Pleurisy-Pleural Effusions-Empyema in Children
Introduction to Pleurisy, Pleural Effusions, and Empyema in Children
Pleurisy, pleural effusions, and empyema are conditions affecting the pleura, the double-layered membrane that surrounds the lungs. These disorders can occur individually or progress from one to another, potentially leading to significant respiratory compromise in children.
Key Concepts:
- Pleurisy: Inflammation of the pleura, often causing chest pain
- Pleural Effusion: Accumulation of fluid in the pleural space
- Empyema: Collection of pus in the pleural space, usually as a complication of pneumonia
- These conditions can be more challenging to diagnose in children due to varying clinical presentations
- Early recognition and appropriate management are crucial to prevent complications
Understanding these conditions is essential for pediatricians, pulmonologists, and emergency physicians to ensure prompt diagnosis and effective treatment in the pediatric population.
Pleurisy in Children
Pleurisy, also known as pleuritis, is inflammation of the pleura that can cause significant chest pain and respiratory distress in children.
Etiology:
- Infectious causes:
- Viral (e.g., influenza, coxsackievirus)
- Bacterial (often associated with pneumonia)
- Mycoplasma pneumoniae
- Non-infectious causes:
- Autoimmune disorders (e.g., systemic lupus erythematosus, juvenile rheumatoid arthritis)
- Malignancy
- Pulmonary embolism (rare in children)
Pathophysiology:
- Inflammation of the visceral and parietal pleura
- Friction between inflamed pleural surfaces during respiration
- Stimulation of pain receptors in the parietal pleura
Clinical Features:
- Chest pain, often sharp and worsening with inspiration
- Shallow, rapid breathing to minimize pain
- Dry cough
- Fever (if infectious etiology)
- Pleural rub on auscultation (not always present)
Challenges in Pediatric Diagnosis:
- Younger children may have difficulty localizing or describing pain
- Symptoms may be mistaken for other respiratory conditions
- Pleural rub can be transient and easily missed
Pleural Effusions in Children
Pleural effusion is the accumulation of excess fluid in the pleural space, which can compromise respiratory function.
Types of Pleural Effusions:
- Transudative: Due to imbalance in hydrostatic or oncotic pressures
- Exudative: Result of inflammation or increased capillary permeability
Etiology:
- Infectious:
- Parapneumonic effusions (associated with pneumonia)
- Tuberculosis
- Non-infectious:
- Congestive heart failure
- Nephrotic syndrome
- Malignancy (e.g., lymphoma)
- Connective tissue disorders
Clinical Features:
- Dyspnea or tachypnea
- Chest pain, often dull and aching
- Cough
- Fever (in infectious cases)
- Decreased breath sounds and dullness to percussion over affected area
Classification of Parapneumonic Effusions:
- Simple: Non-complicated, sterile fluid
- Complicated: Fluid with bacterial invasion, not yet purulent
- Empyema: Frank pus in pleural space
Pediatric Considerations:
- More common in bacterial pneumonias compared to viral
- Can develop rapidly in children
- May present with non-specific symptoms in younger children
Empyema in Children
Empyema is the presence of pus in the pleural space, representing a serious complication of pneumonia or other infectious processes.
Pathophysiology:
- Usually progresses from a complicated parapneumonic effusion
- Stages:
- Exudative: Fluid accumulation
- Fibrinopurulent: Fibrin deposition and loculation
- Organizational: Formation of thick pleural peel
Etiology:
- Bacterial pathogens:
- Streptococcus pneumoniae
- Staphylococcus aureus
- Group A Streptococcus
- Mycoplasma pneumoniae
- Risk factors:
- Delayed or inadequate treatment of pneumonia
- Immunocompromised state
- Underlying lung disease
Clinical Features:
- High fever and chills
- Severe respiratory distress
- Chest pain
- Productive cough
- Tachycardia
- Signs of systemic illness (lethargy, decreased appetite)
Complications:
- Respiratory failure
- Sepsis
- Bronchopleural fistula
- Lung abscess
- Restrictive lung disease (if untreated)
Diagnosis of Pleurisy, Pleural Effusions, and Empyema in Children
Clinical Evaluation:
- Thorough history and physical examination
- Assessment of respiratory status and vital signs
- Auscultation and percussion of the chest
Imaging Studies:
- Chest X-ray:
- May show pleural thickening in pleurisy
- Reveals fluid levels or opacification in effusions/empyema
- Ultrasound:
- Useful for detecting and quantifying pleural fluid
- Can identify septations and loculations
- CT scan:
- Provides detailed imaging of pleural space and lung parenchyma
- Helpful in complex cases or for surgical planning
Laboratory Studies:
- Complete blood count: Often shows leukocytosis
- C-reactive protein and ESR: Elevated in inflammatory processes
- Blood cultures: To identify causative organism
- Pleural fluid analysis (if effusion present):
- Cell count and differential
- Protein and LDH levels
- Glucose
- pH
- Gram stain and culture
Additional Tests:
- Tuberculin skin test or interferon-gamma release assay if TB suspected
- Autoimmune markers in cases of suspected rheumatologic disease
- Echocardiogram if cardiac etiology considered
Diagnostic Criteria for Empyema:
- Purulent pleural fluid
