Empyema in Children: Causes, Symptoms and Treatment Parents Should Know

Empyema in children is a serious medical condition caused by the collection of pus or infected fluid in the pleural space between the lungs and the chest wall. It is commonly seen in children with bacterial pneumonia and is characterised by persistent fever, breathing difficulty, cough, and chest pain.

Empyema treatment involves the use of antibiotics with pus drainage or even surgery in extreme cases. If a child suffering from pneumonia continues to be feverish and experiences coughing and breathing difficulty, despite being treated, there are high chances that she is suffering from empyema.

Fortunately, most of the children suffering from the condition recover well provided they get prompt medical intervention

‍

What Is Empyema In Children?

Empyema in children is a condition characterised by pus or fluid accumulation in the layers between the lungs and the inner surface of the chest wall. Although the space normally contains some amount of fluid to ensure smooth movement of the lungs while breathing,  bacterial infection can lead to thickening of this fluid ultimately resulting in the formation of pus. Experts call this pleural empyema, or empyema thoracis

‍

Stages Of Empyema

Empyema is broadly classified into three different stages based on how it affects the pleural space

1. Early stage, also known as the exudative stage. This is characterised by the accumulation of thin, free-flowing fluid in the pleural cavity. At this stage, the condition is usually treated by prescribing antibiotics, and drainage is recommended if the collection is large.
2. Stage two is known as complicated stage or Fibrinopurulent stage. The fluid in the pleural space has become thick and infected, with internal partitions. At this stage, experts from the best children’s hospital in Thane often recommend a chest drain, sometimes fibrinolytics or thoracoscopic surgery
3. Stage three is the organising stage, which is characterised by the development of a thick peel that prevents lung expansion. This call is for the need for surgical remover or decortication.

The Indian Council of medical research has developed standard treatment work flows for empyema thoracis in  children with special emphasis on monitoring symptoms, imaging findings and response to treatment.

The Indian Council of Medical Research (ICMR) has developed standard treatment workflows for empyema thoracis in children, highlighting the importance of monitoring symptoms, imaging findings and response to treatment.

‍

How Does Empyema Develop in Children?

Empyema often starts as bacterial pneumonia. The bacteria spread from the lungs into the pleural spaces, and as this happens, the body sends immune cells to fight, resulting in the formation and accumulation of pus.

The process is known as parapneumonic effusion, and it progresses into empyema once it is infected. This is most commonly seen in younger children as their immune system is still maturing.

The most common pathway is:

Pneumonia → Infection spreads → Fluid collects around the lungs → Fluid becomes infected → Empyema develops

‍

Causes Of Empyema In Children

Some possible causes of empyema in children include:

1. Pneumonia-related complications

Most common cause of empyema in children is bacterial pneumonia.

Some of these bacteria can enter into the plural cavity, causing infection and triggering an immune response, which leads to the accumulation of fluid or pus.

Common organisms associated with childhood empyema, as per the ICMR workflows, are Streptococcus pneumoniae, Staphylococcus aureus and group A streptococci (Streptococcus pyogenes)

2. Tuberculosis

Although it is rare, tuberculosis can be responsible for empyema in children.

This happens when Mycobacterium tuberculosis spreads into the pleural space through a lesion or infected lymph node in the lung.

Tuberculosis empyma is characterised by the buildup of thick, pus-filled fluid having high Concentration of TB bacilli and  inflammatory proteins.

‍

Other Causes Of Empyema In Children

A review in Indian Pediatrics (2002) from PGIMER, Chandigarh further listed foreign bodies, cerebral palsy, immunosuppression, congenital heart disease and prematurity as predisposing conditions for thoracis empyema

‍

Symptoms Of Empyema In Children

Empyema symptoms in children can sometimes resemble those of pneumonia. If the child's condition is not improving and is getting worse, despite treatment, it is a warning sign for the parents.

Common symptoms of empyema in children include:

• Persistent and recurring fever
• Continuous coughing
• Rapid or laboured breathing due to ability of the lungs ' inability to expand properly
• Chest pain that worsens when the child breathes or coughs
• Unusual tiredness and reduced appetite.
• Reduced feeding, irritability, and sleepiness in younger children

‍

When Should Parents Seek Medical Help?

Parents should consult a doctor immediately if:

• If the fever is not going down despite treatment
• If the child is experiencing breathing difficulties
• If the child is complaining of chest pain persistently
• If the child's lips and fingertips are becoming bluish
• If the child exhibits extreme tiredness and unusual sleepiness
• If the child shows poor feeding and signs of dehydration
• If the child has symptoms of pneumonia that are becoming worse, instead of improving

‍

Empyema Diagnosis In Children

Empyema diagnosis in children largely depends on the evaluation of the symptoms, medical history, and clinical assessments/nvestigations.

