BTS guidelines for the Management of Pleural Infection in Children

1. Thorax Feb 2005 Vol 60 Suppl 1 www.brit-thoracic.org.uk BTS guidelines for theManagement of Pleural Infection in Children Dr Ian Balfour-Lynn Royal Brompton Hospital

2. 3 year old boy – 1w fever, malaise, cough, DIB IVABs no improvement so transferred Drain inserted, urokinase, IV cefuroxime

3. B/C – Pneumococcus. Pleural fluid - sterile 4 days later – well but febrile, drain out & home next day

4. Back to normal by 2 weeks 7 week follow up -

5. Paediatric Pleural Diseases Subcommitteeof the BTS Standards of Care Committee • Dr Ian Balfour-Lynn Paediatric Respiratory Medicine, Royal Brompton Hospital • Dr Ed Abrahamson Paediatric A&E & General Paediatrics, Chelsea & Westminster Hospital • Mr Gordon Cohen Pediatric Cardiothoracic Surgery, Seattle, USA • Dr John Hartley Microbiologist, Great Ormond Street Hospital • Dr Susan King Radiologist, Bristol • Mr Dakshesh Parikh Paediatric Surgeon, Birmingham • Dr David Spencer Paediatric Respiratory Medicine, Newcastle • Dr Anne Thomson Paediatric Respiratory Medicine, Oxford • Dr Donald Urquhart SpR North Thames Paediatric Respiratory Medicine Training Scheme

6. Pneumonia diagnosis Treatment failure at 48 hours New presentation Clinical suspicion parapneumonic effusion Chest x-ray Pleural effusion? YES Confirm on chest ultrasound Refer to respiratory paediatrician

7. Refer to respiratory paediatrician Suggestion of malignancy?

8. Refer to respiratory paediatrician Suggestion of malignancy? Small volume diagnostic tap YES

9. Refer to respiratory paediatrician Suggestion of malignancy? Small volume diagnostic tap YES NO Suggestion of infection? YES Intravenous antibiotics

10. Refer to respiratory paediatrician Suggestion of malignancy? Small volume diagnostic tap YES NO Suggestion of infection? YES Intravenous antibiotics Medical option Early surgical option

11. Medical option Insert chest drain Pleural fluid microbiology & cell diff. Echogenic or loculated on U/S? Thick fluid draining? YES Intrapleural fibrinolytics

12. Medical option Early surgical option Insert chest drain Pleural fluid microbiology & cell diff. Consider chest CT scan VATS or Early mini-thoracotomy Echogenic or loculated on U/S? Thick fluid draining? YES Intrapleural fibrinolytics

13. Is the patient better? (fluid drained and sepsis improved) Medical option Early surgical option Insert chest drain Pleural fluid microbiology & cell diff. Consider chest CT scan VATS or Early mini-thoracotomy Echogenic or loculated on U/S? Thick fluid draining? YES Intrapleural fibrinolytics

14. Is the patient better? (fluid drained and sepsis improved) YES Remove tube Stop IV antibiotics Oral antibiotics 1-4 weeks Discharge & follow-up

15. Is the patient better? (fluid drained and sepsis improved) NO YES Remove tube Consult with paediatric thoracic surgeon re. late surgery Consider chest CT scan Stop IV antibiotics Oral antibiotics 1-4 weeks Discharge & follow-up

16. SIGN levels of evidence • I – meta-analyses, RCTs (incl. systematic reviews) I++, I+, I- • II – case-control or cohort studies (incl. systematic reviews) II++, II+, II- • III – case reports, case studies • IV – expert opinion

17. SIGN grades of recommendations • A – evidence from meta-analysis, systematic review, RCT (I++ or applicable I+) • B – evidence from applicable II++ or extrapolated I++, I+ • C – evidence from applicable II+ or extraploated II++ • D – evidence from III or IV

18. 107 46 7 22 23 13 4 0 Levels of evidence Grades of recommendations n=165 n=57 SIGN ratings

19. Clinical picture • All children with parapneumonic effusion or empyema should be admitted to hospital. [D] • If a child remains pyrexial or unwell 48 hours after admission for pneumonia, parapneumonic effusion / empyema must be excluded. [D]

20. Diagnostic imaging • Postero-anterior or antero-posterior radiographs should be taken, there is no role for a routine lateral radiograph. [D] • Ultrasound must be used to confirm the presence of a pleural fluid collection. [D] • Chest CT scan should not be performed routinely. [D]

21. Diagnostic analysis of pleural fluid • Aspirated pleural fluid should be sent for differential cell count. [D] • Tuberculosis and malignancy must be excluded in the presence of pleural lymphocytosis. [C] • Biochemical analysis of pleural fluid is unnecessary… [D]

22. GOSH Referral to tertiary centre • A respiratory paediatrician should be involved early in the care of all patients requiring chest tube drainage for a pleural infection. [D] • Patients with chest drains should be managed on specialist wards by staff trained in chest drain management. [D]

23. Conservative management (antibiotics  simple drainage) • Effusions which are enlarging and / or compromising respiratory function should not be managed by antibiotics alone. [D]

24. Repeated thoracocentesis • If a child has significant pleural infection then a drain should be inserted at the outset, and repeated taps are not recommended. [D]

25. Antibiotics 1 • All cases should be treated with intravenous antibiotics and must include cover for S pneumoniae. [D] • Broader spectrum cover is required for hospital-acquired infections, as well as those secondary to surgery, trauma and aspiration. [D]

26. Antibiotics 2 • Cefuroxime • Co-amoxiclav • Penicillin and flucloxacillin • Amoxicillin and flucloxacillin • Clindamycin • Discharge: oral co-amoxiclav 1- 4 wks

27. Chest drains 1 • If GA is not being used, IV sedation should only be given by those trained in the use of conscious sedation, airway management & resuscitation of children, using full monitoring equipment. [D] • Ultrasound should be used to guide thoracocentesis or drain placement. [C]

28. Chest drains 2 • Since there is no evidence that large bore chest drains confer any advantage, small drains (including pigtail catheters) should be used whenever possible to minimise patient discomfort. [C] • The drain should be clamped for 1 hour once 10 mls/kg are initially removed. [D]

29. B Intrapleural fibrinolytics • Intrapleural fibrinolytics shorten hospital stay and are recommended for any complicated parapneumonic effusion (thick fluid with loculations) or empyema (overt pus). [B] • Urokinase should be given twice daily for 3 days (6 doses in total) using 40,000 units in 40 mls 0.9% saline for children aged 1 year or above, and 10,000 units in 10 mls 0.9% saline for children aged under 1 year. [B] Thomson et al Thorax 2002;57 343-7

30. Surgery • Failure of chest tube drainage, antibiotics and fibrinolytics should prompt early discussion with a thoracic surgeon. [D] • Patients should be considered for surgical treatment if they have persisting sepsis in association with a persistent pleural collection, despite chest tube drainage and antibiotics. [D] • Organised empyema in a symptomatic child requires formal thoracotomy and decortication. [D]

31. Other management • Chest physiotherapy is not beneficial and should not be performed in children with empyema. [D] • Secondary thrombocytosis (platelet count >500 x109/L) is common but benign; anti-platelet therapy is not necessary. [D]

32. Follow-up • Children should be followed up after discharge until they have recovered completely and their chest radiograph has returned to near normal. [D] • Underlying diagnoses – for example, immunodeficiency, cystic fibrosis – may need to be considered. [D]

33. The messages • The evidence on which to base recommendations is poor / absent • Adult data are not transferable • This is a tertiary condition • Children with empyema almost always have an excellent outcome – whatever the management • Trials are needed…