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LONG-TERM

FOLLOW-UP

OF

STAPHYLOCOCCAL

PNEUMONIA

Melvin B. Wise, M.D., Pierre H. Beaudry, M.D., and David V. Bates, M.D.

Department of Pediatrics, McGill University and the Respiratory Function Unit of the Montreal

Children’s Hospital, Montreal, Canada

TABLE I

CHARAcFERISTICS OF PATIENTS STUDIED

(Received January 11; accepted for publication February 4, 1966.)

This study was aided by a Canadian Dominion-Provincial Grant No. 604-13-48.

ADDRESS: (M.B.W.) The Montreal Children’s Hospital, 2300 Tupper Street, Montreal, Canada.

398

PEDIATRICS, Vol. 38, No. 3, September 1966

LTHOUGH many aspects of the

manage-ment of acute staphylococcal pneu-monia with empyema have been discussed and its increasing relative incidence is well documented,1 there is considerable uncer-tainty whether it leads to chronic lung dis-ease or whether resolution and healing is complete.

Binder, et al.2 Wilson,’ and Hoffman4 have reported an increase in the mci-dence of subsequent pneumonia and in the development of bronchiectasis following staphylococcal pneumonia in childhood. On the other hand, Heberer, et al,’ Hendren and Haggerty,6 and Huxtable, et a!.’ re-ported no significant changes in their fol-low-up studies. None of these studies have included an assessment of pulmonary func-lion. The present study was designed to evaluate the pulmonary, as well as the din-ical and radiological status, of a group of children who had recovered from severe staphylococcal pneumonia and empyema.

METHODS AND SAMPLE

Fifteen of the patients most severely in-volved with staphylococcal pneumonia and empyema, hospitalized at The Montreal

Children’s Hospital during the past 16 years, were studied. In order to enlist the degree of cooperation necessary for reliable ventilation studies and to obtain a detailed long-term follow-up, the following criteria

were established: a minimum age of 6 years and an interval of at least 5 years since the onset of the acute disease.

Table I shows the characteristics of the patients studied and Table lIthe character-istics of the disease.

Each study consisted of:

1. History-a review of the events lead-ing up to the initial illness was obtained, as well as an interim history, including the number of respiratory illnesses in the pa-tient, his parents and siblings.

2. Complete physical examination.

3. Chest x-rays (P-A and lateral views).

4. Pulmonary function studies-this evaluation consisted of the standard lung volumes and capacities [vital capacity

(VC), expiratory reserve volume (ERV), functional residual capacity (FRC), total lung capacity (TLC)} as well as forced ex-piratory volume (FEy0.7, X 40), mixing ef-ficiency (ME) and maximum mid-expiratory flow rate (MMF).

The ventilation studies were performed on a spirometer modified to reduce dead space and bell size for greater accuracy in

Charact#{128}ristc8 Number

Number of patients 15

Sex

Male 6

Female 9

Age at time of illness

(6months 8

6 months- years S

) years 4

(mean: I years)

Interval since illness

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ARTICLES 399

measurements on children. The FRC was determined by the helium dilution technique.s The FEy0.7, was carried out according to the method of Bernstein, et a1.

The mixing efficiency was determined ac-cording to the method of Bates and

Christie.b0 The MMF was determined by the method of Leuallen and Fowler.hl The predicted normal values (on the basis of height) were obtained from data in our laboratoryl2 and compared closely with those of Engstr#{246}m, et al.,” although gener-ally the values are somewhat lower, though not significantly lower, than those of Helli-esen, et al.14

History

RESULTS

The number of acute respiratory illnesses was no greater in the patients than in their healthy siblings. Two patients (S.Y., C.L.) had frequent upper respiratory infections during the first 2 years of life, but subse-quently were quite well. One patient (E.D.) suffered an isolated, uncomplicated, bout of pneumonia in 1952, 6 years after the epi-sode of staphylococcal pneumonia.

Physical Examination

All patients were within the normal range of height and weight for age. The physical examination was completely normal in all patients except for minor variations in one (R.L.) who showed poor lower thoracic respiratory excursion but normal

pulmo-TABLE II

CHARACTERISTICS OF DISEASE

Characteristics Na nber of Patients

Area of lung involved

Right 9

Left 4

Bilateral

Type of disease

Empyema 15

Pneumatocele 11

Pyopneumothorax 5

Abscess 3

nary function tests, and one (J.W.) who showed a moderately severe lumbar

lordo-sis. Small, well healed scars at the former sites of open drainage were noted on pa-tients on whom this procedure had been carried out.

