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Management and prognosis of parapneumonic effusion and empyema in children

Ibrahim A Janahi, MD
Khoulood Fakhoury, MD
Section Editors
Gregory Redding, MD
Morven S Edwards, MD
Deputy Editor
Alison G Hoppin, MD


Parapneumonic effusion is defined as pleural effusion associated with lung infection (ie, pneumonia). These effusions result from the spread of inflammation and infection to the pleura. Much less commonly, infections in other areas adjacent to the pleura, such as the retropharyngeal, vertebral, abdominal, and retroperitoneal spaces, may spread to the pleura resulting in the development of effusion.

Early in the course of parapneumonic effusion, the pleura becomes inflamed; subsequent leakage of proteins, fluid, and leukocytes into the pleural space forms the effusion. At the time of formation, the pleural effusion is usually sterile with a low leukocyte count. With time, bacteria invade the fluid, resulting in empyema, which is defined as the presence of grossly purulent fluid in the pleural cavity. The development of pleural empyema is determined by a balance between host resistance, bacterial virulence, and timing of presentation for medical treatment [1]. (See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children", section on 'Pathophysiology'.)

The management of parapneumonic effusion and empyema in children will be reviewed here. The epidemiology, etiology, pathophysiology, clinical presentation, and evaluation of parapneumonic effusion and empyema in children are discussed separately. (See "Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children".)

The evaluation and management of parapneumonic effusion in adults also are discussed separately. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Imaging of pleural effusions in adults" and "Parapneumonic effusion and empyema in adults".)


Parapneumonic effusion is defined as pleural effusion associated with lung infection (ie, pneumonia). Early in the disease course, the effusion usually is free-flowing (also known as a "simple" effusion) and sterile.

