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Published on January 2, 2009

Author: davejaymanriquez

Source: slideshare.net



VELEZ COLLEGE – COLLEGE OF NURSING A CASE STUDY OF PATIENT K. S. DIAGNOSED WITH EMPYEMA SECONDARY TO PNEUMONIA Presented by: Dave Jay S. Manriquez, RN. CHAPTER ONE INTRODUCTION This is a case study on patient KNS, 3 months old, female, Roman Catholic, Filipino, residing at Candabo, Argao and born on January 26, 2007 via Normal Spontaneous Vaginal Delivery (NSVD) at Argao Isidro Quintana Memorial Hospital, who was admitted for the 1st time in Cebu Velez General Hospital (CVGH) for complaints of fever, cough, and convulsion. The patient was admitted under the services of Dr. Lydia Chang and Dr. Maribel Du under the Department of Pediatrics and Surgery with the case number of 87395 and hospital number of 039874. The case was chosen by the researchers on May 9, 2007 at around 12 noon. PNEUMONIA Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. Although different types of pneumonia tend to affect children in different age groups, pneumonia is most commonly caused by viruses. Some viruses that cause pneumonia are adenoviruses, rhinovirus, influenza virus (flu), respiratory syncytial virus (RSV), and parainfluenza virus (the virus that causes croup). • Often pneumonia begins after an upper respiratory tract infection (an infection of the nose and throat). When this happens, symptoms of pneumonia begin after 2 or 3 days of a cold or sore throat. Types of Pneumonia 1. Community-acquired pneumonia(CAP) a. Pneumococcal –causative agent: S. pneumonia; incidence are common on elderly, with COPD, CHF, alcoholism b. Influenzae pneumonia or Haemophilus influenza- CA: H. pneumoniae; I: splenectomy, alcoholics, in chronic care facilities

c. Viral pneumonia (occur in every 2-3 years) – CA: Influenza viruses A and B, adenovirus, parainfluenza, cytomegalovirus. I: adults d. Aspiration pneumonia- CA: aspiration of food or gastric contents I: children and elderly. 2. Hospital acquired pneumonia a. Pseudomonas pneumonia - CA: pseudomonas aeruginosa b. Staphylococcal pneumonia- CA: Staphylococcus aureus c. Klebsiella pneumonia- CA: Klebsiella pneumonia; I: immunosupressed, IV drug users, complication of epidemic nfluenza 3. In immunocompromised Host a. Pneumocystic carnii pneumonia (PCP)- CA: Pneumocystis carnii; I: patients with AIDS, immunosupressed patients, recipients of organ transplants b. Fungal pneumonia- CA: Aspegillus fumigates; I: immunosupressed patients, recipients of organ transplants immunosupresse patients, neutopenic patients Incubation The incubation period for pneumonia varies, depending on the type of virus or bacteria causing the infection. Some common incubation periods are: respiratory syncytial virus, 4 to 6 days; influenza, 18 to 72 hours. Duration With treatment, most types of bacterial pneumonia can be cured within 1 to 2 weeks. Viral pneumonia may last longer. Mycoplasmal pneumonia may take 4 to 6 weeks to resolve completely. Contagiousness The viruses and bacteria that cause pneumonia are contagious and are usually found in fluid from the mouth or nose of an infected person. Illness can spread when an infected person coughs or sneezes on a person, by sharing drinking glasses and eating utensils, and when a person touches the used tissues or handkerchiefs of an infected person. Signs and Symptoms Symptoms of pneumonia vary, depending on the age of the child and the cause of the pneumonia. Some common symptoms include: • fever • chills • cough • unusually rapid breathing • breathing with grunting or wheezing sounds • labored breathing that makes a child's rib muscles retract (when muscles under the rib cage or between ribs draw inward with each breath)

• vomiting • chest pain • abdominal pain • decreased activity • loss of appetite (in older children) or poor feeding (in infants) • in extreme cases, bluish or gray color of the lips and fingernails Sometimes a child's only symptom is rapid breathing. Sometimes when the pneumonia is in the lower part of the lungs near the abdomen, there may be no breathing problems at all, but there may be fever and abdominal pain or vomiting. When pneumonia is caused by bacteria, an infected child usually becomes sick relatively quickly and experiences the sudden onset of high fever and unusually rapid breathing. When pneumonia is caused by viruses, symptoms tend to appear more gradually and are often less severe than in bacterial pneumonia. Wheezing may be more common in viral pneumonia. Some types of pneumonia cause symptoms that give important clues about which germ is causing the illness. For example, in older children and adolescents, pneumonia due to Mycoplasma (also called walking pneumonia) is notorious for causing a sore throat and headache in addition to the usual symptoms of pneumonia. In infants, pneumonia due to chlamydia may cause conjunctivitis (pinkeye) with only mild illness and no fever. When pneumonia is due to whooping cough (pertussis), the child may have long coughing spells, turn blue from lack of air, or make a classic quot;whoopquot; sound when trying to take a breath. Prevention There are vaccines to prevent infections by viruses or bacteria that cause some types of pneumonia. Children usually receive routine immunizations against Haemophilus influenzae and pertussis (whooping cough) beginning at 2 months of age. (The pertussis immunization is the quot;Pquot; part of the routine DTaP injection.) Vaccines are now also given against the pneumococcus organism (PCV), a common cause of bacterial pneumonia. When to seek prompt treatment? Call your child's doctor immediately if your child has any of the signs and symptoms of pneumonia, but especially if your child: - is having trouble breathing or is breathing abnormally fast - has a bluish or gray color to the fingernails or lips - has a fever of 102 degrees Fahrenheit (38.9 degrees Celsius), or above 100.4 degrees Fahrenheit (38 degrees Celsius) in infants under 6 months of age Treatment