X-rays

There was no radiological evidence of chronic, or active, parenchymal disease. Slight blunting of the costophrenic angle or very slight pleural thickening on the side of the former empyema was noted in seven of the patients. One patient (D.L.) showed fu-sion of the ninth and tenth ribs at the site of the previous drainage. Another patient (S.Y.), whose elder brother had been treated for tuberculosis, showed calcifica-tions of the right hilar, paratracheal, and an-tenor mediastinal lymph nodes.

Pulmonary Function Studies

The data are presented in Table III. The vital capacity, functional residual capacity, residual volume, total lung capacity,

FEy075, MMF and mixing efficiency were all within normal limits.

COMMENT

Although no similar study has included evaluation of pulmonary function, there is a limited literature dealing with the sequelae of staphylococcal pneumonia. Binder, et al.2

reviewed 92 cases and in contrast to our findings reported a history of increased respiratory disease with later pneumonia

occurring 42 times in 21 patients. These

au-thors also found x-rays changes in 18% of the 92 cases showing parenchymal opacities which were suggestive of bronchiectasis and concluded that bronchiectasis was the anatomical basis for the pneumonias which

they observed following recovery from

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400

TABLE III

PULMONARY FUNCTION STUDIES FOLLOWING STAPHYLOCOCCAL PNEUMONIA.

VALUES IN PARENTHESES REPRESENT 95% CONFIDENCE LIMITS FOR INDIVIDUALS.

vC, FRC, AND TLC ARE EXPRESSED AT BTPS; FEY AND MMF ARE EXPRESSED AT ATPS

. Patzent Height (cm) VC . (Liters) FRC . (Liters) TLC . (Liters) FEV0.75X40 . (Linen) MifF (L/sec)

A.E. 19.0 1.46(l.43-.55) 1.06(0.69-1.57) .O1(I.89-3.O8) 44(44-73) 1.74(1.42-3.54) S.w. 124.5 1.43(1.33-2.38) 0.89(0.65-1.49) 1.82(1.77-2.90) 45(40-67) 1.86(1.31-3.28) S.Y. 130.0 1.59(1.46-2.59) 0.69(0.70-1.59) 1.77(1.92-3.13) 44(45-74) 1.60 (1.44-3.61) M.S. 162.0 3.38(2.34-4.16) 2.18(1.01-2.31) 4.50(2.94-4.79) 111(81-133) 3.45(2.48-6.19) R.D. 119.0 1.50(1.19-2.15) 0.94(0.59-1.38) 1.98(1.61-2.65) 48(36-59) 1.88(1.16-92.91)

P.G. 139.5 2.44(1.71-3.03) 1.34(0.80-1.79) 2.90(92.292-3.60) 73(55-91) ‘2.40(1.73-4.392) C.L. 146.0 2.03(1.88-3.31) 1.11(0.80-1.92) 2.65(2.41-3.90) 64(62-101) 92.57(1.992-4.79)

W.B. 156.5 .00(1.64-2.89) 1.21(0.77-1.73) 92.45(92.13-3.45) 66(52-86) 92.75(1.64-4.10) D.L. 163.5 2.55(2.40-4.28) 1.65(1.03-2.36) 3.69(3.00-4.91) 88(83-138) 3.19(2.55-6.38) ED. 149.0 2.49(1.96-3.47) 1.18(0.88-1.99) 2.93(92.51-4.06) 70(65-107) 92.25(2.052-5.04) V.G. 142.0 2.27 (1 .77-3. 12) 1 .20 (0.81-1 .83) 2.76 (52.28-3.70) 61 (57-94) 2.10(1.79-4.48)

R.L. 158.0 2.85(2.22-3.94) 1.74(0.97-2.20) 3.63(2.80-4.56) 106(76-1525) 4.60(92.33-5.2)

J.w.

146.5 2.44(1.91-3.36) 1.21(0.86-1.95) 2.96(2.44-3.96) 70(63-103) 52.20(1.95-4.87) T.T. 158.0 2.30(52.22-3.94) 1.81(0.97-2.21) 3.22(2.80-4.56) 80(76-125) ‘2.46(52.33-5.82)

S.L. 169.0 2.78(2.56-4.58) 1.51(1.08-2.49) 3.76(3.18-5.292) 96(91-149) 52.87(92.75-6.88)

bronchial dilatation, and one demonstrated bronchiectasis. Although we did no bron-chograms, it is difficult to believe that such significant structural change could co-exist with our findings of normal chest x-rays and

normal pulmonary function. As well, our

patients showed no increased susceptibility to subsequent respiratory disease as com-pared with their healthy siblings. Even in the cases with prolonged bronchopleural fistula and in one patient with open drain-age and almost constant hospitalization for 2 years, recovery was complete. Our findings in this regard are supported by the follow-up x-ray studies of Heberer, et

al.,’ Hendren and Haggerty,6 and Huxtable,

etal.

