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Pleural Effusion, Pediatric

Basics

Description

- Ultrasound - Reveals small (3 " 5 mL) loculated collections of pleural fluid - Useful as a guide for thoracentesis - Aids in distinguishing between pleural thickening and pleural effusion

- CT scan - Clearly reveals effusions/empyemas, abscess, or pulmonary consolidations - Useful for defining the extent of loculated effusions

- Pleural biopsy - If thoracentesis is nondiagnostic - Most useful for diseases that cause extensive involvement of the pleura (i.e., tuberculosis, malignancies) - Confirms neoplastic involvement in 40 " 70% of cases

- Transudate - Cardiovascular - CHF - Constrictive pericarditis

- Exudate - Infection - Staphylococcus aureus (increasing incidence of methicillin-resistant species) - Streptococcus pneumoniae (increasing incidence of penicillin-resistant species) - Haemophilus influenzae (decreasing incidence since introduction of H. influenzae type b [Hib] vaccine) - Group A Streptococcus - Anaerobes - Gram-negative enterics - No identified organisms (all cultures sterile) - Tuberculous effusion - Viral effusions (adenovirus, influenza) - Fungal effusions: most not associated with effusions; Nocardia and Actinomyces are most commonly seen. - Parasitic effusions

- Neoplasm: seen mostly in leukemia and lymphoma; uncommon in children - Connective tissue disease - Rheumatoid arthritis - Systemic lupus erythematosus - Wegener granulomatosis

- Pulmonary embolus - Intra-abdominal disease - Subdiaphragmatic abscess - Pancreatitis

- Supportive measures: - Maintain adequate - Oxygenation - Fluid status - Nutritional balance

- Antipyretic agents when febrile - Pain control

- Treat the underlying disease: - Antibiotics for infections - Cardiac medications for CHF - Chemotherapeutic agents for malignancies - Anti-inflammatory agents (i.e., steroids) for connective tissue diseases - Medium-chain triglycerides and low-fat diet for chylothorax

- Duration of chest tube drainage - Discontinue when patient is asymptomatic (afebrile, no distress) and drainage <50 mL/h - Thick, loculated empyema requires prolonged drainage (and possibly a video-assisted thoracic surgery [VATS] procedure if effusion not improving).

- Intrapleural fibrinolytics - Adjunct to aid in drainage of complicated (i.e., multiloculated empyema) pleural effusions - Streptokinase, urokinase, and tPA are the agents of choice.

- VATS - Alternative to more invasive procedures (e.g., open thoracotomy/decortication) - Debridement through pleural visualization and lysis of adhesions/loculations - Useful when - Initial drainage is delayed - Loculations prevent adequate drainage by chest tube alone - Patient is failing more conservative therapy

- Pleurodesis - For recurrent effusions - Chemical agents frequently used include talc, tetracycline, doxycycline, and quinacrine. - Surgical methods include the following: - Mechanical abrasion - Pleurectomy via VATS - Open thoracotomy route

Accumulation of fluid in the pleural cavity

Pathophysiology

  • Normally 1 " 15 mL of fluid in the pleural space
  • Alterations in the flow and/or absorption of this fluid lead to its accumulation.
  • Mechanisms that influence this flow of fluid:Increased capillary hydrostatic pressure (i.e., congestive heart failure [CHF], overhydration)Decreased pleural space hydrostatic pressure (i.e., after thoracentesis, atelectasis)Decreased plasma oncotic pressure (i.e., hypoalbuminemia, nephrosis)Increased capillary permeability (i.e., infection, toxins, connective tissue diseases, malignancy)Impaired lymphatic drainage from the pleural space (i.e., disruption of the thoracic duct)Passage of fluid from the peritoneal cavity through the diaphragm to the pleural space (i.e., hepatic cirrhosis with ascites)
  • 2 types of pleural effusion:Transudate: Mechanical forces of hydrostatic and oncotic pressures are altered, favoring liquid filtration.Exudate: Damage to the pleural surface occurs that alters its ability to filter pleural fluid; lymphatic drainage is diminished.
  • Stages associated with parapneumonic effusions (infectious exudates):See Appendix, Table 3.Exudative stageFree-flowing fluidPleural fluid glucose, protein, lactate dehydrogenase (LDH) level, and pH are normal.Fibrinolytic stageLoculations are forming.Increase in fibrin, polymorphonuclear leukocytes, and bacterial invasion of pleural cavity are occurring.Pleural fluid glucose and pH falls while protein and LDH levels increase.Organizing stage (empyema)Fibroblasts grow.Pleural peal forms.Pleural fluid parameters worsen.

