EFFUSION AND EMPYEMA
J90
DESCRIPTION
A pleural effusion is an accumulation of an exudative or transudative fluid between the visceral and parietal pleura. 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:
- Cloxacillin, IV, 50 mg/kg/dose 6 hourly.
PLUS
- Ampicillin, IV, 25mg/kg/dose 6 hourly for 10 days.
If there is evidence of good clinical response, change to:
- Flucloxacillin, oral, 12.5–25 mg/kg/dose, 6 hourly for a total of 21 days.
OR (if flucloxacillin is unavailable)
- Cephalexin, oral, 6.25–12.5 mg/kg/dose 6 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 antituberculosis therapy.
REFERRAL
If no response, to any of the above therapy.