Version June 2024
| Supportive care |
| Antipyretics should be given. |
| Analgesia is important to keep the child comfortable, particularly if he or she has a chest drain. |
| Chest physiotherapy is not beneficial. |
| Early mobilization is recommended. |
| Antibiotics |
| All cases should be treated with intravenous antibiotics. |
| Coverage for Streptococcus pneumoniae should be included. Broader-spectrum coverage is necessary for children with hospital-acquired infections and effusions secondary to surgery, trauma, or aspiration. |
| Antibiotic therapy should be tailored to microbiology results. |
| Oral antibiotics should be continued at discharge for 1 to 4 weeks or longer if there is residual disease. |
| Chest drains |
| Chest drains should be inserted by adequately trained personnel. |
| Ultrasonography should be used to guide thoracentesis or drain placement. |
| Adequate analgesia and/or sedation, with appropriate monitoring, should be used during the procedure. |
| Small drains (including pigtail catheters) should be used whenever possible to minimize discomfort; there is no evidence that large-bore chest drains confer any advantage over small drains. |
| A chest radiograph should be performed after insertion of the chest drain. |
| A bubbling chest drain should never be clamped. |
| A clamped chest drain should be immediately unclamped if the patient complains of chest pain or breathlessness. |
| The drain should be removed once there is clinical resolution. |
| A drain that cannot be unblocked should be removed and replaced if significant pleural fluid remains. |
| Intrapleural fibrinolytics |
| Intrapleural fibrinolytics may shorten hospital stay and are recommended for any complicated parapneumonic effusion or empyema. |
| Surgery |
| Failure of chest tube drainage, antibiotics, and fibrinolysis should prompt early discussion with a thoracic surgeon. |
| Patients should be considered for surgical treatment if they have persisting sepsis in association with persistent pleural fluid, despite chest tube drainage and antibiotics. |
| Organized empyema in a symptomatic child may require formal thoracotomy and decortication. |
| Follow-up |
| Children should be followed until they have recovered completely and their chest radiograph has returned to near normal. |
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