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BTS Guidelines for the Management of Pleural Infection in Children

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BTS Guidelines for the Management of Pleural Infection in Children i1 BTS GUIDELINES Thorax: first published as 10.1136/thx.2004.030676 on 28 January 2005. Downloaded from BTS guidelines for the management of pleural infection in children I M Balfour-Lynn, E Abrahamson, G Cohen, J Hartley, S King, D Parikh, D Spencer, A H Thomson, D Urquhart, on behalf of the Paediatric Pleural Diseases Subcommittee of the BTS Standards of Care Committee ............................................................................................................................... Thorax 2005;60(Suppl I):i1–i21. doi: 10.1136/thx.2004.030676 ‘‘It seems probable that this study covers the The manuscript was then amended in the light period of practical extinction of empyema as of their comments and the document was an important disease.’’ Lionakis B et al, reviewed by the BTS Standards of Care J Pediatr 1958. Committee following which a further drafting took place. The Quality of Practice Committee of the Royal College of Paediatrics and Child Health also reviewed this draft. After final approval 1. SEARCH METHODOLOGY from this Committee, the guidelines were sub- 1.1 Structure of the guideline mitted for blind peer review and publication. The format follows that used for the BTS guidelines on the management of pleural disease 1.3 Conflict of interest 1 in adults. At the start there is a summary table All the members of the Guideline Committee of the abstracted bullet points from each section. submitted a written record of possible conflicts of Following that is an algorithm summarising the interest to the Standards of Care Committee of management of pleural infection in children the BTS. There were none. These are available for (fig 1). Each section starts with bulleted points inspection on request from the Chairman of this of key recommendations using the revised SIGN Committee. grading system (table 1) available on http:// www.sign.ac.uk/guidelines/fulltext/50/section6. 1.4 Acknowledgements html. Beneath each set of bullet points is a short Funding for literature searches, photocopying paragraph detailing the referenced literature and and travel to the guideline meeting was kindly the rationale behind the recommendations. The provided by the British Thoracic Society. The primary source literature has been individually authors thank the library staff at the National graded for its methodology and the grading is Heart Lung Institute and John Vandridge-Ames http://thorax.bmj.com/ given alongside each reference using the revised at the Royal College of Radiologists for additional SIGN levels of evidence (table 2). searches, Dr Juliet Hale (Consultant Paediatric Oncologist, Royal Victoria Hospital, Newcastle 1.2 Methodology for generation of the upon Tyne) for advice on malignant effusions, Dr guidelines Elizabeth Haxby (Consultant Anaesthetist and The initial literature search was carried out by Lead Clinician for Clinical Risk, Royal Brompton the Library of the National Heart Lung Institute, Hospital, London) for advice on anaesthesia Imperial College London. Further searches were and sedation, Dr Jon Smith (Consultant in then carried out by members of the working Paediatric Cardiothoracic Anaesthesia and on October 4, 2021 by guest. Protected copyright. group who concentrated on their own topics. Intensive Care, Freeman Hospital, Newcastle Details of the search strategy are given in upon Tyne) for advice on analgesia, Dr Ravi Appendix 1. Jayaram (Specialist Registrar, Royal Brompton Each section of the guideline was researched Hospital, London) for advice on Appendix 3, and drafted by a subgroup of the Paediatric and Jayne Wellington for the mountain of Pleural Diseases Subcommittee (itself a subcom- photocopying. mittee of the BTS Standards of Care Committee). The following acted as specialist reviewers: Dr Publications were rated according to the SIGN Robert Dinwiddie (Consultant in Paediatric criteria for the calibre of the methodology of the Respiratory Medicine, Great Ormond Street research to give levels of evidence (table 2). Hospital for Children, London), Dr Iolo Doull Tables of evidence were then produced before (Consultant in Paediatric Respiratory Medicine, writing the guideline sections using the SIGN University Hospital of Wales, Cardiff), Mr Peter See end of article for authors’ affiliations grades of recommendations (table 1). Once all Goldstraw (Consultant Thoracic Surgeon, Royal ....................... parts were merged into one document, the whole Brompton Hospital, London), Dr Robert Primhak group then met to discuss the first draft before (Senior Lecturer and Honorary Consultant in Correspondence to: Dr I Balfour-Lynn, redrafting took place. This draft was based, Paediatric Respiratory