See also

Febrile child 
Pneumonia

Background to condition  

Empyema is defined as the presence of pus in the pleural space. Parapneumonic effusion is a pleural fluid collection in association with an underlying pneumonia.

Empyema is rare in children (0.7% of pneumonia cases). This guideline covers diagnosis and management of both complications of pneumonia.  

How to assess

Red flag features in Red 

Features on history:  

As for pneumonia:

1. Fever
2. Anorexia
3. Lethargy/malaise
4. Breathlessness
5. Persistent fever in the setting of pneumonia despite 48 hours of antibiotics
6. Chest pain or pleuritic pain and refusal to lie on one side  

Features on examination:  

1. Localised decreased air entry
2. Dullness to percussion
3. Decreased chest expansion
4. Appearance of spinal scoliosis due to underlying inflammation and muscle spasm.  

Features on investigations:

AP/PA CXR:

• Blunting of costophrenic angle initially
•  “Meniscus sign” is a rim of fluid ascending the lateral chest wall.
• Should be an erect film
• Scoliosis, mediastinal shift and raised haemi-diaphragm away from side of effusion
• Complications ie pyopneumothorax
• Lateral CXR is not routinely indicated  

Ultrasound of chest:

• Delineates size and location of effusion
• Identifies loculations
• Presence of complication (abscess, pneumatocoele)  

CT chest not routinely indicated. Consider if risk of complications, following treatment failure or query regarding alternative aetiology.  

FBE & Blood film

• Leucocytosis, neutrophilia, thrombocytosis.
• Consider rare complication of Haemolytic Uraemic Syndrome (HUS) with anaemia and thrombocytopenia

CRP is useful as marker of treatment success

U&E [SIADH/HUS]

Blood culture

Pneumococcal PCR on blood

Pleural fluid

• Slide for Gram stain & Microscopy / C&S
• Pneumococcal PCR pleural fluid
• Consider AFB & mycobacterial culture / PCR if risk factors
• No evidence for use of pleural biomarkers in children  

When to admit/consult local paediatric team, or who/when to phone consult at RCH:

• All children with empyema and effusion should be managed as an inpatient
• Consultation with a respiratory physician and paediatric surgeon
• Consider transfer to a tertiary paediatric centre if feasible.  

Ward Management

• No role for chest physiotherapy
• Ensure adequate analgesia for ease of breathing and mobilisation
• Monitor for complications; chest drain blockage, development of air leak.  

Discharge requirements:

• Afebrile and on room air for 24 hours
• Pain free
• Compliance with oral medication as a prolonged course may be indicated.
• Absence of re-accumulation despite 48 hours without drain.  

Additional Notes

• Follow up CXR at 6 weeks. May not be normal until 6 months  

Links for further reading:  

Paediatric Empyema Thoracis: Recommendations for Management

Position statement from the Thoracic Society of Australia and New Zealand www.thoracic.org.au

Acute management