Doctors usually make the diagnosis of pneumonia after a physical examination. The doctor may possibly use a chest X-ray, blood tests, and (sometimes) bacterial cultures of mucus produced by coughing when making a diagnosis. In most cases, pneumonia can be treated with oral antibiotics given to your child at home. The type of antibiotic used depends on the type of pneumonia. Children may be hospitalized for treatment if they have pneumonia caused by pertussis or other bacterial pneumonia that causes high fevers and respiratory distress. They may also be hospitalized if supplemental oxygen is needed, if they have lung infections that may have spread into the bloodstream, if they have chronic illnesses that affect the immune system, if they are vomiting so much that they cannot take medicine by mouth, or if they have recurrent episodes of pneumonia. EMPYEMA Empyema is a pus within a natural body cavity. It must be differentiated from an abscess, which is a collection of pus in a newly formed capsule rather than a pre-existing cavity. Empyema can occur as a complication of pneumonia, tuberculosis or surgical procedures (postsurgical empyema). The incidence of empyema is not well characterized, although a recent study suggests empyema may be common in patients admitted to the medical ICU. Fartoukh et al. reported an 8.4% of patients admitted to the medical ICU had physical and radiographic evidence of pleural effusion. Diagnostic thoracentesis was performed in 73% of these patients, and empyema was diagnosed in 17% of cases of pleural effusion. The infective organism can get into the pleural cavity either through the bloodstream or other circulatory system, in secretions from lung tissue, or on the surfaces of surgical instruments or objects that cause open chest wounds. Microorganisms associated with empyema included Staphylococcus aureus , Streptococcus spp. , E. coli , K. pneumoniae , M. tuberculosis , and PeptoStreptococcus. Its development can be divided into three phases: an acute phase in which the body cavity fills with a thin fluid containing some pus; a second stage in which the fluid thickens and a fibrous, coagulation protein (fibrin) begins to accumulate within the cavity; and a third or chronic stage in which the lung or other organ is encased within a thick covering of fibrous material. In humans, the pleural space surrounding the lungs is most commonly affected. This particular condition is called pyothorax and is usually caused by a bacterial infection of the lungs (pneumonia). Other common empyemas include appendicitis and pyometra. Pleural space empyema Symptoms Typical symptoms are just about the same as tuberculosis which includes: fever (which may be spiking), chest pain, cough, sweating and shortness of breath. Clubbing of the fingernails is present. There is a dull percussion note and reduced breath sounds on the affected side of the chest. Chest x-ray shows a pleural effusion, often with a lateral bulge and pleural thickening. Ultrasound confirms the size and location of the pocket of pus and the presence of fibrin aggregates.There are 3 stages:Exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates. This is followed by the fibrinopurulent stage in which there is loculation of the pleural fluid (the creation of grapelike pus pockets). In the final organizing stage there is the potential for lung entrapment by scarring. If it makes it to the final stage and scarring occurs there is a good chance of pulmonary fibrosis and other conditions that will happen in years to come, such as

right sided heart failure (cor pulmonale). This is due to the high pulmonary pressures due to the scarring and the treatment is most likely a single lung transplant. The only drug that might have any effect is prednisone, but the use of prednisone is only temporary. Diagnosis Diagnosis is confirmed by thoracentesis, X-Ray and CT Scan. Frank pus may be aspirated from the pleural space. The pleural fluid has a low pH, and the blood has a high white blood cell count usually above 20,000. Aspirated fluid is cultured to identify the causitive organism. Arterial blood gases are drawn to determine the pH, CO2 and O2 levels. Another test to confirm empyema is a pleural tap(removing 3-4 pieces of 1 to 2cm of the pleura). Treatment A chest tube is inserted to drain the pus from the pleural space, using ultrasound scan guidance. Intravenous antibiotics are given. If this is insufficient, surgical decortication of the pleura may be required.And 02 therapy. Some evidence suggests that intrapleural fibrinolytic drugs may be useful, especially in children. Also supplemental oxygen via nasal cannula is usually a good idea since the O2 sats will be near 93% or below. If below 90% a venti mask or non-re-breather for higher doses of oxygen is recommended. This is usually when it's in the 3rd stage. Empyema is treated using a combination of medications and surgical techniques. Treatment with medication involves intravenously administering a two-week course of antibiotics. It is important to give antibiotics as soon as possible to prevent first-stage empyema from progressing to its later stages. The antibiotics most commonly used are penicillin and vancomycin. Patients experiencing difficulty breathing are also given oxygen therapy. Prognosis The prognosis for recovery is generally good, except in those cases with complications, such as a brain abscess or blood poisoning, or cases caused by certain types of streptococci.

RATIONALE OF STUDY Pneumonia is a general term that refers to an infection of the lungs, which can be caused by a variety of microorganisms, including viruses, bacteria, fungi, and parasites. According to the World Health Organization, the ten leading causes of morbidity in the Philippines are diarrhea, bronchitis/bronchiolitis, pneumonia, influenza, hypertension, tuberculosis, diseases of the heart, malaria, measles and chickenpox. The prevalence of communicable diseases is still very high while that of non-communicable diseases is increasing and will continue to do so. This double burden of disease places a great toll on the health and economy of the people and of the nation as a whole. The top ten leading causes of mortality are diseases of the heart, diseases of the vascular system, pneumonia, malignant neoplasms, accidents, tuberculosis, chronic obstructive pulmonary diseases, diabetes mellitus, other diseases of the respiratory system, nephritis/nephritic syndrome and nephrosis. The fact that lung disease and other breathing problems are the number one killer of babies younger than one year old is very alarming. Infants and children are born to enjoy and to explore into this world. They are the most fragile citizens of this world and should be taken care of. They should be protected from harm that the environment can give them. They should be shielded and guarded. But if these delicate infants get sick, this reflects greatly on how neglectful his environment is and the people responsible for his well being. This caught our concern, as good citizen of society and as nursing students. It is our great duty, to protect these innocent beings. Respiratory disease is life-threatening, thus, prompting the need to let others be sensitive of the great significance to know its cause and how it affects little children. It is essential that the process of the disease be taken into in-depth study. The feature common to all types of pneumonia is an inflammatory pulmonary response to the offending organism or agent. With the defense mechanism of the lungs, lose effectiveness and allow organisms to penetrate the sterile lower respiratory tract, where inflammation develops. Disruption of the mechanical defenses of cough and cilliary motility leads to colonization of the lungs and subsequent infection. Inflamed and fluid filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. Alveolar exudates tend to consolidate, so it is increasingly difficult t expectorate. Bacterial pneumonia maybe associated with significant ventilation-perfusion mismatched as the infection grows. This study is guided by the following theories by: Comfort Theory of Katharine Kolcaba, Betty Neuman’s Systems Model, and Casey’s Model of Nursing. The comfort theory of Katharine Kolcaba states that in view of these relationships and the fact that children and families want to be comforted in stressful healthcare situations, comfort is an important outcome to measure for pediatric

