Paediatric Pleural Effusion And Empyema

A parapneumonic effusion is pleural fluid accumulation associated with pneumonia. Empyema represents infected pleural fluid containing pus or significant bacterial infection.

The process can progress from a simple free flowing exudative effusion to fibrin deposition, loculation and eventually an organized pleural peel.

Common pathogens include Streptococcus pneumoniae, Streptococcus pyogenes and Staphylococcus aureus.

Chest ultrasound is the preferred modality for defining the size and complexity of pleural fluid and identifying septations or loculations.

Chest radiography may show:

• Blunting of the costophrenic angle
• Homogeneous opacity
• Meniscus
• Hemithorax opacification
• Mediastinal displacement

CT is not routinely required. Reserve it for atypical disease, suspected lung abscess, necrosis, mass lesion or failure to progress despite appropriate management.

If pleural fluid is drained, send for:

• Gram stain
• Bacterial culture
• Cell count where relevant
• Molecular testing where available

Consider tuberculosis in persistent or atypical effusions.

Admit.

Give IV antibiotics covering at minimum:

• Streptococcus pneumoniae
• Streptococcus pyogenes
• Staphylococcus aureus

Choice depends on local resistance and severity. Appropriate regimens may include a beta lactam combined with antistaphylococcal coverage.

All established pleural infections require adequate antimicrobial therapy.

Drainage is indicated when there is:

• Significant respiratory compromise
• Large effusion
• Frank pus
• Loculated infected fluid
• Persistent sepsis despite appropriate antibiotics

Use image guided small bore chest drainage where available.

Intrapleural fibrinolytic therapy may improve drainage in loculated empyema.

Failure of adequate tube drainage and medical therapy may require thoracoscopic surgery or decortication.

Total antibiotic treatment commonly extends for several weeks, transitioning from IV to oral therapy once the child is clinically improving.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Severe Pneumonia In Children

Severe pneumonia is pneumonia associated with significant respiratory compromise, hypoxaemia, systemic illness or inability to safely feed and hydrate.

It can progress rapidly to respiratory failure, sepsis, shock, empyema, pneumothorax or death.

Severe features include:

• SpO₂ below 90%
• Central cyanosis
• Grunting
• Severe chest indrawing
• Marked tachypnoea
• Nasal flaring or head nodding
• Inability to drink or breastfeed
• Altered consciousness
• Apnoea
• Exhaustion
• Silent or markedly reduced air entry

A falling respiratory rate in an exhausted hypoxaemic child may indicate respiratory failure rather than improvement.

Admit urgently.

Give oxygen for hypoxaemia.

First line inpatient therapy:

Benzylpenicillin 50,000 units/kg/dose IV or IM every 6 hours

plus

Gentamicin 7.5 mg/kg IV or IM every 24 hours.

Monitor oxygen saturation, respiratory effort, feeding, perfusion and conscious level closely.

If deterioration or inadequate improvement occurs, reassess for empyema, cavitation, Staphylococcus aureus, Gram negative infection, tuberculosis, Pneumocystis pneumonia or an alternative diagnosis.

Ceftriaxone 50 mg/kg IV every 12 hours, maximum 4 g/day, is an escalation option in severe sepsis or meningitis dosing contexts and may be used according to the clinical syndrome and local antimicrobial policy.

Suspected staphylococcal pneumonia requires antistaphylococcal therapy such as flucloxacillin, with additional Gram negative coverage where appropriate.

Drain significant empyema when indicated.

Escalate respiratory support early when hypoxaemia or respiratory fatigue persists.

Paediatric Pleural Effusion And Empyema

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management