm that uses a minimally invasive approach with video-assisted thoracoscopic surgery (VATS).

  3. Lung biopsy for pulmonary infiltrates and possible lung infection in immunocompromised children may be required when imaging (including high-resolution computerized tomography [HRCT]), bronchoscopy, broncho-alveolar lavage (BAL), and genetic testing for interstitial lung disorders are unsuccessful in obtaining a diagnosis.

  4. Most lung biopsies can be performed using VATS, unless single lung ventilation cannot be safely tolerated.

  5. Lung abscesses, which are uncommon in children, and bronchiectasis, usually complicating cystic fibrosis, rarely require surgery. Use of an algorithmic approach to these disorders may reduce length of hospitalization and morbidity.

Lung Infections

The incidence of community-acquired pneumonia is estimated to be almost 200 per 100,000 population and complications of community-acquired pneumonia lead to hospitalization in less than 10% of these cases. The majority of children hospitalized for community-acquired pneumonia have empyema, which will often require surgical consultation and possible surgery. Other reasons for surgical intervention include necrotizing lung infection resulting in abscess formation, lung infection in the immunocompromised child, and lung infection associated with bronchiectasis.

Thoracoscopic Lung Biopsy

Essentials of Diagnosis

  • Undiagnosed interstitial infiltrates in the immunocompromised child and possible diffuse interstitial lung disease in the immunocompetent child are the most common indications for lung biopsy.

  • Lung biopsy is safe and effective for evaluating the immunocompromised child with suspected infection not responding to empiric antibiotic, antifungal or antiviral therapy, and if serology, high-resolution computerized tomography (HRCT), and broncho-alveolar lavage (BAL) are not diagnostic.

  • Video-assisted thoracoscopic surgery (VATS) is indicated if the child can tolerate single lung ventilation and transbronchial lung biopsy cannot be performed for technical reasons.


Jacobaeus first described thoracoscopy in 1910, when he used it to facilitate collapse therapy for pulmonary tuberculosis. He also used it to perform pleural biopsies. Although the use of thoracoscopy in children was reported in 1971, it was popularized for use in children in 1976 by Rodgers. Today there are fewer indications for lung biopsy than in the past, due to improved diagnostic evaluation using a combination of BAL specimens, HRCT, and genetic testing. Indications for thoracoscopic lung biopsy are listed in Table 30-1. Most children with primary interstitial lung disease have the diagnoses made with the other diagnostic modalities, obviating the need for a biopsy in every patient.

Table 30-1Indications for Lung Biopsy Using Video-Assisted Thoracoscopic Surgery

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