Abstract
What is already known? Complicated pneumonia is an area of debate, and a rapid diagnosis is essential for patient survival. Due to the importance of stage-adapted therapeutic decisions, different classification systems have been established. Depending on the stage of the disease, both antimicrobial and interventional approaches are indicated. Conservative management remains the mainstay for the management of parapneumonic effusion, and continuous pleural fluid drainage is not necessary in some children. However, an established consensus worldwide for the management of complicated pneumonia and thoracic empyema with different therapeutic algorithms lacks clear evidence to evaluate complex cases with minimally invasive intervention versus open decortication. Such controversy concerning the best surgical approach persists, especially for sick patients in intensive care who are not doing well despite chest tube or fibrinolytic agents. This article aimed to review current treatment standards for children with different phases of thoracic empyema and complicated pneumonia, this review article will discuss the usefulness of different diagnostic methods and most recent updates on management. 1. Outline the definition, pathophysiology and common causes 2. Review the diagnosis and current treatment standards for complicated pneumonia 3. Review different surgical approaches and their outcomes 4. Provide an update on the recent utilization of video-assisted thoracoscopy (VATS) 5. Review evidence regarding the best fibrinolytic agent 6. Review evidence concerning when to indicate decortication 7. Provide a simplified pathway for the management of complicated pneumonia (figure 9).
Highlights
(2) Parapneumonic effusion (PPE): pleural effusion that is associated with pneumonia
Intrapleural fibrinolytics are recognized to shorten the hospital stay and are recommended for any complicated PPE or empyema
Conservative therapy is the standard therapy, but early detection and immediate drainage are necessary in patients with complicated PPE/empyema
Summary
(6) Thoracic empyema: an infectious condition of the pleural cavity, leading to pus formation; various underlying infectious diseases with pneumonia are the most common cause. (7) Pus: A fluid product of inflammation, comprising a liquid containing leukocytes and debris of dead cells and tissues. This may comprise a milky-yellow thick material, and/or bad odor and/or increased white blood cells, biochemical pH 1000 IU. (8) Exudative (early): the inflammatory process in the first few days associated with underlying pneumonia, leading to the accumulation of clear and thin fluid in the pleural cavity often with a low white blood cell count and near-normal pH. There is an increase in white blood cells, with fluid thickening (complicated PPE) eventually becoming clear pus (empyema). The presence of septations (fibrinous strands within the pleural fluid) causes loculation of the pleural fluid, and fluids will not flow
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