Effusion and Empyema
Description Diagnostic criteria General and supportive measures Medicine treatment Referral ICD-10 code: J90 DESCRIPTION A pleural effusion is an accumulation of fluid between the visceral and parietal pleura. The fluid can be an exudate or a transudate (see Lights criteria: https://www.mdcalc.com/lights-criteria-exudative-effusions ). Common causes for exudates are infections, inflammation
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Referral
ICD-10 code: J90
DESCRIPTION
A pleural effusion is an accumulation of fluid between the visceral and parietal pleura. The fluid can be an exudate or a transudate (see Lights criteria: https://www.mdcalc.com/lights-criteria-exudative-effusions).
Common causes for exudates are infections, inflammation and malignancy. Common causes of a transudate are cardiac failure, renal failure and hepatic failure. A straw-coloured or haemorrhagic effusion is indicative of tuberculosis. A cloudy or frankly purulent fluid indicates an empyema.
DIAGNOSTIC CRITERIA
- Decreased breath sounds and stony dull on percussion.
- Pleural rub early in disease.
- Chest X-ray shows uniform opacities in a lamellar distribution at the costophrenic angles.
GENERAL AND SUPPORTIVE MEASURES
- Treat small effusions conservatively.
- Drain other effusions by either chest drain (preferably valved) or needle aspiration.
- Send samples for protein, glucose, cytology, microscopy and culture. If pus is identified insert chest drain.
- Transudates do not require drainage unless respiration is significantly compromised by the size of the effusion.
- More aggressive surgical procedures such as open drainage or decortication are rarely indicated in children.
MEDICINE TREATMENT
For purulent effusion:
- Amoxicillin/clavulanate, IV, 25 mg/kg/dose of amoxicillin component 8 hourly (do not exceed 10 mg/kg/day of clavulanate component for 10 days).
OR
- Cefazolin, IV, 25 mg/kg 8 hourly.
If there is evidence of good clinical response, change to:
- Cephalexin, oral, 6.25–12.5 mg/kg/dose 6 hourly
OR
- Amoxicillin/clavulanic acid, oral, 45 mg/kg/dose of amoxicillin component 12 hourly.
If pathogens are cultured in blood from sanctuary sites, e.g. bone, heart valves, etc., treat according to sensitivity for prolonged period of 21–42 days.
For straw-coloured or haemorrhagic effusion:
- Start anti-tuberculosis therapy, see: Tuberculosis.
REFERRAL
If no response, to any of the above therapy.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 15: Respiratory System, 15.2 Pleural Disease, 15.2.1 Effusion And Empyema