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Pleural effusion and empyema

  • See also

    Febrile child 

    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


    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.  

    Information specific to RCH

    Respiratory Fellow

    General Surgical Fellow  

    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

    Acute management

    Pleural Effusion Empyema