Supplementary Table: Evidence for Complicated Pneumonia Algorithm based on 2005 British Thoracic Society Guidelines
BTS Recommendations
Level of
Evidence1
CPC
Decision
D
Concur
D
Concur
D
Partially
concur
D
Concur
C
Concur
D
Concur
Comment, or Rationale if CPC
Differed from BTS
References3
Clinical Picture
All children with parapneumonic effusion or
empyema should be admitted to hospital
If a child does not improve within 48 hours
after admission for pneumonia, parapneumonic
effusion/empyema must be excluded.
Diagnostic Imaging
Posteroanterior or anteroposterior radiographs
should be taken; there is no role for a routine
lateral radiograph.
Ultrasound should be used to confirm the
presence of a pleural fluid collection.
Ultrasound should be used to guide
thoracocentesis or drain placement.
Chest CT scans should not be performed
routinely.
Lateral decubitus radiograph may
be useful in some cases, but
should not be done if it will delay
in treatment.
Prefer ultrasound if available,
otherwise CT scan
Prefer ultrasound if available,
otherwise CT scan
In some cases, CT still has a role,
but can be performed after U/S
for initial fluid collection
39
3, 27, 38, 41-44, 49
40, 45-47
3, 27, 38, 41-44, 48-52
Diagnostic Microbiology
Blood cultures should be performed in all
patients with parapneumonic effusion.
When available, sputum should be sent for
bacterial culture.
Concur
Although cultures may be
negative, they have high
specificity when positive
1, 2, 6-8, 10-18, 36, 37
D
Concur
Induced sputum may be
considered if necessary but
should not delay treatment
20
C
Concur
D
Diagnostic Analysis of Pleural Fluid
Pleural fluid must be sent for microbiological
analysis including Gram stain and bacterial
culture.
23, 24
Aspirated pleural fluid should be sent for
differential cell count.
Tuberculosis and malignancy must be excluded
in the presence of pleural lymphocytosis.
If there is any indication the effusion is not
secondary to infection, consider an initial small
volume diagnostic tap for cytological analysis,
avoiding general anaesthesia/sedation
whenever possible.
Biochemical analysis of pleural fluid is
unnecessary in the management of
uncomplicated parapneumonic
effusions/empyema.
D
Concur
27, 29
C
Concur
24, 25
D
Concur
D
Concur
9, 26, 30-34
Diagnostic Bronchoscopy
There is no indication for flexible
bronchoscopy and it is not routinely
recommended.
D
Disagree
Pulmonary team will make
decision regarding bronchoscopy
based on history and clinical
presentation
Disagree
Initial involvement of infectious
diseases and pediatric surgery;
pulmonologist involved if chronic
pulmonary condition
Referral to a Tertiary Center
A pediatric pulmonologist should be involved
early in the care of all patients requiring chest
tube drainage for a pleural infection.
D
Conservative Management (antibiotics + simple drainage)
Effusions which are enlarging and/or
compromising respiratory function should not
be managed by antibiotics alone.
Give consideration to early active treatment as
conservative treatment results in prolonged
duration of illness and hospital stay.
Repeated Thoracentesis
If a child has significant pleural infection, a
drain should be inserted at the outset and
repeated taps are not recommended.
D
Concur
D
Concur
D
Concur
3, 53
Antibiotics
All cases should be treated with intravenous
antibiotics and must include cover for
Streptococcus pneumoniae.
Broader spectrum cover is required for hospital
acquired infections, as well as those secondary
to surgery, trauma, and aspiration.
Where possible, antibiotic choice should be
guided by microbiology results.
Oral antibiotics should be given at discharge
for 1–4 weeks, but longer if there is residual
disease.
Chest Drains2
Intrapleural Fibrinolytics
Intrapleural fibrinolytics shorten hospital stay
and are recommended for any complicated
parapneumonic effusion (thick fluid with
loculations) or empyema (overt pus).
There is no evidence that any of the three
fibrinolytics are more effective than the others,
but only urokinase has been studied in a
randomized controlled trial in children so is
recommended.
Urokinase should be given twice daily for 3
days (6 doses in total) using 40 000 units in 40
ml 0.9% saline for children weighing 10 kg or
above, and 10 000 units in 10 ml 0.9% saline
for children weighing under 10 kg.
Surgery
Failure of chest tube drainage, antibiotics, and
fibrinolytics should prompt early discussion
with a thoracic surgeon.
Patients should be considered for surgical
treatment if they have persisting sepsis in
association with a persistent pleural collection,
despite chest tube drainage and antibiotics.
D
Concur
54, 55
D
Concur
54, 55
B
Concur
3
D
Partially
Concur
Unclear how “residual disease” is
interpreted; do not need to treat
until radiograph is normal
D
Concur
Summation of 20 separate items
B
Concur
See comments on VATS versus
fibrinolytic therapy in Methods
and Discussion Sections
B
Updated
A new randomized prospective
56
study in children utilized alteplase
B
Concur
D
Partially
concur
D
Partially
concur
27, 56-64
Surgical consultatation early in
presentation based on
radiographic evidence
27, 56-64
VATS is intervention of choice
over elective drain/chest tube
placement at
Organized empyema in a symptomatic child
may require formal thoracotomy and
decortication.
D
Partially
concur
A lung abscess coexisting with an empyema
should not normally be surgically drained.
D
Concur
D
Concur
D
Concur
D
Concur
D
Concur
D
Concur
CNMC due to sedation and
location of procedure (operating
room); cost advantage of
fibrinolytics with chest tube is
negligible at CNMC due to these
issues.
Other Management
Antipyretics should be given.
Analgesia is important to keep the child
comfortable, particularly in the presence of a
chest drain.
Chest physiotherapy is not beneficial and
should not be performed in children with
empyema.
Early mobilization and exercise is
recommended.
Secondary scoliosis noted on the chest
radiograph is common but transient; no
specific treatment is required but resolution
must be confirmed.
Follow Up
Children should be followed up after discharge
Outpatient follow-up more
until they have recovered completely and their
D
Concur
extensively described in CPC
chest radiograph has returned to near normal.
algorithm
Underlying diagnoses—for example,
immunodeficiency, cystic fibrosis—may need
D
Concur
to be considered.
1
Levels range from A (highest) to D (lowest), according to 2005 BTS Guidelines [5], and SIGN grading system [65].
2
This section consisted of standardized procedural details, summarized as evidence level D.
3
References provide background support for CPC decisions.
BTS = British Thoracic Society; CPC = Complex Pneumonia Committee
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