Medicine, Sheffield Chil- Consultant in Paediatric where possible, on the published evidence but dren’s Hospital), Dr Paul Seddon (Consultant Respiratory Medicine, this was then combined with clinical expertise as Paediatrician with an interest in Respiratory Royal Brompton Hospital, required. The resulting draft is therefore a blend Medicine, Royal Alexandra Hospital for Sick Syndey St, SW3 6NP of published evidence and clinical experience. Children, Brighton). London, UK; [email protected] This was sent to a group of specialist reviewers The authors also thank the Quality of Practice ....................... listed in the Acknowledgements. Committee of the Royal College of Paediatrics www.thoraxjnl.com i2 Balfour-Lynn, Abrahamson, Cohen, et al and Child Health for reviewing the guidelines and particu- 2.2 Epidemiology larly for their comments on methodology. Parapneumonic effusion and empyema have an incidence of Thorax: first published as 10.1136/thx.2004.030676 on 28 January 2005. Downloaded from 3.3 per 100 000 children.4 It has been suggested that the 2. INTRODUCTION incidence of childhood empyema increased in the UK in the mid to late 1990s,23although this is not a universal finding.8 2.1 The need for paediatric guidelines It is not clear whether this is related to different referral Although still relatively uncommon, it seems that pleural patterns, changes of antibiotic usage in primary care, or infections have become more prevalent in the UK23 and whether it was a genuine increase in disease incidence. USA.45 More cases are being seen in paediatric respiratory Parapneumonic effusions and empyema are more common in centres, and with fewer chest drains being inserted in district boys than girls and are more frequently encountered in general hospitals, they are often seen at an earlier stage by infants and young children.9 They are also more common in respiratory paediatricians. Empyemas are a significant cause winter and spring,9 presumably due to their infective origin. of morbidity but, fortunately, not mortality in children, and at times can be a therapeutic challenge. Despite this, in the UK there is little consensus over management among 2.3 Definition and staging respiratory paediatricians and thoracic surgeons. Part of the The definitions of parapneumonic effusion (pleural fluid problem has been the lack of evidence from paediatric trials, collection in association with underlying pneumonia) and and it is inappropriate simply to extrapolate adult data to empyema (the presence of pus in the pleural space) are best children. There are differences between adult and paediatric considered by reviewing the staging of pleural fluid asso- pleural infections. The principal one is that, since it is rare for ciated with infection. Pleural infection is a continuum but 10 children to have an underlying lung disease, the final classically it has been divided into three stages: outcome is almost always excellent. This is in contrast to N Exudative: the inflammatory process associated with the the disease in adults where empyema is a cause of significant underlying pneumonia leads to the accumulation of clear morbidity with 40% of patients requiring pleural surgery due 6 fluid with a low white cell count within the pleural cavity to failed catheter drainage. Furthermore, adult empyema (simple parapneumonic effusion). carries a 20% mortality rate7 which is related to co-morbidity (for example, malignancy, immunodeficiency, prolonged N Fibropurulent: there is deposition of fibrin in the pleural hospital stay and nosocomially acquired infection). With space leading to septation and the formation of locula- the publication of the BTS guidelines for the management of tions. There is an increase in white cells, with the fluid pleural disease (in adults),1 it seemed appropriate to produce thickening (complicated parapneumonic effusion) and some for children. eventually becoming overt pus (empyema). The presence of septations (fibrinous strands within the pleural fluid) This guideline has assessed available evidence and does not necessarily mean the fluid does not flow freely, attempted to gauge consensus opinion where evidence is although separate loculations will not communicate with unavailable. The lack of paediatric data, in particular from each other.11 randomised controlled trials, is reflected in the grading of levels of evidence and recommendations in this document. N Organisational: fibroblasts infiltrate the pleural cavity, and Although there are many grade D recommendations, some of the thin intrapleural membranes are reorganised to these are safe current practice based on common sense but, become thick and non-elastic (the ‘‘peel’’). These solid since they have never been subjected to a randomised fibrous pleural peels may prevent lung re-expansion http://thorax.bmj.com/ controlled trial, they
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