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Paediatrics: Pneumonia (effusion, empyema)
The presence, in association with pneumonia, of a small effusion that does not cause any respiratory distress can be managed conservatively without the need for aspirating a sample.
Pneumonia: effusion, empyema
The presence, in association with pneumonia, of a small effusion that does not cause any respiratory distress can be managed conservatively without the need for aspirating a sample. A fluid sample, however, is needed if there is:
- a large effusion;
- no clear underlying diagnosis;
- respiratory distress;
- persistent fever despite antibiotic treatment;
- long history (>14 days).
Fluid sample
After the US of the chest and checking blood-clotting studies, a small chest drain (or pigtail drain) should be inserted into the pleural fluid unless effusion is small. Samples should be sent for the following:
- Microbiology: bacterial culture and sensitivity, acid-fast bacilli.
- Cytology: the presence of pus cells and microscopic assessment of aberrant cell types. Cytology for lymphoma may give false results in up to 10% of cases.
Diagnosis of empyema
The diagnosis of empyema can be based on the presence of:
- Fluid: pH < 7.2, glucose <3.3mmol/L, protein >3g/L, pus cells.
- US scan:loculation or fibrin strands are seen.
Fluid drainage
After inserting the small-bore drain or pigtail catheter, the fluid should be allowed to drain into standard commercially available systems (e.g. water-seal two-bottle system). The drain can be removed if draining <50mL in 24hrs.
Urokinase for empyema
In empyema, as opposed to simple pleural effusion, instillation of urokinase via the chest drain is recommended.
- Dose: 40,000U urokinase in 40mL (10,000U in 10mL if <1yr) given12-hourly for 3 days.
- Method: instill via the chest drain and then clamp the drain and encourage the patient to move and roll around over the next 4hr.
- Suction: use a low-pressure suction device (e.g. Robert’s pump) to maintain suction of 20cmH2O between doses.
- Local anesthetic: bupivacaine around the drain site may control pleural pain. Consult the pain control team.
Surgical referral
If the effusion or empyema fails to resolve over a period of 7 days then a surgical opinion may be sought. Sometimes a chest CT scan is needed. A definitive surgical procedure or large bore drain and manual disruption of loculation may be needed.