Adjunctive Surgical and Non–Anti-infective Therapy Parapneumonic Effusion
ÎHistory and physical examination may be suggestive of parapneumonic effusion in children suspected of having CAP, but chest radiography should be used to confirm the presence of pleural fluid. (SR-H)
Note: If the chest radiograph is not conclusive, then further imaging with chest ultrasound or computed tomography (CT) scan is recommended.
ÎThe size of the effusion is an important factor that determines management (Table 7, Figure 1). (SR-M)
ÎThe child's degree of respiratory compromise is an important factor that determines management of parapneumonic effusions (Table 7, Figure 1). (SR-M)
ÎGram stain and bacterial culture of pleural fluid should be performed whenever a pleural fluid specimen is obtained. (SR-H)
ÎAntigen testing or nucleic acid amplification through polymerase chain reaction increases the detection of pathogens in pleural fluid and may be useful for management. (SR-M)
ÎAnalysis of pleural fluid parameters such as pH, glucose, protein, and lactate dehydrogenase rarely change patient management and are NOT recommended. (WR-VL)
ÎAnalysis of the pleural fluid white blood cell count, with cell differential analysis, is recommended primarily to help differentiate bacterial, mycobacterial and malignant etiologies. (SR-M)
ÎSmall, uncomplicated parapneumonic effusions should NOT routinely be drained and can be treated with antibiotic therapy alone. (SR-M)
ÎModerate parapneumonic effusions associated with respiratory distress, large parapneumonic effusions, or documented purulent effusions should be drained. (SR-M)
ÎBoth chest thoracostomy tube drainage with the addition of fibrinolytic agents and VATS have been demonstrated to be effective methods of treatment. (SR-H)
Note: The choice of drainage procedure depends on local expertise. Both these methods are associated with decreased morbidity when compared to chest tube drainage alone. However, in patients with moderate-to-large effusions that are free-flowing (no loculations), placement of a chest tube without fibrinolytic agents is a reasonable first option.
ÎVATS should be performed when there is persistence of moderate- large effusions and ongoing respiratory compromise despite ~ 2-3 days of management with a chest tube and completion of fibrinolytic therapy. Open chest debridement with decortication represents another option for management of these children but is associated with higher morbidity. (SR-L)
13