- Positive Gram stain or culture of pleural fluid
- Pleural fluid pH < 7.2 or glucose < 40 mg/dL
Management of Pleurisy, Pleural Effusions, and Empyema in Children
General Principles:
- Treatment of underlying cause
- Pain management
- Respiratory support as needed
- Close monitoring of clinical status
Pleurisy Management:
- Analgesics (NSAIDs or acetaminophen)
- Antitussives for symptomatic relief
- Targeted therapy for underlying cause (e.g., antibiotics for bacterial infection)
Pleural Effusion Management:
- Small, uncomplicated effusions:
- Often resolve with treatment of underlying condition
- Observation and serial imaging
- Larger or symptomatic effusions:
- Thoracentesis for diagnostic and therapeutic purposes
- Chest tube placement for continuous drainage
Empyema Management:
- Antibiotics:
- Broad-spectrum initially, then targeted based on culture results
- Typically 2-4 weeks duration
- Drainage procedures:
- Chest tube placement with fibrinolytic therapy
- Video-assisted thoracoscopic surgery (VATS) for loculated empyema
- Open thoracotomy and decortication for advanced cases
- Supportive care:
- Oxygen therapy
- Pain management
- Nutritional support
Pediatric-Specific Considerations:
- Lower threshold for interventional procedures in children
- Careful medication dosing based on weight
- Emphasis on minimally invasive techniques when possible
- Family education and support
Prognosis and Complications
Pleurisy:
- Generally good prognosis with appropriate treatment of underlying cause
- Most cases resolve within a few days to weeks
- Potential for recurrence depending on etiology
Pleural Effusions:
- Prognosis varies based on underlying cause and timely management
- Simple effusions often resolve completely with treatment
- Potential complications:
- Progression to empyema
- Respiratory compromise if large or rapidly accumulating
- Pleural thickening or fibrosis in chronic cases
Empyema:
- Generally good prognosis with appropriate and timely management
- Most children recover fully with no long-term sequelae
- Potential complications:
- Prolonged hospitalization
- Need for multiple procedures
- Bronchopleural fistula
- Lung abscess
- Sepsis in severe cases
- Rarely, chronic pleural thickening leading to restrictive lung disease
Long-term Considerations:
- Regular follow-up to ensure complete resolution
- Pulmonary function testing may be warranted in severe or recurrent cases
- Attention to catch-up growth and development in children who experienced prolonged illness
- Immunization status review and update, especially pneumococcal and influenza vaccines
- Monitoring for recurrence, particularly in cases with underlying predisposing conditions
- Psychological support for children who experienced prolonged hospitalization or multiple procedures
Factors Influencing Prognosis:
- Age of the child: Younger children may have more rapid progression of disease
- Underlying health status: Immunocompromised children may have poorer outcomes
- Causative organism: Some pathogens are associated with more aggressive disease
- Time to diagnosis and initiation of treatment: Earlier intervention generally leads to better outcomes
- Adequacy of drainage in cases of effusion or empyema
- Compliance with prescribed treatments, including completion of antibiotic courses
Prevention Strategies:
- Routine immunizations, including pneumococcal and influenza vaccines
- Prompt treatment of respiratory infections
- Good hygiene practices to prevent spread of infectious agents
- Management of underlying conditions that may predispose to pleural disease
- Education of parents and caregivers about early signs of respiratory distress
Emerging Research and Future Directions:
- Development of rapid diagnostic techniques for earlier identification of causative organisms
- Investigation of novel fibrinolytic agents for more effective drainage of loculated effusions
- Studies on optimal duration of antibiotic therapy in pediatric empyema
- Research into genetic factors that may predispose children to complicated pleural infections
- Evaluation of long-term outcomes and quality of life in children who have recovered from empyema
Special Populations:
- Neonates: Higher risk of complications and need for more aggressive management
- Children with chronic lung diseases: May have atypical presentations and require tailored management
- Immunocompromised children: Higher risk of unusual pathogens and more severe disease course
- Children in resource-limited settings: May face challenges in access to advanced diagnostic and therapeutic modalities
Quality of Life Considerations:
- Impact on school attendance and academic performance
- Effects on physical activity and sports participation during recovery
- Potential for anxiety or medical trauma related to hospitalization and procedures
- Family stress and socioeconomic impact of prolonged illness
Introduction to Empyema in Children
Empyema is defined as the presence of purulent fluid in the pleural space. In children, it most commonly occurs as a complication of bacterial pneumonia. The incidence of empyema has been increasing in recent years, particularly in the post-pneumococcal vaccine era. It represents a significant cause of morbidity and prolonged hospitalization in pediatric populations.
