The document discusses pleural effusions and empyema. It defines pleural effusions as excess fluid in the pleural space, which can be transudative or exudative based on its cause. Empyema is defined as pus or microorganisms present in the pleural fluid. Empyema progresses through exudative, fibrinopurulent and organizational stages. Treatment of empyema involves antibiotics, chest tube drainage, and sometimes surgery.

2.  The pleural space lies between the lung and chest wall and
normally contains a thin layer of fluid.
 Pleural effusion is present when there is an excess quantity of
fluid in pleural space.

4.  Increased capillary/pleural membrane
permeabiltiy
 Increased capillary hydrostatic pressure
 Decreased intravascular oncotic pressure
 Lymphatic obstruction
 Abnormal sites of entry

6.  TRANSUDATIVE EFFUSION –results from alteration in
hydrostatic or oncotic pressure of capillaries in parietal pleura
 EXUDATIVE EFFUSION- results from change in
permeability of capillaries or pleural membranes or from
obstruction in lymphatic drainage.

7. Transudative effusion
 Nephrotic syndrome
 Congestive cardiac failure
 Hepatic failure
 PEM
 Hypothyroidism
Exudative effusion
 Infections-Pneumonia,lung
abcess,bronchiectasis,TB
 Malignancy-
Metastasis,leukemia/lymph
oma
 Collagen vascular diseases-
SLE,JRA
 Traumatic
 Drugs-
Amiodarone,bromocriptine
 Postradiation

9. Light’s criteria
Exudative effusion meet atleast one of the following
criteria,wheras transudative effusions meet none.
 Pleural fluid protein/serum protein > 0.5
 Pleural fluid LDH/serum LDH > 0.6
 Pleural fluid LDH-more than two third of serum LDH
The above criteria misidentify 25% of transudates
as exudates.

10.  Symptoms depend on the underlying cause of pleural
effusion
 Commonly presents with pleuritic chest pain(sharp stabbing
pain worsened by deep inspiration),dyspnoea,cough
On examination
 Tachypnea,chest retractions
 Decreased chest movements on the affected side (hoover’s
sign)
 Tracheal and mediastinal shift in large effusions

11.  Decreased vocal fremitus and vocal resonance
 Decreased or absent breath sounds
 Bronchophony or aegophony above the level of effusion.
 Dullness on Traube space percussion

12. CHYLOTHORAX
 Accumulation of chyle in pleural space.
 Common causes are
-Trauma to thoracic duct
-Tumor
-Lymphatic obstruction
 Pleural fluid characteristics-milky white,high triglyceride
levels

14. Hemothorax
 Presence of blood in pleural space.
Common causes are
- Chest wall injuries
- Malignancy
- Bleeding disorders
- Pulmonary infarction

16.  Parapneumonic effusion – sterile pleural effusion
with few or no inflammatory cells.It occurs in
around 40% of bacterial pneumonias.
 Empyema –presence of pus or microorganism in
pleural fluid.

18.  Common causative organisms – Staphylococcus
aureus,streptococcus pneumoniae,Hemophilus influenza,
streptococcus pyogenes
 Gram negative organisms and MRSA are more common pathogens
in HIV associated empyema.
 Anaerobic organisms like bacteroides are common in empyemas
following aspiration pneumonia
 Atypical organisms like mycoplasma,Chlamydia, viruses,fungi like
candida,aspergillus rarely cause empyema.
 Although tuberculous effusions are relatively common,tuberculous
empyema is quite rare.

19. It occurs in three stages
Exudative stage
 Clear sterile fluid accumulates in pleural space as a result of
increased pleural and capillary permeability associated with
infection
Fibrinopurulent stage
 Bacterial invasion of pleural space
 Deposition of fibrin in pleural space leading to septation or
loculations
 Characterised by presence of turbid fluid or frank pus

20. Organisational stage ( >14days)
 Infiltration of fibroblasts in pleural space
 Thin fibrin membranes transformed into thick pleural
peels,resulting in ‘trapped lung’.
 More common in staphylococcal empyema
 Complications like chronic empyema,bronchopleural fistula
and spontaneous perforation through chest wall (empyema
necessitans)

21.  Presents with high grade fever with chills,malaise,dyspnoea,
pleuritic chest pain.Child prefers to lie on affected side
splinting the chest with knees drawn up to the chest.
 On examination,in addition to usual findings of pleural
effusion,erythema,edema and tenderness of chest wall on
affected side may be noted.