care and research. With its inherent emphasis on simultaneous physical, psychospiritual, sociocultural, and environmental aspects of comfort, will contribute to a well-articulated, multifaceted approach to pediatric education and practice. On the other hand, the Neuman’s Systems Model emphasized that broad and comprehensive enough to provide structural nursing interventions to not only older patients but to pediatric clients as well. This theory is applicable in this study because of how it describes the patient as an open system. The environment both internal and external, play a very crucial task in the development of a child as presented by the 5 interrelated variables. Furthermore, Casey’s model of nursing stresses that with the importance of the partnership between the parents and caregiver, the service rendered to the child will be adequate enough to bring back his optimum level of functioning. REVIEW OF RELATED LITERATURE CASE REPORT A 3 year-old Caucasian boy, with a past history of croup, presented with a three-day history of vomiting and diarrhea. He was admitted to hospital because of right middle lobe and lower lobe consolidation, neutropenia and a markedly elevated C-reactive protein of 216 mg/L consistent with a diagnosis of pneumonia. Treatment was started with intravenous penicillin and cefotaxime. On day 3, blood Streptococcus pneumoniae, fully sensitive to penicillin, was isolated from blood cultures. By then his fever had settled and treatment was continued with high dose penicillin only. On day 5, his fever recurred. A chest X-ray demonstrated a small right-sided loculated effusion, but an ultrasound revealed only a 1 cm rim of fluid that was deemed ‘not drainable’. Cefotaxime was restarted. By day 10, an ultrasound revealed that the pleural fluid collection on the right side was 3 cm deep and contained particulate matter and septa. Intravenous flucloxacillin was substituted for penicillin. Because the child had clinically deteriorated with worsening fever, tachypnea and an increasing oxygen requirement, an urgent right thoracotomy, decortication and chest tube insertion under general anesthesia was performed. A left internal jugular central line was inserted at the same time due to problems with peripheral venous access. The pleural fluid drained was seropurulent with many leukocytes, but no organisms were found on culture. On day 12, the patient again deteriorated and a chest X-ray revealed left sided collapse/consolidation with pleural effusion. An ultrasound revealed a left sided 4 cm loculated pleural fluid collection. A left thoracotomy, decortication and chest tube insertion was performed under general anesthesia. After consultation with the hospital’s infectious diseases service, oral rifampicin was added to the flucloxacillin and cefotaxime antibiotic regimen. Culture of the pleural fluid did not reveal any organisms. Abdominal, cardiac and major vessel ultrasounds did not reveal any other infective sites, thrombosis, or fluid collections. Serum immunoglobulin levels were normal. Subsequently the child’s condition slowly improved. He was discharged home well on day 26. REVIEW Empyema in children is usually the result of under-lying lung infection with Staphylococcus aureus or Streptococcus pneumoniae. Several studies report an increase in the incidence of empyema in children; even in developed countries.1 Staphylococcal infections now outnumber streptococcal infections as the leading cause in countries where widespread pneumococcal vaccination occurs.1 Haemophilus influenzae infection is now a rare cause of empyema, again due to an effective vaccination strategy. Mycoplasma pneumoniae commonly causes a parapneumonic effusion, and is a recognized cause of empyema in children.2 Mixed infections, including anaerobes, can also occur, especi-ally in adults with underlying illnesses.3 In developed countries it is now most common for the purulent fluid drained from the pleural cavity to be sterile, due to prolonged and broad-spectrum antibiotic treatment prior to drainage. In the United States of America, initial treatment with vancomycin