Key points:
- Empyema affects approximately 2-3 per 100,000 children annually
- Peak incidence is in children under 5 years of age
- Boys are slightly more affected than girls
- Seasonal variation exists, with more cases in winter and early spring
Etiology of Pediatric Empyema
The most common causative organisms in pediatric empyema include:
- Streptococcus pneumoniae: Despite vaccination, remains the most frequent cause
- Staphylococcus aureus: Including methicillin-resistant strains (MRSA)
- Streptococcus pyogenes (Group A Streptococcus)
- Haemophilus influenzae: Less common since the introduction of Hib vaccine
Less common causes include:
- Mycoplasma pneumoniae
- Fusobacterium species
- Mycobacterium tuberculosis
- Fungi (in immunocompromised patients)
Pathophysiology of Empyema
The development of empyema typically follows a three-stage process:
- Exudative phase (1-3 days):
- Accumulation of sterile, protein-rich fluid in the pleural space
- Increased capillary permeability due to inflammation
- Fibrinopurulent phase (4-14 days):
- Bacterial invasion of the pleural space
- Accumulation of pus and fibrin deposition
- Formation of loculations and septations
- Organizing phase (>14 days):
- Fibroblast proliferation and collagen deposition
- Formation of a thick, non-elastic pleural peel
- Potential for lung entrapment
Clinical Presentation of Empyema in Children
The clinical presentation of empyema in children can vary, but common features include:
- Persistent fever despite appropriate antibiotic therapy for pneumonia
- Respiratory distress: tachypnea, dyspnea, chest pain
- Productive cough
- Chest wall tenderness
- Decreased breath sounds and dullness to percussion on the affected side
- Reduced chest wall movement on the affected side
- General malaise, fatigue, and decreased appetite
Note that younger children may present with more nonspecific symptoms such as abdominal pain or lethargy.
Diagnosis of Pediatric Empyema
Diagnostic approach includes:
- Imaging studies:
- Chest X-ray: Shows pleural effusion, often with mediastinal shift
- Ultrasound: Identifies loculations and septations, guides thoracentesis
- CT scan: May be necessary for complex cases or pre-surgical planning
- Laboratory tests:
- Complete blood count: Leukocytosis with left shift
- Elevated inflammatory markers: CRP, ESR
- Blood cultures: Positive in 10-20% of cases
- Pleural fluid analysis:
- Appearance: Turbid or purulent
- pH < 7.2
- Glucose < 40 mg/dL
- LDH > 1000 IU/L
- Protein > 3 g/dL
- Gram stain and culture
Management of Empyema in Children
Treatment approach depends on the stage and severity of empyema:
- Antibiotics:
- Empiric broad-spectrum coverage, typically including anti-staphylococcal agent
- Adjusted based on culture results and local antibiogram
- Duration: 2-4 weeks, often with initial IV therapy followed by oral
- Drainage procedures:
- Thoracentesis: For diagnostic purposes and small, early effusions
- Chest tube drainage: For larger effusions or more advanced stages
- Intrapleural fibrinolytics: Consider in loculated empyema (e.g., tissue plasminogen activator)
- Surgical interventions:
- Video-assisted thoracoscopic surgery (VATS): For complex, loculated empyema
- Open thoracotomy: Reserved for cases refractory to VATS or with organized empyema
- Supportive care:
- Oxygen therapy as needed
- Pain management
- Nutritional support
- Chest physiotherapy
Complications of Pediatric Empyema
Potential complications include:
- Bronchopleural fistula
- Lung abscess
- Pneumatocele formation
- Pneumothorax
- Sepsis
- Chronic pleural thickening
- Restrictive lung disease
- Scoliosis (rare, in cases of chronic empyema)
Prognosis of Empyema in Children
With appropriate management, the prognosis for children with empyema is generally good:
- Most children recover completely with no long-term sequelae
- Lung function typically returns to normal within 3-6 months
- Factors affecting prognosis include:
- Timing of diagnosis and intervention
- Underlying health status of the child
- Causative organism (MRSA associated with worse outcomes)
- Presence of complications
- Long-term follow-up is recommended to monitor for potential chronic effects
Pleurisy in Children
- What is pleurisy?
