Pediatric emergency medicine trisk 4090 4090
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diagnostically indicated when there is concern for a noninfectious cause of the
collection. Gram stain and culture should always be sent when pleural fluid is
available. Nucleic acid amplification testing through polymerase chain reaction
(PCR) or specific antigen testing of pleural fluid may increase the likelihood of
pathogen detection, particularly in patients who have been partially treated with
antibiotics. Fluid should be sent for a cell count with differential since this can
help distinguish between various infectious pathogens and malignancy. Cytology
should be sent as well when malignancy is suspected. Analysis of other pleural
fluid parameters that have historically been assessed such as pH, LDH, glucose,
and protein have been used to predict the need for further interventions, but are
not routinely required as they rarely alter management.
Thin, free-flowing pleural fluid may sometimes be managed by simple
thoracentesis (which may be repeated as needed) or the effusion may resolve as
the underlying condition is treated. Alternatively, a small-diameter tube, such as
an 8F to 12F pigtail percutaneous tube, can be placed in the anterior or
midaxillary line. Early and continued administration of fibrinolytics into the
catheter can be helpful in fostering resorption and preventing fibrin and other
products from obstructing tube drainage. Thick fluid, such as blood, pus, and
sometimes chyle, often requires the placement of a larger diameter tube. Either
tube must be attached to a pleural drainage system. When the drainage decreases
significantly, to approximately 1 mL/lb of body weight per day, the drain may be
removed. The drain should not be removed in the presence of an accompanying
“air leak” caused by a bronchopleural connection. See section below on empyema
for discussion of further drainage modalities.
Disposition
Pleural effusions that require drainage or further diagnostic evaluation clearly
warrant inpatient admission. There is a role for outpatient antibiotic therapy in the
setting of very small effusion in the well-appearing child who has close followup. Please refer to the pneumonia clinical pathway for suggested empiric
antibiotic
therapy
( ). This should be tailored, however, to
local sensitivities for common pathogens.
Empyema
Goals of Treatment
The goals of treatment for empyema include the provision of adequate antibiotic
treatment for the underlying infection and evacuation of significant pleural
