Management of Bilateral Pleural Effusion in a 7-Year-Old with Cough
This child requires immediate ultrasound confirmation of the pleural effusion, followed by hospital admission for intravenous antibiotics and likely chest tube drainage with fibrinolytics, as bilateral pleural effusions in the context of respiratory symptoms represent parapneumonic effusion/empyema until proven otherwise. 1
Immediate Diagnostic Steps
Ultrasound is mandatory to confirm the presence and characteristics of the pleural fluid collection. 1 The chest X-ray alone cannot differentiate between parapneumonic effusion and empyema, nor can it distinguish fluid from severe lung consolidation. 1
Essential Initial Investigations
Perform the following workup immediately upon hospital admission 1:
- Blood cultures (including anaerobic bottle) - critical for identifying causative organisms
- Full blood count with differential to assess white cell count and check for anemia
- Electrolytes to detect syndrome of inappropriate ADH
- Serum albumin (often low in these cases)
- C-reactive protein as a marker of disease progression
- Antistreptolysin O titre (ASOT) to evaluate for post-streptococcal infection
- Sputum culture if the child can produce sputum
Do NOT routinely order a CT scan - it exposes the child to radiation equivalent to 20-400 chest X-rays and adds no clinically useful information beyond what ultrasound provides. 1
Hospital Admission and Initial Management
All children with parapneumonic effusion or empyema must be admitted to hospital. 1 The absence of fever does NOT exclude bacterial infection - this child's 7-day symptom duration suggests possible progression from simple pneumonia to complicated parapneumonic effusion. 1
Antibiotic Therapy
Start intravenous antibiotics immediately that cover Streptococcus pneumoniae - the most common causative organism in pediatric parapneumonic effusions. 1, 2, 3
Recommended regimens 2:
- Second-generation cephalosporin (e.g., cefuroxime) PLUS metronidazole, OR
- Aminopenicillin with beta-lactamase inhibitor (e.g., amoxicillin-clavulanate), OR
- Aminopenicillin PLUS metronidazole
Avoid aminoglycosides - they have poor penetration into the pleural space and are ineffective. 2
Plan for 1-4 weeks of oral antibiotics after discharge, extending longer if residual disease persists on follow-up imaging. 1, 2, 3
Drainage Decision
Effusions that are enlarging or compromising respiratory function should NOT be managed by antibiotics alone. 1, 2 Given bilateral involvement and 7-day symptom duration, this child likely requires drainage.
When to Insert Chest Drains
If the child has significant pleural infection, insert a drain at the outset rather than performing repeated thoracentesis. 1 Indicators for drainage include:
- Respiratory compromise (oxygen saturation <92%) 1
- Enlarging effusions on serial imaging 1
- Persistent fever despite 48 hours of appropriate antibiotics 1
- Thick fluid with loculations on ultrasound 1
Use ultrasound guidance for drain placement to identify the optimal insertion site and reduce complications. 1, 2
Small-bore percutaneous drains are preferred for initial drainage, as there is no evidence that large-bore drains are more effective. 1, 2
Fibrinolytic Therapy
Intrapleural fibrinolytics are recommended for any complicated parapneumonic effusion (thick fluid with loculations) or empyema (overt pus) - they shorten hospital stay significantly. 1
Urokinase dosing 1:
- For children ≥10 kg: 40,000 units in 40 mL of 0.9% saline
- For children <10 kg: 10,000 units in 10 mL of 0.9% saline
- Give twice daily for 3 days (6 doses total)
Urokinase is the only fibrinolytic studied in a randomized controlled trial in children and is therefore the recommended agent. 1
Specialist Involvement
A respiratory pediatrician should be involved early in the care of all patients requiring chest tube drainage for pleural infection. 1, 2 Consider thoracic surgery consultation if the child shows:
- Persistent sepsis despite chest tube drainage, antibiotics, and fibrinolytics 1
- No clinical improvement within 7 days 2
- Organized empyema requiring decortication 1
Critical Pitfalls to Avoid
The bilateral nature of this effusion is unusual - bilateral empyemas are rare except in specific populations, and this finding should prompt consideration of tuberculosis, especially if pleural fluid shows lymphocytosis. 1, 2 Tuberculosis must be excluded in the presence of pleural lymphocytosis. 1
Do not delay drainage - conservative management with antibiotics alone results in prolonged illness and hospital stay. 1 Early active treatment is essential to prevent morbidity.
Do not perform chest physiotherapy - it is not beneficial and should not be done in children with empyema. 1
Check oxygen saturation carefully - levels below 92% indicate severe disease requiring aggressive intervention. 1
Follow-Up
Follow the child until complete recovery and near-normal chest radiograph. 1 The chest X-ray returns to normal in 60-83% of children by 3 months, over 90% by 6 months, and all by 18 months. 1 Consider underlying diagnoses such as immunodeficiency or cystic fibrosis if recovery is atypical. 1
Prognosis is excellent - the majority of children make complete recovery with normal lung function, despite the severity of initial presentation. 1