or clindamycin has been recommended due to the prevalence of resistant staphylococcal and streptococcal organisms.1 In Australia severe pediatric pneumonia with effusion is usually treated initially with flucloxacillin and a third generation cephalosporin, with or without a macrolide antibiotic, as resistant pneumococcal disease is rare. Vancomycin is used initially only if meningitis is suspected.4 Staging of parapneumonic effusions An exudative parapneumonic effusion without loculations or septa (Stage 1) has minimal leukocytes in the fluid. The fluid is characterized by an elevated lactate dehydrogenase (LDH), a low pH and low glucose concentration. In the fibrinopurulent stage (Stage 2) these biochemical abnormalities worsen, the leukocyte count remains low, although there still may be extensive fibrinous coating of the pleura and loculations. In Stage 3 disease frank pus develops. Stage 4 disease is characterised by loculated pus. The ideal management strategy for empyema has not been elucidated due to a paucity of properly conducted randomized controlled trails. This situation is compounded by the fact that parapneumonic effusions (Stage 1 and 2 disease) are much more common that true empyema (Stage 3 and 4 disease). Earlier stage disease could be over- or under-represented in the various case series. Staging is also unreliable when based on clinical criteria, e.g. the age of the fluid collection. It is known that Stage 4 disease can occur within 7 days of the initial fluid collection, but the fluid can remain relatively serous for much longer than this.5 Accurate staging of an empyema can only be done by a combination of computerized tomography and fluid aspiration. In adults, empyema increases the mortality related to community-acquired pneumonia, usually from over-whelming sepsis, by seven times if bilateral and by more than three times if unilateral.5 The overall mortality in several series ranges from 1 - 61%.6 Out-comes are almost certainly influenced by management strategy. Daily thoracentesis In a case series from Denmark,3 adults with empyema had markedly reduced hospital stays (2.3 vs 5 weeks), fewer complications (bronchopleural or pleurocutaneous fistulae) and less need for thoracotomy or rib resection (6 vs 79%), if their empyema was managed by daily needle thoracentesis and lavage with or without intrapleural antibiotic administration versus chest tube drainage. Mortality was equal between the two groups at 8.5%. The two groups of patients were managed by different units (medical and surgical) and may have had different illness severities or other compounding factors. Daily thoracentesis, even if effective, may be impractical in children due to the daily requirement for deep sedation or general anesthesia. Initial chest tube drainage In a series of complex adult patients from Taiwan, 6 with mostly Gram-negative bacterial infections, unsuccessful initial chest tube drainage (defined as incomplete drainage with ongoing signs of sepsis or death) resulted in a significantly higher mortality (47%) and longer hospital stays (28 days vs 16 days) than immediate thoracotomy and decortication or successful chest tube drainage (6% and 11% mortality respectively). Similar findings have been reported previously.7 It appears that incomplete drainage with ongoing signs of sepsis heralds a poor prognosis. It is important to note that inflammatory markers such as CRP and ESR can remain elevated for up to 4 weeks despite adequate antibiotic treatment and drainage, although blood leukocyte count and fever falls by one week post drainage.8 This delayed resolution of inflammatory markers makes assessment of recovery after drainage difficult. The efficacy of pleural fluid drainage thus remains the key to the clinical decision- making process. A large survey of practice in Britain indicates that only 11% of all pediatric empyemas are managed surgically. Long-term outcome is excellent.9 Most cases are adequately treated with simple chest tube drainage. In a recent series from Great Ormond Street, later chest drain insertion (8.1 vs 6.3 days after effusion detected) was associated with a trend towards requirement for surgical drainage. 8 Those children requiring surgery had a longer hospital stay (18.6 vs 13.4 days), but surgery was only undertaken if chest tube drainage failed to result in complete drainage and clinical symptoms persisted. The authors felt that inadequate chest tube size contributed to some failures. Chest tube size need not be routinely large, but should be determined by the degree of viscosity of the fluid.5 The adult literature reveals a key point, which is that successful complete drainage by chest tube alone can occur even when loculations are evident on ultrasound or computerized tomography scan. However, the presence of loculations makes complete chest tube drainage less likely, with only 40% of loculated effusions drained completely versus 76% of simple effusions.5 A non-dependent chest tube position does not affect drainage in non-loculated effusions. Truly loculated effusions require ultrasound guidance to achieve the correct tube location. Surprisingly a lower pleural fluid leukocyte count is associated with failure of conservative management.5 Fibrinolytic therapy

In adults the addition of fibrinolytic agents to the pleural cavity can improve chest tube drainage impeded by loculations and fibrin debris,10 and may reduce the need for thoracotomy or video assisted thoracoscopic surgery (VATS).11,12 In a series of 501 children with multiloculated empyema intrapleural fibrinolytic therapy (IPFT) was successful in avoiding surgery in 81% of cases.13 In a series of 22 children with complicated parapneumonic effusions from Taiwan, streptokinase resulted in a reduction in requirement for surgery and shorter duration of fever when compared with 20 historical controls.14 There is one randomized controlled trial from India of routine administration of streptokinase intrapleurally 24 hours after chest tube insertion. No benefit was detected in terms of chest tube drainage rates, duration of illness or development of loculatons.15 Intrapleural streptokinase may rarely lead to local bleeding complications. This was seen in one child administered 250,000 units of streptokinase.13 Streptokinase can cause fever, pleural pain, arthralgia, anaphylaxis and the acute respiratory distress syndrome (ARDS).11 Urokinase may be the safest choice, with no recorded complications at a dose of 100,000 Units intrapleurally used in the Oscelik series13 and in another series from Israel.16 Pigtailed catheters and tissue plasminogen activator (tPA) Literature regarding the use of intrapleural tissue plasminogen (tPA) activator is limited, with only one report of its use in 12 children17 until Hawkins et al,18 published a recent report of tPA combined with small bore pigtail catheter drainage of empyema in children. They reported successful management of empyema in 54 of 58 cases with a mean time to catheter removal of 6 days and a mean hospital stay of 9.1 days, using this minimally invasive technique. Video assisted thoracoscopic surgery (VATS) Surgical options include a choice between VATS and formal thoracotomy. A study in 1997 of 20 adults compared VATS with chest tube drainage plus IPFT with streptokinase in loculated effusions unresponsive to isolated chest tube drainage only.19 Ninety one percent of patients undergoing VATS avoided further surgery. However, 44% of the chest tube plus IPFT treated group required further thoracotomy. In another study comparing immediate VATS with VATS after failed chest tube drainage and IPFT in late stage disease,20 shorter hospital stays (4.5 versus 7.5 days) were demonstrated in the early VATS group. At least two adult studies report VATS debridement to be better than thoracotomy in terms of hospital stay and cosmesis.21,22 VATS is reported to be rapidly successful in the majority of pediatric empyema cases with failed chest tube drainage when performed within 7 days of the initial attempt at chest tube drainage.23,24 VATS also resulted in shorter hospital stays (9 - 13 days) when compared with previous series of children managed with chest tube drainage and delayed thoracotomy. In the recent series of 230 children from the United States of America, 1 children that received very early VATS (within 48 hours of admission), had a shorter hospital stay (11.5 versus 15.2 days, P = 0.008) than those who had VATS performed later. However, VATS is not widely available, especially for children. Early thoracotomy Thoracotomy is traditionally resorted to only after the more conservative management strategies, discussed above, have failed. This surgery is associated with potential anesthesia difficulties, complications such as pneumothorax, postoperative pain and cosmetic scarring. Some authors have challenged this traditional notion of deferring thoracotomy. Hoff et al,25 in a series of 61 children, reported that resolution of the disease process was more prolonged in patients managed by chest tube alone (16.8 days in hospital) than resolution after thoracotomy (6.7 days, P < 0.001). Carey et al, 26 reported a series of 22 children with empyema referred to a pediatric cardiothoracic unit. Those children who had immediate thoracotomy (18 cases) were afebrile and had their chest tubes removed by 2 days. Their mean hospital stay was 4 days. The authors suggested that early thoracotomy remains the benchmark treatment. A similar case series of 44 children undergoing thoracotomy27 also revealed very short duration of fever (mean 1 day) and an average of 3 days until chest tube removal. Both series authors point out that their mean hospital stays were shorter than series of children managed with VATS. In summary, the available evidence indicates early and complete drainage of an empyema remains the cornerstone of treatment, however it is achieved. Morbidity and mortality increases with increasing delay in achieving this goal. Most patients can be managed with antibiotics and chest tube drainage only, especially early in the disease process. It is harder to treat late stage disease conservatively. Conservative treatment results in prolonged hospital stays. Intrapleural fibrinolytics, ideally urokinase, may help to avoid surgery. Surgery in the form of VATS or thoracotomy, when

