Pediatric emergency medicine trisk 4091 4091
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collections to allow for lung reexpansion. Patients who develop small
parapneumonic effusions will frequently improve clinically with appropriate
antibiotic therapy, and small- to moderate-sized simple effusions may resorb as
the underlying intraparenchymal infection resolves. Large effusions that compress
the lung or complex, loculated effusions are best treated with drainage. Simple
layering effusions may be effectively evacuated with tube thoracostomy alone,
while large or complex, loculated effusions and simple effusions not effectively
managed with tube thoracostomy may require chemical fibrinolysis or surgical
drainage and debridement. Surgical drainage and debridement, which can
typically be done via a minimally invasive thoracoscopic approach, serves to
relieve acute lung compression and to prevent a complex parapneumonic effusion
from organizing and establishing a thick pleural peel, which could entrap the lung
and result in chronic restriction on the affected side.
CLINICAL PEARLS AND PITFALLS
Utilize ultrasound for moderate to large pleural effusions to better
characterize the fluid collection and identify loculations.
For patients with empyema, early consultation with surgical consultants
can facilitate more rapid intervention and resolution in appropriate
patients.
Current Evidence
An empyema is the presence of infected fluid within the pleural cavity and is
typically a sequela of an underlying pneumonia. The incidence of empyema has
varied over recent decades, largely due to variation in invasive pneumoccoal
disease with widespread vaccination. Empyemas seem to have seasonal variation,
being more common in the winter and spring months. While chronic medical
problems do predispose children to having more complicated pneumonias and
empyemas, they also occur in previously healthy children. The predominant
organisms implicated in empyemas have varied over time with vaccination and
resistance patterns but they generally include Streptococcus pneumoniae ,
Staphylococcus aureus , group A streptococci, and Haemophilus influenza among
others. When empyema follows trauma or surgery, other bacterial organisms may
be involved. Viruses and Mycoplasma pneumoniae infections can also cause
parapneumonic effusions but these rarely require intervention and patients are
generally less severely ill than with traditional bacterial collections.