23. Chest xray
 An anteroposterior chestxray should be done in all
children with suspected pleural effusion. Atleast 300ml of
fluid should be present to detect effusion clinically and
radiographically in AP view.
 Lateral decubitus CXR with affected side inferior allows
recognition of smaller volumes of fluid.
 Xray features- Obliteration of costophrenic and cardiophrenic
angles
 homogenous opacity of affected hemithorax with mediastinal
shift to contralateral side

27. Ultrasound
 Helps to differentiate consolidated lung from pleural fluid
especially when there is white out on CXR and clinical signs
do not clearly distinguish
 Identify pleural thickening and loculated effusions
 To guide thoracocentesis and chest tube insertion
CT thorax
 Useful if effusion is minimal or loculated
 to differentiate effusion from pleural thickness

29. Thoracocentesis(pleural tap)
 Indicated if pleural fluid thickness from chest wall more
than 1 cm in lateral decubitus xray and that is of uncertain
etiology
 Pleural fluid analysis- Gross examination
Cell count
pH
Glucose
LDH
Protein
Gram stain and culture

30.  Lymphocytois-suggestive of tuberculous effusion or
malignancy
 Pleural fluid ADA > 70IU/L is suggestive of tuberculous
effusion.
 Biochemical analysis of pleural fluid is unnecessary in case
of frank pus.

32. Blood culture
 Positive in 10-20% of cases of empyema
 Sputum,tracheal aspirate and bronchoalveolar lavage sent for
cultures if possible in parapneumonic effusions
Investigations relevant to underlying cause

33. • Treatment of underlying cause
• Parapneumonic effusions - appropriate antibiotic therapy
and supportive treatment
Simple drainage in case of large effusions and
compromised pulmonary function
• Empyema –Antibiotic therapy,supportive treatment and
chest tube drainage.

34. Supportive treatment
 Adequate oxygenation to maintain spO2>92%
 Nutrition and adequate hydration
Antibiotic therapy
 Commonly used antibiotic combinations are cloxacillin and
amikacin
 Cloxacillin and third generation cephalosporins

35.  In immunocompromised children,cloxacillin and
ceftazidime started to cover pseudomonas and other gram
negative anaerobes.
 If response is poor ,if multiple loculations or putrid
smelling pus present,antibiotics for anaerobic cover like
clindamycin or metronidazole added.
 If MRSA suspected,vancomycin is added.
 Treatment is modified based on culture and sensitivity
reports.

36.  Parenteral therapy should be continued for 48-72 hrs after
abatement of fever and then oral therapy can be used to
complete the course.
 Antibiotics should be continued till the patient is afebrile
and,chest tube drainage is less than 50ml/day.
 Duration of antibiotics- 7-14days in case of s.pneumonia or
h.influenza
3-4weeks in case of s.aureus

37. Chest tube drainage
 Chest drain should be inserted in all children diagnosed
with empyema.Repeated taps are not recommended.
 Preferred site for insertion- preferentially in midaxillary line
through safe triangle or as suggested by ultrasound
 Tube is connected to underwater seal drainage.

41.  Chest drain should be removed if fluid drainage is less than
30ml/day and no residual air or fluid collection noted.
Exercises
 Early ambulation and breathing exercises are advised to
improve lung expansion ,once toxemia subsides.
 Chest physiotherapy is not beneficial and not recommended
in children.

42. Intrapleural fibrinolytic therapy
 Instillation of fibrinolytic agents in pleural space via chest
drain lyses fibrin strands and clears lymphatic pores ,thus
facilitating better drainage.
 Agents used – urokinase-proven safe and effective in
children
Streptokinase
Alteplase

43. Surgery
 Considered when empyema fails to resolve despite above
mentioned treatment or in cases of organized
empyema(trapped lung)
 bronchopleural fistula
 Options – minithoracotomy and debridement
Open decortication
Video assisted thoracoscopic adhesiolysis
(VATS)

44. Complications of empyema
 Pyopneumothorax
 Bronchopleural fistula
 Empyema necessitns
 Septicemia

45. THANK YOU