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
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 D Concur
effusion/empyema must be excluded.
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
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
for initial fluid collection
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
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
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
Biochemical analysis of pleural fluid is
unnecessary in the management of
D Concur 9, 26, 30-34
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
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.
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
duration of illness and hospital stay.
If a child has significant pleural infection, a
drain should be inserted at the outset and D Concur
repeated taps are not recommended.
All cases should be treated with intravenous
antibiotics and must include cover for D Concur 54, 55
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
for 1–4 weeks, but longer if there is residual D interpreted; do not need to treat
disease. until radiograph is normal
Chest Drains2 D Concur Summation of 20 separate items
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
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.
Failure of chest tube drainage, antibiotics, and Surgical consultatation early in
fibrinolytics should prompt early discussion D presentation based on
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
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
negligible at CNMC due to these
A lung abscess coexisting with an empyema
should not normally be surgically drained.
Antipyretics should be given. D Concur
Analgesia is important to keep the child
comfortable, particularly in the presence of a D Concur
Chest physiotherapy is not beneficial and
should not be performed in children with D Concur
Early mobilization and exercise is
Secondary scoliosis noted on the chest
radiograph is common but transient; no
specific treatment is required but resolution
must be confirmed.
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.
Levels range from A (highest) to D (lowest), according to 2005 BTS Guidelines , and SIGN grading system .
This section consisted of standardized procedural details, summarized as evidence level D.
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BTS = British Thoracic Society; CPC = Complex Pneumonia Committee
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