What is the management of pleural effusion in children?

Management of Pleural Effusion in Children

All children with pleural effusion should be admitted to hospital immediately and started on intravenous antibiotics covering Streptococcus pneumoniae, with early consideration for chest tube drainage if the effusion is enlarging or compromising respiratory function. 1

Initial Assessment and Diagnosis

Clinical Recognition

• Suspect pleural effusion in any child with pneumonia who remains febrile or unwell 48 hours after starting antibiotics 1
• Look specifically for: decreased chest expansion, dullness to percussion, reduced or absent breath sounds on the affected side 1
• Measure oxygen saturation immediately—levels below 92% indicate severe disease requiring aggressive intervention 1, 2
• Children may present with pleuritic chest pain, or abdominal pain if lower lobes are involved 1

Mandatory Diagnostic Workup

Imaging:

• Obtain posteroanterior or anteroposterior chest radiograph (lateral films are unnecessary) 1
• Ultrasound is mandatory to confirm the presence of pleural fluid and must be used to guide any thoracocentesis or drain placement 1, 2
• Do NOT perform routine chest CT scans 1

Laboratory Studies:

• Blood cultures (including anaerobic bottle) 1, 2
• Sputum culture if available 1, 2
• Full blood count with differential 1, 2
• Electrolytes to detect inappropriate ADH syndrome 1, 2
• Serum albumin (often low) 1, 2
• C-reactive protein as a marker of progress 1, 2
• Antistreptolysin O titre 1, 2

Pleural Fluid Analysis (when obtained):

• Gram stain and bacterial culture (mandatory) 1
• Differential cell count 1
• pH measurement (better discriminator than glucose in pleural infection) 3
• Glucose level (low glucose <2.2 mmol/L suggests complicated effusion) 3
• Do NOT routinely send biochemical analysis for uncomplicated parapneumonic effusions 1
• Exclude tuberculosis and malignancy if pleural lymphocytosis is present 1

Treatment Algorithm

Antibiotic Therapy

Immediate initiation:

• Start intravenous antibiotics immediately upon admission covering Streptococcus pneumoniae (the most common pathogen) 1, 2, 4
• Recommended regimens: second-generation cephalosporin, aminopenicillin with beta-lactamase inhibitor, or aminopenicillin plus metronidazole 2
• Avoid aminoglycosides—they have poor pleural space penetration and are ineffective 2
• Broaden coverage for hospital-acquired infections or those secondary to surgery, trauma, or aspiration 1
• Tailor antibiotics based on culture results when available 1
• Continue oral antibiotics at discharge for 1-4 weeks, longer if residual disease persists 1, 2

Drainage Decision-Making

Effusions requiring drainage (do NOT manage with antibiotics alone): 1

• Enlarging effusions on serial imaging
• Effusions compromising respiratory function
• Persistent fever despite 48 hours of appropriate antibiotics
• Thick fluid with loculations on ultrasound
• Pleural fluid pH <7.2 or glucose <2.2 mmol/L 3
• Positive Gram stain or culture 3
• Frank pus present 3

Important principle: Give consideration to early active treatment, as conservative management results in prolonged duration of illness and hospital stay 1, 2

Drainage Technique

• Use ultrasound guidance for all drain placements 1, 2
• Insert small-bore percutaneous drains at the optimum site suggested by ultrasound 1, 2
• Ensure adequately trained personnel perform the procedure with a suitable assistant and trained nurse present 1
• Check and correct any coagulopathy or platelet defect before insertion 1
• Do NOT perform repeated thoracocentesis—if significant pleural infection exists, insert a drain at the outset 1

Fibrinolytic Therapy

• Administer intrapleural fibrinolytics for complicated parapneumonic effusion or empyema, as they significantly shorten hospital stay 2
• Use urokinase: 40,000 units in 40 mL of 0.9% saline for children ≥10 kg, or 10,000 units in 10 mL of 0.9% saline for children <10 kg 2
• Give twice daily for 3 days 2

Specialist Involvement

• Involve a respiratory pediatrician early in the care of all patients requiring chest tube drainage 1, 2
• Consider thoracic surgery consultation if: persistent sepsis, no clinical improvement within 7 days, or organized empyema requiring decortication 2

Monitoring and Follow-Up

Response Assessment

If no improvement within 5-7 days: 3

• Check drain position
• Consider CT scan for residual collection
• Consider intrapleural fibrinolytics if not already given
• Obtain surgical consultation

Long-Term Prognosis

• The prognosis is excellent—the majority of children make complete recovery with normal lung function 1, 2
• Chest radiograph returns to normal in 60-83% by 3 months, over 90% by 6 months, and all by 18 months 1, 2
• Follow until complete recovery and near-normal chest radiograph 2

Critical Pitfalls to Avoid

• Do NOT delay drainage—this results in prolonged illness and hospital stay 1, 2
• Do NOT perform chest physiotherapy—it is not beneficial in children with empyema 2
• Do NOT perform flexible bronchoscopy routinely—there is no indication 1
• Do NOT rely on absence of fever to exclude bacterial infection 2
• Do NOT fail to recognize that pH is a better discriminator than glucose in pleural infection 3
• Do NOT overlook tuberculosis or malignancy in cases with lymphocytic predominance 3