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					Supplementary Table: Evidence for Complicated Pneumonia Algorithm based on 2005 British Thoracic Society Guidelines

                                                   Level of    CPC        Comment, or Rationale if CPC
           BTS Recommendations                                                                                           References3
                                                  Evidence1   Decision        Differed from BTS
Clinical Picture
All children with parapneumonic effusion or
                                                     D        Concur
empyema should be admitted to hospital
If a child does not improve within 48 hours
after admission for pneumonia, parapneumonic         D        Concur
effusion/empyema must be excluded.
Diagnostic Imaging
                                                                          Lateral decubitus radiograph may
Posteroanterior or anteroposterior radiographs
                                                              Partially   be useful in some cases, but
should be taken; there is no role for a routine      D                                                          39
                                                               concur     should not be done if it will delay
lateral radiograph.
                                                                          in treatment.
Ultrasound should be used to confirm the                                  Prefer ultrasound if available,
                                                     D        Concur                                            3, 27, 38, 41-44, 49
presence of a pleural fluid collection.                                   otherwise CT scan
Ultrasound should be used to guide                                        Prefer ultrasound if available,
                                                     C        Concur                                            40, 45-47
thoracocentesis or drain placement.                                       otherwise CT scan
                                                                          In some cases, CT still has a role,
Chest CT scans should not be performed
                                                     D        Concur      but can be performed after U/S        3, 27, 38, 41-44, 48-52
routinely.
                                                                          for initial fluid collection
Diagnostic Microbiology
                                                                          Although cultures may be
Blood cultures should be performed in all
                                                     D        Concur      negative, they have high              1, 2, 6-8, 10-18, 36, 37
patients with parapneumonic effusion.
                                                                          specificity when positive
                                                                          Induced sputum may be
When available, sputum should be sent for
                                                     D        Concur      considered if necessary but           20
bacterial culture.
                                                                          should not delay treatment
Diagnostic Analysis of Pleural Fluid
Pleural fluid must be sent for microbiological
analysis including Gram stain and bacterial          C        Concur                                            23, 24
culture.
Aspirated pleural fluid should be sent for
                                                    D     Concur                                         27, 29
differential cell count.
Tuberculosis and malignancy must be excluded
                                                    C     Concur                                         24, 25
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,     D     Concur
avoiding general anaesthesia/sedation
whenever possible.
Biochemical analysis of pleural fluid is
unnecessary in the management of
                                                    D     Concur                                         9, 26, 30-34
uncomplicated parapneumonic
effusions/empyema.
Diagnostic Bronchoscopy
                                                                     Pulmonary team will make
There is no indication for flexible
                                                                     decision regarding bronchoscopy
bronchoscopy and it is not routinely                D     Disagree                                       3, 53
                                                                     based on history and clinical
recommended.
                                                                     presentation
Referral to a Tertiary Center
                                                                     Initial involvement of infectious
A pediatric pulmonologist should be involved
                                                                     diseases and pediatric surgery;
early in the care of all patients requiring chest   D     Disagree
                                                                     pulmonologist involved if chronic
tube drainage for a pleural infection.
                                                                     pulmonary condition
Conservative Management (antibiotics + simple drainage)
Effusions which are enlarging and/or
compromising respiratory function should not        D     Concur
be managed by antibiotics alone.
Give consideration to early active treatment as
conservative treatment results in prolonged
                                                    D     Concur
duration of illness and hospital stay.

Repeated Thoracentesis
If a child has significant pleural infection, a
drain should be inserted at the outset and          D     Concur
repeated taps are not recommended.
Antibiotics
All cases should be treated with intravenous
antibiotics and must include cover for              D   Concur                                          54, 55
Streptococcus pneumoniae.
Broader spectrum cover is required for hospital
acquired infections, as well as those secondary     D   Concur                                          54, 55
to surgery, trauma, and aspiration.
Where possible, antibiotic choice should be
                                                    B   Concur                                          3
guided by microbiology results.
Oral antibiotics should be given at discharge                       Unclear how ―residual disease‖ is
                                                        Partially
for 1–4 weeks, but longer if there is residual      D               interpreted; do not need to treat
                                                        Concur
disease.                                                            until radiograph is normal
Chest Drains2                                       D   Concur      Summation of 20 separate items
Intrapleural Fibrinolytics
Intrapleural fibrinolytics shorten hospital stay
                                                                    See comments on VATS versus
and are recommended for any complicated
                                                    B   Concur      fibrinolytic therapy in Methods     27, 56-64
parapneumonic effusion (thick fluid with
                                                                    and Discussion Sections
loculations) or empyema (overt pus).
There is no evidence that any of the three
fibrinolytics are more effective than the others,
                                                                    A new randomized prospective
but only urokinase has been studied in a            B   Updated                                          56
                                                                    study in children utilized alteplase
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       B   Concur
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                    Surgical consultatation early in
                                                        Partially
fibrinolytics should prompt early discussion        D               presentation based on
                                                         concur
with a thoracic surgeon.                                            radiographic evidence
Patients should be considered for surgical                                                              27, 56-64
treatment if they have persisting sepsis in             Partially   VATS is intervention of choice
                                                    D
association with a persistent pleural collection,        concur     over elective drain/chest tube
despite chest tube drainage and antibiotics.                        placement at
                                                                           CNMC due to sedation and
                                                                           location of procedure (operating
Organized empyema in a symptomatic child
                                                               Partially   room); cost advantage of
may require formal thoracotomy and                  D
                                                                concur     fibrinolytics with chest tube is
decortication.
                                                                           negligible at CNMC due to these
                                                                           issues.
A lung abscess coexisting with an empyema
                                                    D          Concur
should not normally be surgically drained.
Other Management
Antipyretics should be given.                       D          Concur
Analgesia is important to keep the child
comfortable, particularly in the presence of a      D          Concur
chest drain.
Chest physiotherapy is not beneficial and
should not be performed in children with            D          Concur
empyema.
Early mobilization and exercise is
                                                    D          Concur
recommended.

Secondary scoliosis noted on the chest
radiograph is common but transient; no
                                                    D          Concur
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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