Inflammation of the pleura, the membrane covering the lungs - What are the two layers of the pleura?
Visceral pleura and parietal pleura - What is the most common symptom of pleurisy in children?
Chest pain that worsens with breathing - How does the chest pain in pleurisy typically change with breathing?
Pain increases during inspiration (breathing in) - What is the medical term for painful breathing associated with pleurisy?
Pleuritic pain - Which of the following is a common cause of pleurisy in children?
Viral respiratory infections - What bacterial infection is a frequent cause of pleurisy in children?
Streptococcus pneumoniae - How can tuberculosis (TB) affect the pleura in children?
TB can cause tuberculous pleurisy - What autoimmune condition can lead to pleurisy in children?
Systemic lupus erythematosus (SLE) - What is the characteristic sound heard on auscultation in pleurisy?
Pleural friction rub - Which imaging technique is commonly used to diagnose pleurisy?
Chest X-ray - What additional imaging modality might be used for better visualization of the pleura?
Chest ultrasound - What blood test can help determine the presence of inflammation in pleurisy?
C-reactive protein (CRP) - What procedure might be performed to obtain a sample of pleural fluid for analysis?
Thoracentesis - What is the primary goal of treatment for pleurisy in children?
Addressing the underlying cause - Which medication class is commonly used to manage pain and inflammation in pleurisy?
Nonsteroidal anti-inflammatory drugs (NSAIDs) - In cases of bacterial pleurisy, what is the primary treatment approach?
Antibiotic therapy - What complication can occur if pleurisy is left untreated?
Pleural effusion - How does pleurisy affect a child's breathing pattern?
Shallow, rapid breathing to minimize chest wall movement - What position do children with pleurisy often prefer to minimize pain?
Lying on the affected side - Can pleurisy occur without an underlying lung infection?
Yes, it can be caused by various conditions - What is the role of corticosteroids in treating pleurisy?
May be used in certain cases, especially autoimmune-related pleurisy - How can physical activity affect pleurisy symptoms in children?
Physical activity often exacerbates pain - What is the typical duration of viral pleurisy in children?
Usually resolves within a few days to weeks - Can pleurisy recur in children?
Yes, especially if associated with chronic conditions - What is the importance of follow-up chest X-rays in pleurisy?
To ensure resolution and rule out complications - How does cold weather affect pleurisy symptoms?
Cold air can exacerbate pleuritic pain - What is the role of chest physiotherapy in managing pleurisy?
Can help in clearing secretions and preventing complications - Can pleurisy lead to long-term lung damage in children?
Rarely, if the underlying cause is not properly treated - What is the significance of fever in a child with pleurisy?
May indicate an infectious cause
Pleural Effusions in Children
- What is a pleural effusion?
Abnormal accumulation of fluid in the pleural space - What are the two main types of pleural effusions?
Transudative and exudative - Which of the following is a common cause of transudative pleural effusions in children?
Congestive heart failure - What is a frequent cause of exudative pleural effusions in children?
Pneumonia - What symptom might a child with a large pleural effusion experience?
Shortness of breath (dyspnea) - How does a pleural effusion typically affect breath sounds on auscultation?
Decreased or absent breath sounds over the affected area - What percussion finding is characteristic of a pleural effusion?
Dullness to percussion - Which imaging modality is the initial test of choice for suspected pleural effusion?
Chest X-ray - What is the minimum amount of pleural fluid typically visible on a standard chest X-ray?
About 200-300 mL - Which view on chest X-ray is most sensitive for small pleural effusions?
Lateral decubitus view - What imaging technique can detect smaller amounts of pleural fluid than a chest X-ray?
Ultrasound - What procedure is used to obtain a sample of pleural fluid for analysis?
Thoracentesis - What test is used to differentiate between transudative and exudative effusions?
Light's criteria - Which of the following is included in Light's criteria?
Pleural fluid to serum protein ratio - What is the typical appearance of a transudative effusion?
Clear and straw-colored - What color might an exudative effusion be?
Cloudy or bloody - What is the primary treatment approach for transudative effusions?
Treating the underlying cause (e.g., heart failure management) - In cases of parapneumonic effusions, what is an important aspect of management?
