Paeds · respiratory-sleep-and-airway
Pleural effusion and empyema
Also known as Parapneumonic effusion · Complicated parapneumonic effusion · Empyema thoracis · Pleural infection · Pyothorax
Fellowship guide to paediatric pleural effusion and empyema: the parapneumonic fluid that turns a child's pneumonia into persistent fever and pleuritic pain; Light's criteria and the exudative, fibrinopurulent and organising stages; ultrasound as the pivotal investigation; antibiotics for all, chest drain with intrapleural fibrinolytics or primary VATS for empyema; the excellent long-term prognosis; and the ANZ, UK and North American guideline differences.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- A child with pneumonia who stays febrile and unwell after 48–72 hours of appropriate antibiotics — suspect a parapneumonic effusion or empyema and get an ultrasound, do not simply wait
- Increasing respiratory distress with a large effusion, tracheal or mediastinal shift, and hypoxia — a tension effusion that needs urgent drainage, not observation
- A septic, toxic child with a pleural collection — resuscitate for sepsis, give intravenous antibiotics now and involve the surgical and intensive care teams early
- A sudden air–fluid level, surgical emphysema or a persistent air leak after drainage — think bronchopleural fistula and escalate to the surgical team
- Pleural fluid that is frank pus, or that has a low pH or low glucose — this is a complicated effusion or empyema that will not settle on antibiotics alone and needs drainage
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Respiratory medicine
- Lower respiratory tract infection and its complications
- Current 2026 PREP curriculum — Learning goal 5: Clinical assessment – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Acute and critical care
- Paediatric respiratory and infection competencies
- Clinical Applications
- Respiratory infection and the unwell child
- Long Cases
- Complex respiratory presentations
- Communication scenarios
- 4. Professional skills and knowledge: Patient management
- 6. Acute and emergency care
- General Paediatrics: Recognises and manages respiratory infection and its complications
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Respiratory infection; pleural disease
- Clinical
- History and management planning
- Respiratory assessment
- General Pediatrics Content Outline — Domain 17: Respiratory System
- General Pediatrics Content Outline — Domain 12: Infectious Diseases
- General Pediatrics EPA: Assess and manage the acutely ill child
- Patient Care 1: History and Physical Examination
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Emergency and acute care
- Medical Knowledge 1: Clinical Knowledge
- Systems-Based Practice: multidisciplinary and surgical escalation
- Medical Expert
- Communicator
- Collaborator
- Scholar
- Pediatrics: Core EPA — Assess and manage the acutely ill child with respiratory illness
Overview & Definition
Picture the four-year-old admitted three days ago with a lobar pneumonia who should be turning the corner but is not: she is still spiking fevers to 39.5 °C, she is breathing fast, she flinches when she coughs, and the intern notices her breath sounds are now stony-dull at the right base. That failure to improve, not any single dramatic sign, is the classic way a parapneumonic effusion announces itself, and recognising it early is what turns a long, complicated admission into a treatable one. [1] [2]
A pleural effusion is simply an abnormal collection of fluid in the pleural space, the potential space between the visceral pleura covering the lung and the parietal pleura lining the chest wall. In children the overwhelming cause is a parapneumonic effusion — fluid that gathers next to a bacterial pneumonia — and when the fluid becomes infected and thick with pus it is called an empyema. [1] [9]
Why this matters at fellowship level is that empyema is not rare and has been rising: it is a predictable, recognisable complication of a common illness, it responds well to the right treatment, and the marks are earned by spotting the child who is not improving, choosing ultrasound over a plain film, and knowing when antibiotics alone will not be enough. [8] [2]
References11ShowHide
- [1]Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax, 2005.PMID 15681514
- [2]Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg, 2012.PMID 23164006
- [3]Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax, 2002.PMID 11923554
- [4]Sonnappa S, Cohen G, Owens CM, et al. Comparison of urokinase and video-assisted thoracoscopic surgery for treatment of childhood empyema. Am J Respir Crit Care Med, 2006.PMID 16675783
- [5]St Peter SD, Tsao K, Spilde TL, et al. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg, 2009.PMID 19159726
- [6]Redden MD, Chin TY, van Driel ML. Surgical versus non-surgical management for pleural empyema. Cochrane Database Syst Rev, 2017.PMID 28304084
- [7]Light RW, Macgregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med, 1972.PMID 4642731
- [8]Grijalva CG, Nuorti JP, Zhu Y, et al. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis, 2010.PMID 20166818
- [9]Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis, 2002.PMID 11797168
- [10]Griffith D, Boal M, Rogers T. Evolution of practice in the management of parapneumonic effusion and empyema in children. J Pediatr Surg, 2018.PMID 28781127
- [11]Roberts ME, Rahman NM, Maskell NA, et al. British Thoracic Society Guideline for pleural disease. Thorax, 2023.PMID 37553157