Volume 195 - Issue 2
Recommendations for managing paediatric empyema thoracis
Authors: Roxanne E Strachan and Adam Jaffé, on behalf of the Australian Research Network in Empyema (ARNiE)
Med J Aust 2011; 195 (2): 95. || doi: 10.5694/j.1326-5377.2011.tb03218.x
Published online: 18 July 2011
Published online: 18 July 2011
Paediatric empyema thoracis occurs in 0.7% of pneumonias in Australia and general paediatricians may only see a few cases in their career. A recent survey demonstrated a lack of consensus in management across Australia, highlighting the need for a local guideline.
Empyema is an accumulation of infected fluid in the pleural space caused by a disruption in the equilibrium of pleural fluid secretion and absorption by the pleural lymphatic drainage system. Children with empyema typically present with symptoms and signs of pneumonia. A persistent fever despite 48 hours of appropriate antibiotic treatment may indicate development of empyema. Children with empyema should be managed in a hospital with paediatric expertise — preferably by or in consultation with respiratory paediatricians, and in conjunction with paediatric surgeons (recommendation [R], strong; evidence [E], low quality). If feasible, children should be transferred to a tertiary paediatric centre; treatment of paediatric empyema is very different to that of adult disease.
A chest x-ray should be carried out for children in whom empyema is suspected (R, strong; E, high quality); a routine lateral film is not needed. A lateral decubitus or erect film may be used to differentiate a simple parapneumonic effusion from an empyema if ultrasound is not available (R, strong; E, none). Daily x-rays are not necessary to monitor progress as changes on chest x-ray lag behind clinical status (R, strong; E, none). Ultrasound is the central investigation in the management of paediatric empyema; it should be used for all children with empyema as it is the best technique for differentiating pleural fluid and consolidation, estimating effusion size and grading complexity, demonstrating the presence of fibrinous septations and guiding chest drain placement (R, strong; E, high quality). A preoperative chest computed tomography (CT) scan should not be routinely performed (R, strong; E, moderate quality) but should be reserved for complicated cases in which the condition has not responded to treatment or there is concern that another pathological condition, such as a tumour, is involved. Blood tests such as blood culture (R, strong; E, high quality), full blood count and measurement of C-reactive protein level (R, strong; E, none) may help in supporting the diagnosis and monitoring the progress of the disease, but there is no role for routine blood tests.
Children with empyema should receive high-dose, intravenous antibiotic therapy to ensure pleural penetration (R, strong; E, high quality). The majority of causative organisms in Australia are Streptococcus pneumoniae (in particular, serotypes 1, 3 and 19A), Streptococcus pyogenes, methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus (MRSA). In the absence of a positive culture result, the initial choice depends on the local hospital infection control policy for managing community-acquired pneumonia. Appropriate antibiotics should cover at least S. pneumoniae and S. aureus (R, strong; E, high quality). Consideration should be given to coverage of MRSA for children from communities with a high prevalence of MRSA (R, strong; E, high quality). Anaerobic infection should be considered in children who are at risk of aspiration. Macrolides should be used when Mycoplasma pneumoniae is thought to be the causative organism but should not be used routinely (R, weak; E, moderate quality).
Moderate to large effusions require drainage. There is no role for diagnostic thoracocentesis. If there is a need to access the pleural cavity, the placement of a drain should be considered, thus ensuring that the child undergoes only one invasive intervention (R, strong; E, high quality). Pleural fluid should be sent for cytological testing, microscopic examination and culture, including culture for Mycobacterium tuberculosis (R, strong; E, high quality). Ideally, pleural fluid should be tested using enhanced molecular techniques such as polymerase chain reaction (R, strong; E, high quality). There is currently no role for pleural biochemical markers to guide therapy in children (R, weak; E, low quality).
Chest drainage with a large bore drain alone is not recommended (R, strong; E, moderate quality). Instead, percutaneous small bore drainage with a fibrinolytic agent (preferably urokinase) or video-assisted thoracoscopic surgery (VATS) is recommended (R, strong; E, moderate quality). Open thoracotomy is not recommended as it has largely been superseded by the use of VATS.
Children with an oxygen saturation level below 93% on room air should be given supplemental oxygen (R, strong; E, high quality). Other standard therapy includes fluid replacement (R, strong; E, none), use of antipyretic agents (R, strong; E, none specific to empyema) and analgesia (R, strong; E, none). There is no role for chest physiotherapy — apart from early mobilisation and encouragement of deep breathing and coughing, particularly after surgical intervention or tube drainage (R, strong; E, low quality) — and no indication for routine bronchoscopy in children with empyema (R, strong; E, weak).
If a child has been afebrile for 24 hours, a change from intravenous to oral antibiotic therapy can be considered (R, weak; E, none). The choice of oral antibiotic depends on the organism identified (if any) or the class of antibiotic that was successfully used by intravenous therapy. There is no consensus on duration of oral antibiotic therapy, which varies from 1 week to 6 weeks (R, weak; E, none). A follow-up chest x-ray should be carried out 4–6 weeks after discharge from hospital to confirm that changes are resolving (R, weak; E, none). Further imaging is not required unless there are persistent clinical symptoms or complications (R, weak; E, none). There is no need for routine investigations to identify a possible underlying cause in previously healthy children without a history of recurrent infections (R, weak; E, very low quality).
The full position statement is available at http://www.thoracic.org.au/ professional-information/position-papers-guidelines.
Competing interests
Adam Jaffé has received an unrestricted grant, paid to his institution, from GlaxoSmithKline, and Roxanne Strachan has received funding to attend a conference from GlaxoSmithKline.
Provenance: Not commissioned; not externally peer reviewed.