With specffic reference to pneumatoceles our study corroborates the well document-ed evidence of their benign course and ulti-mate spontaneous resolution.15

A point of particular interest arose dur-the interviews with the parents and pa-tients. Even though all the children had been in excellent health following their

mi-tial disease (5 to 16 years), there was a uni-form expression of continuing concern, on

the parents’ part, which in a few cases re-suited in stifling overprotection of other-wise healthy children. It is hoped that evi-dence here documented may contribute to-wards reducing such concern for patients recovering from staphylococcal pneumonia.

SUMMARY

Fifteen patients who had recovered from severe staphylococcal pneumonia in infancy and early childhood were studied 5 to 16 years after the original disease. From the interim history, there was no suggestion of subsequent increased incidence or severity of respiratory disease. Physical examination and chest x-rays were all within normal lim-its. There was no evidence of disturbance of pulmonary function, as measured by vital capacity, functional residual capacity, residual volume, total lung capacity, forced

expiratory volume, maximum

mid-expirato-ry flow rate and mixing efficiency. Thus, all information obtained from these 15 patients indicates their complete recovery.

REFERENCES

1. Ravitch, MM., and Fein, R. : The changing

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in-ARTICLES 401

fants and children. J.A.M.A., 175:1039, 1961.

2. Binder, L., Dud#{225}s,P., Haidekker, J., and Schl#{228}ffer, E.: The later fate of children with staphylococcal pneumonia. Acta Pae-diat. Acad. Sci. Hung., 2:155, 1961.

3. Wilson, B. D. R.: Problems arising in the

management of staphylococcal pneumonia

in infants and children. Proc. Roy. Soc.

Med., 49:634, 1956.

4. Hoffman, E.: Empyema in childhood. Thorax,

16:128, 1961.

5. Heberer, G., Schermuly, W., and Von Buch,

K. G.: Das Spat#{235}re Schiksal der

Pleura-empyeme fin Sauglings-und Kindesalter.

Deutsch. Med. Wschr., 82:280, 1957.

6. Hendren, W. H., and Haggerty, R. J.:

Staph-ylococcal pneumonia in infancy and child-hood. J.A.M.A., 168:1, 1958.

7. Huxtable, K. A., Tucker, A. S., and

Wedg-wood, R. J.: Staphylococcal pneumonia in

childhood. Amer. J. Dis. Child., 108:262,

1964.

8. Meneely, G. R., and Kaltreider, N. L.: The

volume of the lung determined by helium

dilution. Description of the method and

comparison with other procedures. J. Clin.

Invest., 28:129, 1949.

9. Bernstein, L., D’Silva, J. L., and Mendel, D.: The effect of the rate of breathing on the

maximum breathing capacity determined with a new spirometer. Thorax, 7:255, 1952. 10. Bates, D. V., and Christie, R. V. :

Intrapul-monary mixing of helium in health and in emphysema. Clin. Sci., 9:17, 1950.

11. Leuallen, E. C., and Fowler, W. S.: Maximal midexpiratory flow. Amer. Rev. Tuberc., 72: 783, 1955.

12. Beaudry, P. H.: Unpublished data.

13. Engstr#{246}m, I., Karlberg, P., and Kraepelien, S.:

Respiratory studies in children. I. Lung

volumes in healthy children, 6-14 years of

age. Acta Paediat. (Uppsala), 46:277, 1956. 14. Helliesen, P. J., Cook, C. D., Friedlander, L.,

and Agathon, S.: Studies of respiratory physiology in children. I. Mechanics of

res-piration and lung volumes in 85 normal

children 5-17 years of age. PEDIATRICS,

22:80, 1958.

15. Caffey, J.: On the natural regression of

pul-monary cysts during early infancy.

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1966;38;398

Pediatrics

Melvin B. Wise, Pierre H. Beaudry and David V. Bates

LONG-TERM FOLLOW-UP OF STAPHYLOCOCCAL PNEUMONIA

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1966;38;398

Pediatrics

Melvin B. Wise, Pierre H. Beaudry and David V. Bates

LONG-TERM FOLLOW-UP OF STAPHYLOCOCCAL PNEUMONIA

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References

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