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Literature review current through: Oct 2017. | This topic last updated: Jul 06, 2017.
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  1. Tuomanen EI, Austrian R, Masure HR. Pathogenesis of pneumococcal infection. N Engl J Med 1995; 332:1280.
  2. Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005; 60 Suppl 1:i1.
  3. Jaffé A, Balfour-Lynn IM. Management of empyema in children. Pediatr Pulmonol 2005; 40:148.
  4. Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med 1998; 19:363.
  5. Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
  6. Panitch HB, Papastamelos C, Schidlow DV. Abnormalities of the pleural space. In: Pediatric Respiratory Medicine, Taussig LM, Landau LI (Eds), Mosby, St. Louis 1999. p.1184.
  7. Moran JF. Surgical management of pleural space infections. Semin Respir Infect 1988; 3:383.
  8. Herold BC, Immergluck LC, Maranan MC, et al. Community-acquired methicillin-resistant Staphylococcus aureus in children with no identified predisposing risk. JAMA 1998; 279:593.
  9. Frank AL, Marcinak JF, Mangat PD, Schreckenberger PC. Increase in community-acquired methicillin-resistant Staphylococcus aureus in children. Clin Infect Dis 1999; 29:935.
  10. Alfaro C, Fergie J, Purcell K. Emergence of community-acquired methicillin-resistant Staphylococcus aureus in complicated parapneumonic effusions. Pediatr Infect Dis J 2005; 24:274.
  11. Mishaan AM, Mason EO Jr, Martinez-Aguilar G, et al. Emergence of a predominant clone of community-acquired Staphylococcus aureus among children in Houston, Texas. Pediatr Infect Dis J 2005; 24:201.
  12. Hussain FM, Boyle-Vavra S, Bethel CD, Daum RS. Current trends in community-acquired methicillin-resistant Staphylococcus aureus at a tertiary care pediatric facility. Pediatr Infect Dis J 2000; 19:1163.
  13. Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012; 47:2101.
  14. Carter E, Waldhausen J, Zhang W, et al. Management of children with empyema: Pleural drainage is not always necessary. Pediatr Pulmonol 2010; 45:475.
  15. Grewal H, Jackson RJ, Wagner CW, Smith SD. Early video-assisted thoracic surgery in the management of empyema. Pediatrics 1999; 103:e63.
  16. Rahman NM, Maskell NA, Davies CW, et al. The relationship between chest tube size and clinical outcome in pleural infection. Chest 2010; 137:536.
  17. Lin CH, Lin WC, Chang JS. Comparison of pigtail catheter with chest tube for drainage of parapneumonic effusion in children. Pediatr Neonatol 2011; 52:337.
  18. Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002; 57:343.
  19. Pierrepoint MJ, Evans A, Morris SJ, et al. Pigtail catheter drain in the treatment of empyema thoracis. Arch Dis Child 2002; 87:331.
  20. Stavas J, vanSonnenberg E, Casola G, Wittich GR. Percutaneous drainage of infected and noninfected thoracic fluid collections. J Thorac Imaging 1987; 2:80.
  21. Eibenberger KL, Dock WI, Ammann ME, et al. Quantification of pleural effusions: sonography versus radiography. Radiology 1994; 191:681.
  22. Maier A, Domej W, Anegg U, et al. Computed tomography or ultrasonically guided pigtail catheter drainage in multiloculated pleural empyema: a recommended procedure? Respirology 2000; 5:119.
  23. Hunnam GR, Flower CD. Radiologically-guided percutaneous catheter drainage of empyemas. Clin Radiol 1988; 39:121.
  24. Hyde J, Sykes T, Graham T. Reducing morbidity from chest drains. BMJ 1997; 314:914.
  25. Laws D, Neville E, Duffy J, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the insertion of a chest drain. Thorax 2003; 58 Suppl 2:ii53.
  26. Trapnell DH, Thurston JG. Unilateral pulmonary oedema after pleural aspiration. Lancet 1970; 1:1367.
  27. Pietsch JB, Whitlock JA, Ford C, Kinney MC. Management of pleural effusions in children with malignant lymphoma. J Pediatr Surg 1999; 34:635.
  28. Rosen DA, Morris JL, Rosen KR, et al. Analgesia for pediatric thoracostomy tube removal. Anesth Analg 2000; 90:1025.
  29. Scherer LR, West KW, Weber TR, et al. Staphylococcus epidermidis sepsis in pediatric patients: clinical and therapeutic considerations. J Pediatr Surg 1984; 19:358.
  30. Wheeler JG, Jacobs RF. Pleural effusions and empyema. In: Textbook of Pediatric Infectious Diseases, 6th, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.325.
  31. Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med 1980; 69:507.
  32. Potts DE, Taryle DA, Sahn SA. The glucose-pH relationship in parapneumonic effusions. Arch Intern Med 1978; 138:1378.
  33. Orringer MB. Thoracic empyema--back to basics. Chest 1988; 93:901.
  34. Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med 2006; 174:221.
  35. St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106.
  36. Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 2005; 115:1652.
  37. Tokuda Y, Matsushima D, Stein GH, Miyagi S. Intrapleural fibrinolytic agents for empyema and complicated parapneumonic effusions: a meta-analysis. Chest 2006; 129:783.
  38. Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev 2008; :CD002312.
  39. Hanson SJ, Havens PL, Simpson PM, et al. Intrapleural alteplase decreases parapneumonic effusion volume in children more than saline irrigation. Pediatr Pulmonol 2015; 50:1328.
