What is the best treatment for empyema?

A 7 year old child with a history of cough and fever for 1 week, has bronchial breathing over her left lower zone on auscultation. A diagnosis of lobar pneumonia is made, confirmed on plain chest x-ray, and she is treated with appropriate intravenous antibiotics. However, she continues to have a spiking fever and develops signs of a left sided pleural effusion. Repeat chest x-ray shows a ‘white out’ of the left chest with no mediastinal shift. She is referred to the regional thoracic centre for consideration of thoracotomy and drainage of a left sided parapneumonic effusion. Should she be referred to the surgeons and if so, what should they do?

Clinical Bottom Line

There is no evidence to support a better clinical outcome from VATS compared to a chest drain with intrapleural fibrinolytic in children with empyema. Most children will do well with this therapy alone. [Grade B]

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Orlena Kerek (Respiratory Registrar, Bristol Royal Hospital for Children) [orlenakerek@yahoo.com]

Tom Hilliard, Paediatric Respiratory Consultant, Bristol Royal Hospital for Children

John Henderson, Reader in Paediatric Respiratory Medicine, University of Bristol

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