| Supportive care |
- Antipyretics should be given.
- Analgesia is important to keep the child comfortable, particularly if they have a chest drain.
- Chest physiotherapy is not beneficial.
- Early mobilization is recommended.
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| Antibiotics |
- All cases should be treated with intravenous antibiotics.
- Coverage for Streptococcus pneumoniae should be included. Broader-spectrum coverage is necessary for children with hospital-acquired infections and effusions secondary to surgery, trauma, or aspiration.
- Antibiotic therapy should be tailored to microbiology results.
- Oral antibiotics should be continued at discharge for 1 to 4 weeks or longer if there is residual disease.
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| Chest drains |
- Chest drains should be inserted by adequately trained personnel.
- Ultrasonography should be used to guide thoracentesis or drain placement.
- Adequate analgesia and/or sedation, with appropriate monitoring, should be used during the procedure.
- Small drains (including pigtail catheters) should be used whenever possible to minimize discomfort; there is no evidence that large-bore chest drains confer any advantage over small drains.
- A chest radiograph should be performed after insertion of the chest drain.
- A bubbling chest drain should never be clamped.
- A clamped chest drain should be immediately unclamped if the child complains of chest pain or breathlessness.
- The drain should be removed once there is clinical resolution.
- A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains.
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| Intrapleural fibrinolytics |
- Intrapleural fibrinolytics may shorten hospital stay and are recommended for any complicated parapneumonic effusion or empyema.
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| Surgery |
- Failure of chest tube drainage, antibiotics, and fibrinolysis should prompt early discussion with a thoracic surgeon.
- A child should be considered for surgical treatment if they have persisting sepsis in association with persistent pleural fluid, despite chest tube drainage and antibiotics.
- Organized empyema in a symptomatic child may require formal thoracotomy and decortication.
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| Follow-up |
- Children should be followed until they have recovered completely and their chest radiograph has returned to near-normal.
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