done early, appears to result in the most rapid disease resolution, from the limited pediatric evidence available. Thoracotomy may be superior to VATS in terms of length of stay, contrary to the adult literature. The former has significant cosmetic disadvantages; the latter is not as widely available. CONCLUSION Empyema in children occurs infrequently in Western societies. The underlying causative organism is usually Staphylococcus aureus or Streptococcus pneum-oniae. Optimal management strategies have not been developed due to a paucity of randomised controlled trials. Staging is difficult to assess clinically and radiologically. Most cases can be successfully managed with simple chest tube drainage, plus appropriate antibiotic therapy. Based on available evidence, thoracotomy with decortication, in children, may provide the most effective treatment when compared with VATS and chest tube drainage with or without intrapleural fibrinolytic therapy. The more conservative approaches to treatment may be appropriate initially to avoid the cosmetic disadvantages of thoracotomy. However, delayed complete drainage increases morbidity and potentially mortality. The case presented might have been managed differently. Under general anesthesia, a pleural tap would have revealed the relatively serous nature of the fluid and chest tube drainage only may well have been successful. However, the loculated nature of the collection and the illness of the child prompted initial thoracotomy. VATS is not available for children in our institution. Our treatment decision is difficult to criticize in light of the available evidence that early thoracotomy leads to the most rapid resolution of the disease process, earlier discharge, and reduced mortality. The major drawback of thoracotomy is the life-long surgical scar. This drawback is not insignificant, but has to be weighed against the potential morbidity and mortality from ongoing infection. In retrospect, it is the authors’ view that a less aggressive approach in our case could also have been justified and may have resulted in a better cosmetic result. This approach would be initial chest tube drainage only, under ultrasound guidance, instillation of urokinase on the second day if required, then proceeding to thoracotomy within 48 - 72 hours of initial chest tube insertion if pleural fluid drainage were incomplete. REFERENCES 1. Schultz KD, Fan LL, Pinsky J et al. The changing face of pleural effusions in children: Epidemiology and Management. Pediatrics 2004;113:1735-1740. 2. Chan W, Keyser-Gauvin E, Davis GM, Nguyen LT, Laberge JM. Empyema thoracis in children: A 26 year review of the Montreal Children’s Hospital experience. J Ped Surg 1997;32:870-872. 3. Storm HKR, Krasnik M, Bang K, Frimodt-Moller N. Treatment of pleural empyema secondary to pneumonia: thoracentesis regimen versus tube drainage. Thorax 1992;47:821-824. 4. Paxton G, Munro J, eds. Paediatric Handbook. Blackwell Publishing, Carlton, 2003. 5. Light RW, Rodriguez RM. Management of parapneumonic effusions. Clinics Chest Med 1998;19:373-382. 6. Huang HC, Chang HY, Chen CW, Lee CH, Hsiue TR. Predicting factors for outcome of tube thoracostomy in complicated parapneumonic effusion or empyema. Chest 1999;115:751-756. 7. Pothula V, Krellenstein DJ. Early aggressive surgical management of parapneumonic empyemas. Chest. 1994;105:832-836. 8. Chan PWK, Crawford O, Wallis C, Dinwiddie R. Treatment of pleural empyema. J Paediatr Child health 2000;36:375-377. 9. McLaughlin FJ, Goldmann DA, Rosenbaum DM, Harris GBC, Schuster SR, Strieder DJ. Empyema in children: Clinical course and long-term follow-up. Pediatrics 1984;73:587-593. 10. Chin NK, Lim TK. Controlled trial of intrapleural streptokinase in the treatment of pleural empyema and complicated parapneumonic effusions. Chest 1997;111:275-279. 11. Bilaceroglu S, Cagirici U, Cakan A. Management of complicated patapneumonic effusions with image-guided drainage and intrapleural urokinase or streptokinase – A controlled randomised trial. Eur Respir J 1997;10:325S. 12. Bouros D, Schiza S, Patsourakis G, Chalkiadakis G, Panagou P, Siafakas NM. Intrapleural streptokinase versus urokinase in the treatment of complicated parapneumonic effusions: A prospective, double-blind study. Am J Respir Crit Care Med 1997;155:291-295. 13. Ozcelik C, Inci I, Nizam O, Onat S. Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas. Ann Thorac Surg 2003;76:1849-1853 14. Yao CT, Wu JM, Liu CC, Wu MH, Chuang HY, Wang JN. Treatment of complicated streptokinase in children. Chest 2004;125:566-571. 15. Singh M, Mathew JL, Chandra S, Katariya S, Kumar L. Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children. Acta Paediatr 2004;93:1443-1445. 16. Kornecki A, Sivan Y. Treatment of loculated pleural effusion with intrapleural urokinase in children. J Pediatr Surg 1997;32:1473-1475. 17. Weinstein M, Restrepo R, Chait PG, Connolly B, Temple M, Macarthur C. Effectiveness and safety of tissue plasminogen activator in the management of complicated parapneumonic effusions. Pediatrics 2004;113:182-185. 18. Hawkins JA, Scaife ES, Hillman ND, Feola GP. Current treatment of pediatric empyema. Semin Thorac Cardiovasc Surg 2004;16:196-200. 19. Wait MA, Sharma S, Holn J, Nogare AD. A randomised trial of empyema therapy. Chest 1997;111:1548-1551.

