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.

Suspect pleural infection when a child with pneumonia has:

• Persistent fever despite antibiotics
• Increasing respiratory distress
• Pleuritic chest pain
• Reduced breath sounds
• Dullness to percussion
• Reduced chest expansion
• Persistent oxygen requirement
• Toxic appearance

A large effusion may produce mediastinal shift and severe respiratory compromise.

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.