Diagnosis

History

  • Underlying disease determines most systemic symptoms.
  • Patient may be asymptomatic until the amount of fluid is large enough to cause cardiorespiratory compromise/distress.
  • Dyspnea and cough are associated with large effusions.
  • Fever (if infectious etiology)
  • Pleuritic pain (pneumonia may cause irritation of the parietal pleura, causing pleural pain; as the effusion increases and separates the pleural membrane, the pain may disappear)

Physical Exam

  • Decreased thoracic wall excursion on the ipsilateral side
  • Fullness of intercostal spaces on the ipsilateral side
  • Trachea and cardiac apex displaced toward the contralateral side (may produce a mediastinal shift that can reduce venous return and compromise the cardiac output)
  • Dull or flat percussion on the ipsilateral side (suggesting the presence of consolidation of pleural effusion)
  • Decreased tactile and vocal fremitus
  • Decreased whispering pectoriloquy
  • Pleural rub during early phase (may resolve as fluid accumulates in the pleural space)
  • Decreased breath sounds

Diagnostic Tests & Interpretation

  • Cytologic exam of pleural fluidFresh and heparinized specimen should be refrigerated at 4 °C (39.2 °F) until it can be processed.Fixatives should not be added.
  • Pleural fluid parameters to be routinely measured include the following (Appendix, Table 4):pHLDHProteinGlucoseNote: Glucose of <40 mg/dL suggests a para-pneumonic, tuberculosis, malignant, or rheumatic etiology to the effusion.

Lab

Initial lab tests

Serology values to follow the degree of inflammation and the response to therapy:

  • Erythrocyte sedimentation rate (ESR)
  • C-reactive protein (CRP)

Imaging

  • Chest radiographAnteroposterior projection can show >400 mL of pleural fluid.Lateral projection can show <200 mL of pleural fluid.Lateral decubitus film to evaluate for free-flowing pleural fluid can show as little as 50 mL of pleural fluid.
  • UltrasoundReveals small (3 " 5 mL) loculated collections of pleural fluidUseful as a guide for thoracentesisAids in distinguishing between pleural thickening and pleural effusion
  • CT scanClearly reveals effusions/empyemas, abscess, or pulmonary consolidationsUseful for defining the extent of loculated effusions

Diagnostic Procedures/Other

  • ThoracentesisIndicated whenever etiology is unclear or if the effusion causes symptoms (e.g., prolonged fever or respiratory distress)
  • Pleural biopsyIf thoracentesis is nondiagnosticMost useful for diseases that cause extensive involvement of the pleura (i.e., tuberculosis, malignancies)Confirms neoplastic involvement in 40 " 70% of cases

Differential Diagnosis

  • TransudateCardiovascularCHFConstrictive pericarditisNephrotic syndrome with hypoalbuminemiaCirrhosisAtelectasis
  • ExudateInfectionStaphylococcus aureus (increasing incidence of methicillin-resistant species)Streptococcus pneumoniae (increasing incidence of penicillin-resistant species)Haemophilus influenzae (decreasing incidence since introduction of H. influenzae type b [Hib] vaccine)Group A StreptococcusAnaerobesGram-negative entericsNo identified organisms (all cultures sterile)Tuberculous effusionViral effusions (adenovirus, influenza)Fungal effusions: most not associated with effusions; Nocardia and Actinomyces are most commonly seen.Parasitic effusionsNeoplasm: seen mostly in leukemia and lymphoma; uncommon in childrenConnective tissue diseaseRheumatoid arthritisSystemic lupus erythematosusWegener granulomatosisPulmonary embolusIntra-abdominal diseaseSubdiaphragmatic abscessPancreatitisSarcoidosisEsophageal ruptureHemothoraxChylothoraxDrugsChemical injuryPostirradiation effusion

Treatment

Medication

  • AntibioticsUsed when effusion is caused by a bacterial infectionSpecific antibiotics dictated by organism identifiedIf effusion is sterile, broad-spectrum antibiotics are indicated to cover for the usually seen organisms.Clinical improvement usually begins within 48 " 72 hours of therapy.Continue IV antibiotics until afebrile.Complete remainder of therapy on oral antibiotics.
  • Duration of antibiotic therapy depends on the infectious organism and the degree of illness:Total duration is controversial.Usually, at least 2 " 4 weeks of total IV and PO

Additional Treatment

General Measures

  • Supportive measures:Maintain adequateOxygenationFluid statusNutritional balanceAntipyretic agents when febrilePain control
  • Treat the underlying disease:Antibiotics for infectionsCardiac medications for CHFChemotherapeutic agents for malignanciesAnti-inflammatory agents (i.e., steroids) for connective tissue diseasesMedium-chain triglycerides and low-fat diet for chylothorax
  • Effective drainage of pleural fluidThoracentesisChest tube drainageSurgical drainage
  • Duration of chest tube drainageDiscontinue when patient is asymptomatic (afebrile, no distress) and drainage <50 mL/hThick, loculated empyema requires prolonged drainage (and possibly a video-assisted thoracic surgery [VATS] procedure if effusion not improving).