20. Petrakis IE, Kogerakis NE, Drositis IE, Lasithiotakis KG, Bouros D, Chalkiadakis GE. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure? Am J Surg. 2004;187:471-474. 21. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, Piedras MA, Angaramo G, Emery J. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Ann Thorac Surg 1996;61:1626-1630. 22. Lawrence DR, Ohri SK, Moxon RE, Townsend ER, Fountain SW. Thoracoscopic debridement of empyema thoracis. Ann Thorac Surg 1997;64:1448-1450. 23. Stovroff M, Teague G, Heiss KF, Parker P, Ricketts RR. Thoracoscopy in the management of pediatric empyema. J Pediatr Surg 1995;30:1211-1215. 24. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993;28:1128-1132. 25. Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: Decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis 1991;10:194-199. 26. Carey JA, Hamilton JRL, Spencer DA, Gould K, Hasan A. Empyema thoracis: A role for open thoracotomy and decortication. Arch Dis Child 1998;79:510-513. 27. Alexiou C, Goyal A, Firmin RK, Hickey MJ. Is open thoracotomy still a good treatment option for the management of empyema in children? Ann Thorac Surg 2003;76:1854-58. http://www.jficm.anzca.edu.au/pdfdocs/Journal/Journal2005/J2005%20(b)%20June/Case1a.p ANATOMY OF THE RESPIRATORY SYSTEM The respiratory system can be conveniently subdivided into an upper respiratory tract (or conducting zone) and lower respiratory tract (respiratory zone), trachea and lungs. The conducting zone starts with the nares (nostrils) of the nose, which open into the nasopharynx (nasal cavity). The primary functions of the nasal passages are to: 1) filter, 2) warm, 3) moisten, and 4) provide resonance in speech. The nasopharnyx opens into the oropharynx (behind the oral cavity). The oropharynx leads to the laryngopharynx, and empties into the larynx (voicebox), which contains the vocal cords, passing through the glottis, connecting to the trachea (wind pipe). The trachea leads down to the thoracic cavity (chest) where it divides into the right and left quot;main stemquot; bronchi. The subdivision of the bronchus are: primary, secondary, and tertiary divisions (first, second and third levels). In all, they divide 16 more times into even smaller bronchioles. The bronchioles lead to the respiratory zone of the lungs which consists of respiratory bronchioles, alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas exchange occurs. Ventilation of the lungs is carried out by the muscles of respiration. Ventilation occurs under the control of the autonomic nervous system from the part of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected neurons within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped or shaken violently. The result can be death due to quot;shaken baby syndrome.quot;[1]

Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the strap muscles of the neck. Inhalation is driven primarily by the diaphragm. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume, which in turn causes a decrease in intrathoracic pressure. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity. Exhalation is generally a passive process, however active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium.[2] During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces air out of the lungs. The right side of the heart pumps blood from the right ventricle through the pulmonary semilunar valve into the pulmonary trunk. The trunk branches into right and left pulmonary arteries to the pulmonary blood vessels. The vessels generally accompany the airways and also undergo numerous branchings. Once the gas exchange process is complete in the pulmonary capillaries, blood is returned to the left side of the heart through four pulmonary veins, two from each side. The pulmonary circulation has a very low resistance, due to the short distance within the lungs, compared to the systemic circulation, and for this reason, all the pressures within the pulmonary blood vessels are normally low as compared to the pressure of the systemic circulation loop. Virtually all the body's blood travels through the lungs every minute. The lungs add and remove many chemical messengers from the blood as it flows through pulmonary capillary bed . The fine capillaries also trap blood clots that have formed in systemic veins. The major function of the respiratory system is gas exchange. As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained two opposing conditions could occur: 1) respiratory acidosis, a life threatening condition, and 2) respiratory alkalosis. Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres), and are permeable to gases. The alveoli are lined with pulmonary capillaries, the walls of which are also thin enough to permit gas exchange. All gases diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation follows, thereby ridding the body of the carbon dioxide and completing the cycle of respiration. In an average resting adult, the lungs take up about 250ml of oxygen every minute while excreting about 200ml of carbon dioxide. During an average breath, an adult will exchange from 500 ml to 700 ml of air. This average breath capacity is called tidal volume. The respiratory system lies dormant in the human fetus during pregnancy. At birth, the respiratory system is drained of fluid and cleaned to assure proper functioning of the system. If an infant is born before forty weeks gestational age, the newborn may experience respiratory failure due to the under-developed lungs. This is due to the incomplete development of the alveoli type II cells in the lungs. The infant lungs do not function due to the collapse of the alveoli caused by surface tension of water remaining in the lungs. Surfactant is lacking from the lungs, leading to the condition. This condition may be avoided if the mother is given a series of steroid shots in the final week prior to delivery. The steriods accelerate the development of the type II cells. STATEMENT OF THE PROBLEM This case study aims to determine “How the patient acquired the illness, and the process by which the body responds to the situation”. This also specifically attempts to answer the following questions: • What is Pneumonia and Empyema? • What organs and parts of the body are affected by the disease process?

