BTS GUIDELINES BTS guidelines for the management of pleural infection in children

ed bullet points Clinical picture N All children with parapneumonic effusion or empyema should be admitted to hospital. [D] N If a child remains pyrexial or unwell 48 hours after admission for pneumonia, parapneumonic effusion/empyema must be excluded. [D] Diagnostic imaging N Posteroanterior or anteroposterior radiographs should be taken; there is no role for a routine lateral radiograph. [D] N Ultrasound must be used to confirm the presence of a pleural fluid collection. [D] N Ultrasound should be used to guide thoracocentesis or drain placement. [C] N Chest CT scans should not be performed routinely. [D] Diagnostic microbiology N Blood cultures should be performed in all patients with parapneumonic effusion. [D] N When available, sputum should be sent for bacterial culture. [D] Diagnostic analysis of pleural fluid N Pleural fluid must be sent for microbiological analysis including Gram stain and bacterial culture. [C] N Aspirated pleural fluid should be sent for differential cell count. [D] N Tuberculosis and malignancy must be excluded in the presence of pleural lymphocytosis. [C] N 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. [D] N Biochemical analysis of pleural fluid is unnecessary in the management of uncomplicated parapneumonic effusions/ empyema. [D] Diagnostic bronchoscopy N There is no indication for flexible bronchoscopy and it is not routinely recommended. [D] Referral to tertiary centre N A respiratory paediatrician should be involved early in the care of all patients requiring chest tube drainage for a pleural infection. [D] Conservative management (antibiotics ¡ simple drainage) N Effusions which are enlarging and/or compromising respiratory function should not be managed by antibiotics alone. [D] N Give consideration to early active treatment as conservative treatment results in prolonged duration of illness and hospital stay. [D] Repeated thoracocentesis N If a child has significant pleural infection, a drain should be inserted at the outset and repeated taps are not recommended. [D] Antibiotics N All cases should be treated with intravenous antibiotics and must include cover for Streptococcus pneumoniae. [D] N Broader spectrum cover is required for hospital acquired infections, as well as those secondary to surgery, trauma, and aspiration. [D] N Where possible, antibiotic choice should be guided by microbiology results. [B] N Oral antibiotics should be given at discharge for 1–4 weeks, but longer if there is residual disease. [D] Chest drains N Chest drains should be inserted by adequately trained personnel to reduce the risk of complications. [C] N A suitable assistant and trained nurse must be available. [D] N Routine measurement of the platelet count and clotting studies are only recommended in patients with known risk factors. [D] N Where possible, any coagulopathy or platelet defect should be corrected before chest drain insertion. [D] N Ultrasound should be used to guide thoracocentesis or drain placement. [C] N If general anaesthesia is not being used, intravenous sedation should only be given by those trained in the use of conscious sedation, airway management and resuscitation of children, using full monitoring equipment. [D] N Small bore percutaneous drains should be inserted at the optimum site suggested by chest ultrasound. [C] N Large bore surgical drains should also be inserted at the optimum site suggested by ultrasound, but preferentially placed in the mid axillary line through the ‘‘safe triangle’’. [D] N Since there is no evidence that large bore chest drains confer any advantage, small drains (including pigtail catheters) should be used whenever possible to minimise patient discomfort. [C] BTS guidelines for the management of pleural infection in children i3 www.thoraxjnl.com group.bmj.com on June 23, 2017 Published by http://thorax.bmj.com/ Downloaded from