Complementary & Alternative Therapies

  • ThoracentesisFor diagnosis purposesTo distinguish between a transudate and an exudateFor culture material (if infection is suspected)For cytology (if malignancy is suspected)For relief of dyspnea or cardiorespiratory distress
  • Chest tube thoracostomyReduce reaccumulation of fluid.Drain parapneumonic effusion (before loculations develop which will prevent fluid drainage).
  • Intrapleural fibrinolyticsAdjunct to aid in drainage of complicated (i.e., multiloculated empyema) pleural effusionsStreptokinase, urokinase, and tPA are the agents of choice.

Surgery/Other Procedures

  • VATSAlternative to more invasive procedures (e.g., open thoracotomy/decortication)Debridement through pleural visualization and lysis of adhesions/loculationsUseful whenInitial drainage is delayedLoculations prevent adequate drainage by chest tube alonePatient is failing more conservative therapy
  • PleurectomyChylothoraxMalignant effusions
  • PleurodesisFor recurrent effusionsChemical agents frequently used include talc, tetracycline, doxycycline, and quinacrine.Surgical methods include the following:Mechanical abrasionPleurectomy via VATSOpen thoracotomy routeIn cases of malignant effusion:Sclerosing procedures are usually ineffective.Chest tube drainage can create a pneumothorax because the lung is incarcerated by the tumor.

Ongoing Care

Follow-up Recommendations

  • Clinical improvement usually within 1 " 2 weeks
  • With empyemas, the patient may have fever spikes for up to 2 " 3 weeks after improvement is noted.

Diet

When the effusion is a chylothorax:

  • Medium-chain triglycerides
  • Nutritional replacement
  • At least 4 " 5 weeks on this regimen

Prognosis

Depends on underlying disease process:

  • Properly treated infectious cause: excellent prognosis
  • Malignancy: poor prognosis

Complications

  • Hypoxia
  • Respiratory distress
  • Persistent fevers
  • Decreased cardiac function
  • Malnutrition (seen in chylothorax)
  • Shock (secondary to blood loss in cases of hemothorax)
  • Trapped lung

Additional Reading

  • Beers SL, Abramo TJ. Pleural effusions. Pediatr Emerg Care. 2007;23(5):330 " 334. [View Abstract]
  • Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children. Pediatr Infect Dis. 2003;22(6):499 " 504. [View Abstract]
  • Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol. 2009;39(6):527 " 537. [View Abstract]
  • Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic collections in infants and children. J Pediatr Surg. 2000;35(2):265 " 268; discussion 269 " 270. [View Abstract]
  • Heffner JE. Discriminating between transudates and exudates. Clin Chest Med. 2006;27(2):241 " 252. [View Abstract]
  • Krenke K, Peradzynska J, Lange J. Local treatment of empyema in children: a systematic review of randomized controlled trials. Acta Paediatr. 2010;99(10):1449 " 1453. [View Abstract]
  • Merino JM, CarpinteroI I, Alvarez T, et al. Tuberculous pleural effusion in children. Chest. 1999;115(1):26 " 30. [View Abstract]
  • Proesmans M, De Boeck K. Clinical Practice: Treatment of childhood empyema. Eur J Pediatr. 2009;168(6):639 " 645. [View Abstract]
  • Rocha G. Pleural effusions in the neonate. Curr Opin Pulm Med. 2007;13(4):305 " 311. [View Abstract]

Codes

ICD09

  • 511.9 Unspecified pleural effusion
  • 510.9 Empyema without mention of fistula
  • 511.81 Malignant pleural effusion
  • 012.00 Tuberculous pleurisy, unspecified
  • 511.89 Other specified forms of effusion, except tuberculous

ICD10

  • J90 Pleural effusion, not elsewhere classified
  • J86.9 Pyothorax without fistula
  • J91.0 Malignant pleural effusion
  • A15.6 Tuberculous pleurisy
  • J91.8 Pleural effusion in other conditions classified elsewhere

SNOMED

  • 60046008 Pleural effusion (disorder)
  • 58554001 Empyema of pleura
  • 83270006 Neoplastic pleural effusion (disorder)
  • 446986002 Tuberculous pleural effusion (disorder)

FAQ

  • Q: When will the chest radiograph findings become normal?
  • A: They may take up to 6 months (or longer) to return to normal appearance.
  • Q: When will the pulmonary function tests normalize?
  • A: Depending on extent of effusion, they may take up to 6 " 12 months.