Appropriate antibiotic therapy - What procedure might be necessary for large or symptomatic effusions?
Therapeutic thoracentesis - What is the role of chest tubes in managing pleural effusions?
Drainage of large or recurrent effusions - What complication can occur if a pleural effusion becomes infected?
Empyema - How does a pleural effusion affect lung expansion?
It can cause atelectasis (lung collapse) - What is a potential long-term complication of recurrent pleural effusions?
Pleural thickening and fibrosis - In which position might a child with a unilateral pleural effusion prefer to lie?
On the affected side - What is the role of diuretics in managing some types of pleural effusions?
Can help reduce fluid in transudative effusions due to heart failure - How can malignancy present as a pleural effusion in children?
As a malignant pleural effusion, often in lymphoma or leukemia - What is the significance of glucose levels in pleural fluid analysis?
Low glucose levels may indicate infection or malignancy - How does a chylothorax differ from other types of pleural effusions?
Contains chyle (lymphatic fluid rich in triglycerides) - What is a potential cause of chylothorax in children?
Thoracic duct injury during surgery - How can pleural effusions affect the cardiovascular system in severe cases?
Can cause cardiac tamponade-like effects if large enough
Empyema in Children
- What is empyema?
Collection of pus in the pleural space - What is the most common cause of empyema in children?
Bacterial pneumonia - Which bacteria is the most frequent cause of empyema in children?
Streptococcus pneumoniae - What are the three stages of empyema?
Exudative, fibrinopurulent, and organizing - What is the characteristic of the exudative stage of empyema?
Thin, free-flowing pleural fluid - In the fibrinopurulent stage, what happens to the pleural fluid?
Becomes thicker with fibrin deposition - What characterizes the organizing stage of empyema?
Formation of a thick pleural peel - What is a common presenting symptom of empyema in children?
Fever - How does empyema typically affect a child's breathing?
Causes respiratory distress and tachypnea - What physical examination finding is often present in empyema?
Decreased breath sounds on the affected side - Which imaging modality is typically used first in suspected empyema?
Chest X-ray - What might a chest X-ray show in empyema?
Pleural effusion with or without loculations - What imaging technique is particularly useful for detecting loculations in empyema?
Ultrasound - When might a CT scan be necessary in evaluating empyema?
To assess for complications or plan surgical intervention - What procedure is used to obtain a sample of pleural fluid in empyema?
Thoracentesis - What is the appearance of the fluid typically obtained from an empyema?
Thick, purulent fluid - What is an important aspect of empyema management in children?
Prompt antibiotic therapy - How is the initial antibiotic therapy typically administered in empyema?
Intravenously - What is the role of chest tube drainage in empyema management?
To remove purulent fluid and promote lung re-expansion - When might intrapleural fibrinolytic therapy be considered?
For loculated empyemas not responding to chest tube drainage alone - What surgical procedure may be necessary for advanced empyema?
Video-assisted thoracoscopic surgery (VATS) - What is the purpose of decortication in empyema management?
To remove the restrictive pleural peel and allow lung re-expansion - How long do children with empyema typically require antibiotic treatment?
2-4 weeks, depending on clinical response - What complication can occur if empyema extends through the chest wall?
Empyema necessitans - How does empyema affect the pH of pleural fluid?
Pleural fluid becomes acidic (pH < 7.2) - What is the significance of glucose levels in empyema fluid?
Typically low (<40 mg/dL) due to bacterial consumption - How does empyema affect LDH levels in pleural fluid?
LDH levels are typically elevated - What long-term complication can occur after severe empyema?
Pleural thickening and restrictive lung disease - How does vaccination against Streptococcus pneumoniae affect empyema incidence?
It has reduced the incidence of pneumococcal empyema - What is the role of nutrition in managing children with empyema?
Adequate nutrition supports immune function and recovery
External Links for Further Reading
- Pediatric Empyema: An Overview - NCBI
- ATS Guidelines: Management of Pleural Infection in Children
- Pediatric Empyema - Medscape
- Pleural Effusion in Children - UpToDate
- Pediatric Pleural Effusions: Diagnosis and Management - Comprehensive review in Paediatric Respiratory Reviews
- Management of parapneumonic effusion and empyema - British Thoracic Society Guidelines
- Pediatric Empyema: An Updated Narrative Review - American Journal of Respiratory and Critical Care Medicine
- The Management of Pediatric Empyema: A Core Curriculum - Journal of Pediatric Surgery
- Paediatric pleural infections: a narrative review - European Respiratory Journal