Experts at MRRCH recommend the following tests based on the initial investigation and symptoms.

1. Chest X-ray: This is recommended by the doctor to suspect complications related to pneumonia in order to identify the presence of fluid around the lungs.

2. Chest Ultrasound: This is a very useful investigation that helps to assess the amount of fluid that has accumulated around the lungs to understand whether the fluid is trapped or free-flowing, as well as to detect any thickening in the pleural lining

3. Blood Tests: Blood tests like CBC, reactive protein and blood culture are done to assess the severity of the infection and monitor how the child is responding to certain treatment.

4. Pleural Fluid Testing: This involves the assessment of fluid drained from around the lungs to assess the type of bacteria, cell count, chemical markers, and culture sensitivity, all of which are crucial for determining the most appropriate antibiotic for treating the child.

5. CT Scan: This is not a routine test for empyema, and it is only recommended in complicated cases where the child is being prepared for surgery or when the doctors need more detailed information about the lungs and pleural space.

‍

Empyema Treatment In Children

Empyema treatment in children focuses on controlling infection, removing pus, improving lung function and preventing long-term damage. Experts from MRRCH curate the treatment based on the stage of empyema, the amount of fluid that has accumulated, and the overall condition of the child. Common treatment techniques used include:

1. Antibiotics

Antibiotics form an important part of the treatment since empyema is caused by bacterial infection. Doctors may initially proceed with broad-spectrum antibiotics and then modify them later based on the culture reports.

It is important to note that the choice and duration of the antibiotics vary greatly depending upon the severity of the infection, the type of bacteria, how well the child is responding to the treatment and the presence of any complications.

2. Drainage of Infected Fluid

Drainage may be required in cases where there is excessive pus buildup around the lungs and antibiotic alone are not sufficient for treating the child.

The most common drainage procedure used is intercostal chest drainage, or ICD, in which a thin tube is inserted into the chest wall to drain the pus. Apart from removing the pus, the technique also helps to reduce unnecessary pressure on the lungs and improve breathing.

Whether a child needs drainage or not is determined carefully after carrying out proper assessment using detailed imaging techniques.

3. Intrapleural Fibrinolytic Therapy

In some cases, the flow accumulated around the lung becomes thick and develops internal partitions. These are called septations.

In such cases, special medicines called fibrinolytics may be used. These are introduced using a chest tube to help breakdown the internal barriers and improve drainage.

4. Surgery

While antibiotics and drainage  prove to be effective in most of the cases, surgery may sometimes be required in selected cases:

One of the most common surgical methods used is VATS or Video-Assisted Thoracoscopic Surgery. This aims at removing the infected material, breaking down the loculation and allowing better lung function.

Thoracotomy and Decortication Maybe recommended in long-standing cases where the lung gets covered by a thick layer of tissue that prevents proper expansion. The procedures aim at removing this external layer and are recommended for patients who continue to experience the infection, despite treatment via antibiotics and drainage.

‍

Empyema Recovery

Recovery varies depending on various factors such as severity of infection, how early the condition was diagnosed, treatment method used and overall health of the child.

Even after the treatment, doctors may recommend the patients to complete full course of antibiotic and come for follow-up appointments. Regular monitoring of breathing and activity levels is also important to ensure gradual return to normal life..

‍

Can Empyema in Children Be Prevented?

Empyema cannot always be prevented, however, the risk can be significantly decreased with the help of timely vaccination against pneumococcal disease and Haemophilus influenzae type b (Hib). Even the World Health Organization (WHO) recommends pneumococcal vaccination as an important strategy for reducing severe pneumococcal disease in children. (WHO Pneumococcal Vaccines)

Any respiratory infection should be addressed and treated at the earliest. Parents should seek medical advice if a child develops:

• Persistent high fever
• Fast breathing
• Chest pain
• Breathing difficulty

Early treatment of pneumonia can reduce the risk of complications.

​Emphasis should also be laid on the overall health and well-being of the child. Parents should prioritise balance, diet, activity, sleep, and good hygiene practices.

‍

Conclusion

Empyema in children  is a potentially serious complication of pneumonia, however with early diagnosis and treatment, the child can lead a normal and healthy life. To know more about empyema treatment, consider the experts from MRRCH, which is one of the leading Children's Hospital in Thane.