  40. Rahman NM, Maskell NA, West A, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365:518.
  41. Wells RG, Havens PL. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children. Radiology 2003; 228:370.
  42. Maskell NA, Davies CW, Nunn AJ, et al. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005; 352:865.
  43. Hawkins JA, Scaife ES, Hillman ND, Feola GP. Current treatment of pediatric empyema. Semin Thorac Cardiovasc Surg 2004; 16:196.
  44. Stringel G, Hartman AR. Intrapleural instillation of urokinase in the treatment of loculated pleural effusions in children. J Pediatr Surg 1994; 29:1539.
  45. Alfageme I, Vázquez R. Ventricular fibrillation after intrapleural urokinase. Intensive Care Med 1997; 23:352.
  46. Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions. Chest 2003; 123:432.
  47. Kercher KW, Attorri RJ, Hoover JD, Morton D Jr. Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series. Chest 2000; 118:24.
  48. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993; 28:1128.
  49. Angelillo Mackinlay TA, Lyons GA, Chimondeguy DJ, et al. VATS debridement versus thoracotomy in the treatment of loculated postpneumonia empyema. Ann Thorac Surg 1996; 61:1626.
  50. Cohen G, Hjortdal V, Ricci M, et al. Primary thoracoscopic treatment of empyema in children. J Thorac Cardiovasc Surg 2003; 125:79.
  51. Klena JW, Cameron BH, Langer JC, et al. Timing of video-assisted thoracoscopic debridement for pediatric empyema. J Am Coll Surg 1998; 187:404.
  52. Merry CM, Bufo AJ, Shah RS, et al. Early definitive intervention by thoracoscopy in pediatric empyema. J Pediatr Surg 1999; 34:178.
  53. Quintero DR, Fan LL. Approach to pleural effusions and empyemas. Paediatr Respir Rev 2004; 5 Suppl A:S151.
  54. Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 2004; 113:1735.
  55. Gates RL, Caniano DA, Hayes JR, Arca MJ. Does VATS provide optimal treatment of empyema in children? A systematic review. J Pediatr Surg 2004; 39:381.
  56. Stovroff M, Teague G, Heiss KF, et al. Thoracoscopy in the management of pediatric empyema. J Pediatr Surg 1995; 30:1211.
  57. Yim AP, Low JM, Ng SK, et al. Video-assisted thoracoscopic surgery in the paediatric population. J Paediatr Child Health 1995; 31:192.
  58. Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic collections in infants and children. J Pediatr Surg 2000; 35:265.
  59. Subramaniam R, Joseph VT, Tan GM, et al. Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children. J Pediatr Surg 2001; 36:316.
  60. Jaffé A, Cohen G. Thoracic empyema. Arch Dis Child 2003; 88:839.
  61. Bouros D, Antoniou KM, Chalkiadakis G, et al. The role of video-assisted thoracoscopic surgery in the treatment of parapneumonic empyema after the failure of fibrinolytics. Surg Endosc 2002; 16:151.
  62. Sit SC, Cohen G, Jaffe A. Urokinase in the treatment of childhood empyema. Thorax 2003; 58:93; author reply 93.
  63. Kurt BA, Winterhalter KM, Connors RH, et al. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006; 118:e547.
  64. Mukherjee S, Langroudi B, Rosenthal M, Balfour-Lynn IM. Incidence and outcome of scoliosis in children with pleural infection. Pediatr Pulmonol 2007; 42:221.
  65. Fraga JC, Kim P. [Surgical treatment of parapneumonic pleural effusion and its complications]. J Pediatr (Rio J) 2002; 78 Suppl 2:S161.
  66. Chan PW, Crawford O, Wallis C, Dinwiddie R. Treatment of pleural empyema. J Paediatr Child Health 2000; 36:375.
  67. Gocmen A, Kiper N, Toppare M, et al. Conservative treatment of empyema in children. Respiration 1993; 60:182.
  68. Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1.
  69. Satish B, Bunker M, Seddon P. Management of thoracic empyema in childhood: does the pleural thickening matter? Arch Dis Child 2003; 88:918.
  70. Hartl H. Pleuropulmonary suppurations. Prog Pediatr Surg 1977; 10:257.
  71. Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis 1984; 3:578.
  72. Bartlett JG. Bacterial infections of the pleural space. Semin Respir Infect 1988; 3:308.
  73. Wise MB, Beaudry PH, Bates DV. Long-term follow-up of staphylococcal pneumonia. Pediatrics 1966; 38:398.
  74. Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child 2003; 88:915.
  75. Khakoo GA, Goldstraw P, Hansell DM, Bush A. Surgical treatment of parapneumonic empyema. Pediatr Pulmonol 1996; 22:348.
  76. Cohen E, Mahant S, Dell SD, et al. The long-term outcomes of pediatric pleural empyema: a prospective study. Arch Pediatr Adolesc Med 2012; 166:999.
  77. Honkinen M, Lahti E, Svedström E, et al. Long-term recovery after parapneumonic empyema in children. Pediatr Pulmonol 2014; 49:1020.
  78. Meyerovitch J, Shohet I, Rubinstein E. Analysis of thirty-seven cases of pleural empyema. Eur J Clin Microbiol 1985; 4:337.
  79. Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis J 1991; 10:194.
  80. Redding GJ, Walund L, Walund D, et al. Lung function in children following empyema. Am J Dis Child 1990; 144:1337.
  81. Sarihan H, Cay A, Aynaci M, et al. Empyema in children. J Cardiovasc Surg (Torino) 1998; 39:113.
  82. Kontouli K, Hatziagorou E, Kyrvasilis F, et al. Long-term outcome of parapneumonic effusions in children: Lung function and exercise tolerance. Pediatr Pulmonol 2015; 50:615.