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Thorax Feb 2005 Vol 60 Suppl 1. www.brit-thoracic.org.uk. BTS guidelines for the Management of Pleural Infection in Children. Dr Ian Balfour-Lynn Royal Brompton Hospital. 3 year old boy – 1w fever, malaise, cough, DIB IVABs no improvement so transferred

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Bts guidelines for the management of pleural infection in children l.jpg

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


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3 year old boy – 1w fever, malaise, cough, DIB

IVABs no improvement so transferred

Drain inserted, urokinase, IV cefuroxime


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B/C – Pneumococcus. Pleural fluid - sterile

4 days later – well but febrile, drain out & home next day


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Back to normal by 2 weeks

7 week follow up -


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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


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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


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Refer to respiratory paediatrician

Suggestion of

malignancy?


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Refer to respiratory paediatrician

Suggestion of

malignancy?

Small volume

diagnostic tap

YES


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Refer to respiratory paediatrician

Suggestion of

malignancy?

Small volume

diagnostic tap

YES

NO

Suggestion of

infection?

YES

Intravenous antibiotics


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Refer to respiratory paediatrician

Suggestion of

malignancy?

Small volume

diagnostic tap

YES

NO

Suggestion of

infection?

YES

Intravenous antibiotics

Medical

option

Early surgical

option


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Medical

option

Insert chest drain

Pleural fluid microbiology & cell diff.

Echogenic or loculated on U/S?

Thick fluid draining?

YES

Intrapleural

fibrinolytics


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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


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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


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Is the patient better?

(fluid drained and sepsis improved)

YES

Remove tube

Stop IV antibiotics

Oral antibiotics 1-4 weeks

Discharge & follow-up


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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


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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


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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


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107

46

7

22

23

13

4

0

Levels of evidence

Grades of recommendations

n=165

n=57

SIGN ratings


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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]


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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]


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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]


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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]


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Conservative management

(antibiotics  simple drainage)

  • Effusions which are enlarging and / or compromising respiratory function should not be managed by antibiotics alone. [D]


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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]


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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]


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Antibiotics 2

  • Cefuroxime

  • Co-amoxiclav

  • Penicillin and flucloxacillin

  • Amoxicillin and flucloxacillin

  • Clindamycin

  • Discharge: oral co-amoxiclav 1- 4 wks


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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]


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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]


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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


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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]


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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]


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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]


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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…


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