• Where and how the illness was obtained, how it progressed and affected the body? • What were the predisposing factors that lead the patient to acquire the disease? • What interventions are needed to manage the such condition? • Why was Chest Tube Thoracotomy was performed to the patient? • Were the interventions effective in helping the patient recover? CHAPTER TWO Data Collection, Analysis and Interpretation OPT Model CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION KNS, 3 months old, female, Roman Catholic, ER Blotter Doctor’s Orders Filipino, residing at Candabo, Argao and born At the CVGH-ER, patient was given oxygen on January 26, 2007 via Normal Spontaneous Accompanied by mother and aunt, patient inhalation at 1L/min via nasal cannula at Vaginal Delivery (NSVD) at Argao Isidro arrived at CVGH-ER at 10:58pm on May 5, 11:40pm. He was started with an IVF of Quintana Memorial Hospital, was admitted for 2007 per ambulance, febrile, with the following D5IMB 1 pint at 27ugtts/min. the 1st time in Cebu Velez General Hospital vital signs: PR: 116 bpm RR: 78 cpm T: 38.1 C/ (CVGH) for complaints of fever, cough, and axilla. At around 12:10 am, she was admitted to convulsion. Patient was admitted under the the Pediatrics department under the services of services of Dr. Lydia Chang and Dr. Maribel Dr. Lydia Chang and Dr. Maribel Du with case Du under the Department of Pediatrics and # 87395 and was transported around 12:30 am Surgery with the case number of 87395 and to Ward 6-A per mother’s arm in a wheelchair. hospital number of 039874. DATE OF ASSESSMENT: May 9, 2007 History of Present Illness General Measurements: mid-arm: 15.5 cm 1 month PTA, patient had an onset of chest circumference: 45 cm intermittent nonproductive cough. No medical Head circumference: 40.5 cm consult was done. Abdominal circumference: 48 cm 9 days PTA, patient had an onset of intermittent Ht: 63.5 cm fever ranging from 38.0-38.5oC/axilla with Wt: 6.5 kg

nonproductive cough still noted. No chills nor IBW: 8.3 kg convulsion were manifested. This prompted the Fontanels: anterior: open patient’s mother to seek consultation at Dr. posterior: closed Villaflor’s clinic at Argao Isidro Quintana Memorial Hospital where the patient was Physiologic Measurements nebulized with Salbutamol 1 cycle (a T°: 37°C/axilla bronchodilator which binds to beta-2 adrenergic RR: 78 cpm receptors in airway smooth muscle, leading to PR: 120 bpm activation of adenyl cyclase and increased levels of -3, -5 adenosine monophosphate) and May 9, 2007 GENERAL APPEARANCE was prescribed with cetirizine (an antihistamine which antagonizes the effect of histamine at 3pm >seen per aunt’s arm, awake, conscious, with O2 inhalation via nasal cannula at 1L/min, H1-receptor sites; does not bind to or inactivate histamine) and amoxicillin (an anti-infective with Chest Tube Thoracotomy (CTT) attached on left lung in the left lower chest, with IVF 3 which binds to bacterial cell wall, causing cel death), both of unrecalled dose. Ibuprofen D5IMB 1 pint @ 27 mgtts per minute infusing well on right hand, with pulse oximeter on big (Dolan) 100mg/5ml 2ml (an antipyretic, non- opioid analgesic and a non-steroidal anti- toe of right foot, with the following vital signs: PR: 120 bpm RR: 60 cpm inflammatory agent, which inhibits prostaglandin synthesis) as needed for T: 37°C/axilla temperature above 38oC/axilla was also Skin and appendages: Presence of IV catheter prescribed. There was no relief of fever and on right arm, with good skin turgor, no edema, cough, as claimed by patient’s mother. no lesions, long fingernails and toenails with 1 week PTA, patient had an acute attack of convulsion with fever of 40oC/axilla, pinkish nail beds, CRT <2 secs, no cyanosis, as well as jaundice. accompanied by pallor, profuse sweating and Head: normocephalic, (+) ROM, Hair is fine, nonproductive cough; thus, was brought to straight, black and evenly distributed, with no Miller Hospital. There, nebulization of dandruff nor lice infestations, open anterior Salbutamol was done and patient was fontanel, closed posterior fontanel. prescribed with ceftriaxone (an anti-infective and 3rd generation cephalosporin, which binds Eyes : symmetrical, anicteric sclerae, smooth, moist and pale palpebral conjunctivae and clear to bacterial cell wall membrane, causing cell bulbar conjuctivae, (-)discharges, equal death), prostaphlin (an anti-infective and distribution of eyebrows and eyelashes, (+) penicillin, which binds to bacterial cell wall, Pupils Equally Round and Reactive to Light and resulting in cell death) and ibuprofen, all of Accomodation, unrecalled dose. Chest X-ray was done and Ears : symmetrical, no lesions, pinna is in line revealed moderate pleural fluid on left lung.

3 days after Chest X-ray was done, patient was with the outer canthus of the eye, no swelling, referred to CVGH for insertion of Chest Tube pinna is nontender, no discharges noted on Thoracotomy. auditory meatus. Nose: symmetrical, no masses, no discharges, PAST HISTORY nasal septum at midline Prenatal History Mouth and throat: lips are symmetrical but pale, no ulcerations and no lesions, buccal Mother is a 35 year old with an obstetrical score mucosa pink, pinkish gums with no ulcerations, of G4P4004. Prenatal care was started at 5 tongue located at midline, uvula at midline, no months Age of Gestation (AOG) at their deciduous teeth Barangay Health Center in Argao. Regular pre- Chest: Symmetrical, no lesions, equal chest natal check-up was done once every month expansion, presence of CTT incision on left thereafter. Mother claimed to have had an onset anterior lower chest. of fever during the course of pregnancy, Lungs: Equal lung expansion, (+) rales on left specifically during the 7th month AOG and was lower lung field upon auscultation, CTT prescribed Paracetamol (Biogesic) 500mg (an attached to left lung anti-pyretic, non-opioid analgesic, which Heart: distinct s1 and s2 heart sounds upon inhibits the synthesis of prostaglandins that may ausculation, no murmurs heard, heart rate of serve as mediators of pain and fever, primarily 120 bpm with regular rhythm. in the central nervous system) three times a day Abdomen: protuberant, no masses, no upon pre-natal visit. Condition improved. tenderness, presence of bowel sounds at 15 Vitamins taken during the course of pregnancy gurgling sounds/minute auscultated at right included Ferrous Sulfate (an anti-anemic and lower quadrant iron supplement, which is required for the GUT-Reproductive: grossly female, no production of hemoglobin necessary for O2 swelling, no abnormal discharges, no lesions, transport to cells), which was prescribed by the no rashes. physician at the Health Center. Mother claimed Anus: no lesions, no hemorrhoids, no rashes. to have had a complete Tetanus Toxoid Extremities: symmetrical, (+) ROM for all immunization. Mother was confined for a day at extremities, no lesions, presence of pulse Argao Isidro Quintana Memorial Hospital after oximeter on right toe. delivery and was discharged with improved Musculoskeletal: no deformities, good muscle condition. No distress was detected on the baby. tone. Previous Hospitalizations: NEUROLOGIC ASSESSMENT Patient has no previous hospitalization. Mental Status/Cerebral Functioning Awake, alert, coherent. Able to cry. Irritable Labor and Delivery behavior

Motor/Cerebellar Functioning Age of Gestation was 9 months. Patient’s Able to grasp student nurse’s fingers tightly. mother experienced 1 hour and 45 minutes of Extremities symmetrically folded inward with spontaneous labor. She delivered a live baby good muscle tone. girl with cephalic presentation at Argao Isidro Reflexes Quintana Memorial Hospital, assisted by an (+) palmar grasp obstetrician of unrecalled name. The patient (+)babinski reflex was 6.5 pounds upon birth. Patient had a loud Sensory Functioning cry upon delivery and had no congenital Responsive to light touch (hanky) and pain (slight anomalies noted. Patient was given a shot of pinch) at both upper and lower extremities and both Vitamin K and Hepatitis B vaccine as well as sides of the face. terramycin (an anti-infective and tetracycline, Cranial Nerve Testing which inhibits bacterial protein synthesis at the CN 1 (Olfactory) – not assessed cannot verbally level of the 30s bacterial ribosome), express himself immediately after delivery. Patient stayed for a CN 2 (Optic) – (+) PERRLA, (+) Blinking reflex day at the hospital and was discharged CN 3 (Oculomotor) – (+) PERRLA improved. CN 4 (Trochlear) – (+) PERRLA CN 5 (Trigeminal) – (+) rooting reflex, (+) sucking reflex Feeding History CN 6 (Abducens) – (+) PERRLA CN 7 (Facial) – able to close eyes, can smile, Patient was immediately breastfed after birth. wrinkle forehead, cry. Currently, the patient is breastfed every 2 hours CN 8 (Auditory) – (+) moro reflex with loud noise, or per demand. Vitamins taken were Ceelin (for eyes follow direction of sound treatment and prevention for vitamin C CN 9 (Glossopharyngeal) – (+) gag reflex, able to deficiency in infants and children) and Tiki- swallow Tiki, a multivitamin supplement, 0.6 ml thrice a CN 10 (Vagus)- (+) gag reflex , able to swallow day prescribed by Dr. Lydia Chang. CN 11 (Accessory) – cannot be assessed CN 12 (Hypoglossal) – mouth opens when nose is pinched, tongue midline at protrusion Health History Current Developmental Skills Patient has no known food and drug allergies. Gross Motor skills: Immunizations received were BCG1, DPT1 and (+) Landau reflex , able to lift head on prone DPT 2, Hep1 and Hep2 as well as OPV1. position, slight lag present when pulled to a sitting position, able to support part of weight upon Elimination Pattern standing Fine Motor Skills: Can attempt to reach for pacifier Patient defecates at least 4 times a day with

Language skills: soft, light brown stools and urinates at least 4 to Makes cooing sounds and is able to slightly laugh, 5 times a day. cries when hungry or wet Family History: Developmental Theories: Patient’s father, a 40 year old, is a highschool Jean Piaget’s theory of Cognitive Development: graduate, currently working as a house painter. sensory motor stage His mother is a 35-year old housewife and is a Patient relates through senses, primarily reflex highschool undergraduate. The patient has 3 behavior. siblings; the first of which is a 6-year old male, currently in kindergarten, followed by a 4- year Erikson's Psychosocial Development: old male, now enrolled in Day Care and the Trust vs. mistrust third sibling is a 2-year old female. The patient was provided with 3 primary care givers The patient has no known heredofamilial with whom trust can be established. The student diseases (HFDs) on both maternal and paternal nurses provided experiences that add to security, side. such as keeping voices low and providing soft touches. Genogram: Freud’s theory of Psychosexual development: oral stage Paternal Maternal Patient uses a pacifier (oral stimulation) and is breastfed by the mother every 2 hours or as needed. DATE OF ASSESSMENT: May 10, 2007 General Appearance: 3pm> Seen lying on bed, awake, conscious, afebrile, with O2 inhalation via nasal cannula at 1L/min, with CTT attached to left lung, with IVF of 5 D5 IMB 1 pint @ 27 ugtts / min, Legend: infusing well at right hand, with pulse oximeter attached to big toe of right foot, with the Deceased male Deceased female following vital signs: Temperature: 36.3ºC/axilla female male Pulse Rate: 136 bpm Respiratory rate: 70 cpm patient Significant findings:

Skin and appendages: Presence of IV catheter Personal and Social history: on right arm Eyes: pale palpebral conjuntivae Mouth and Throat: pale lips The personal caretaker of the child is her Lungs: rales still heard upon auscultation of left mother. Mother also readily feeds the patient lower lung fields. CTT still attached to left through breastfeeding every 2 hours or per anterior lower chest demand. The baby sleeps in between her mother Extremities: pulse oximeter still attached to and father using one pillow. There is only 1 right toe room in the house and 6 people in the household. The family goes to church every Sunday, as claimed by the patient’s mother. Patient’s parents have been married for 7 years DATE OF ASSESSMENT: May 11, 2007 now. They believe in consulting a doctor General Appearance: whenever a health problem arises. They do not 3pm> Seen per mother’s arm, awake, believe in quack doctors. conscious, afebrile, with O2 inhalation via nasal cannula at 1L/min, with CTT attached to left Environmental History: lung, with IVF of 6 D5 IMB 1 pint @ 27 ugtts / min, infusing well at right hand, with the Patient lives with her mother, father, and 3 following vital signs: siblings in Candabo, Argao, Cebu in a 1-storey Temperature: 36.5ºC/axilla house made of mixed materials. They

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