Medical Reviewer: Dr. Luigi Matera, MD, Department of Maternal & Pediatric Sciences, Sapienza University of Rome
Pleural empyema is a serious complication of pneumonia—it’s when pus accumulates in the thin space between the lung and the chest wall (the pleural cavity). Normally, that space contains just a tiny amount of fluid that helps the lungs move smoothly during breathing. But when infection strikes, this fluid can become thick, turn into pus, and form what we call empyema.
What Causes Pleural Empyema?
Pleural empyema most often develops as a complication of bacterial pneumonia, especially when the infection doesn’t fully resolve with treatment. The culprits commonly include Streptococcus pneumoniae, especially in well-vaccinated areas; Staphylococcus aureus, including MRSA, is more frequent in some regions or in immunocompromised children (cps.ca). Rarely, fungi or other microbes can be involved, particularly in children with weakened immune systems. Less frequently, empyema can arise from lung abscesses, chest trauma, or surgery complications (MD Searchlight).
Who’s at Risk?
Any child with pneumonia may develop empyema, but the risk is higher in very young children, those with immune system issues, and where vaccination rates are low (brit-thoracic.org.uk). Proper vaccination (e.g., against pneumococcus) is crucial for reducing risk.
What Symptoms Should You Watch For?
Children with empyema often experience:
- Persistent fever, sometimes worsening despite antibiotics
- Chest pain that worsens with breathing or coughing
- Difficulty breathing, rapid respiratory rate, or fatigue
- Poor appetite and overall weakness, sometimes even abdominal pain
- Signs of pneumonia that seem to worsen again after starting treatment (alderhey.nhs.uk, rch.org.au, nhs.uk)
How Is Empyema Diagnosed?
Diagnosis begins with tips from the medical history and physical examination; key clues include persistent symptoms or worsening condition despite treatment (rch.org.au). Then imaging is essential:
- Chest X-ray – can show fluid buildup but may not distinguish empyema
- Chest ultrasound – more sensitive; helps identify fluid and locate it precisely (alderhey.nhs.uk)
- CT scan – used if the empyema is complex or not clearly defined (pch.health.wa.gov.au)
In some cases, a doctor may collect fluid via thoracentesis or from a chest tube to find the exact bacteria and guide antibiotic treatment.
How Is It Treated?
1. Antibiotics
Immediate antibiotics are essential, tailored to the bacteria suspected or found. IV antibiotics are often required initially, sometimes followed by oral antibiotics once the child improves (alderhey.nhs.uk).
2. Draining the Pus
If pus is confirmed, doctors usually insert a chest tube (tube thoracostomy) to drain it. In many cases this is enough, especially when guided by imaging like ultrasound. Fibrinolytic agents (like urokinase) may be instilled into the chest tube to help break up thick pockets of pus.
3. Surgery
If drainage and antibiotics don’t resolve the empyema, video-assisted thoracoscopic surgery (VATS) may be needed. It’s minimally invasive and usually successful. Open surgery is rare, reserved for complex or advanced cases.
How Serious Is It—and What’s the Recovery?
Pleural empyema is serious, but with prompt treatment, most children recover fully. They recover best when drainage and appropriate antibiotics are started early (JAMA Network).
Long-term complications (like persistent scarring or need for further surgery) are rare but monitored with follow-up. Mortality in children remains low—generally under 3%—with good outcomes in the vast majority.
Bottom Line for Parents and Caregivers
- Empyema is a serious but treatable complication of pneumonia—your child may need a chest tube or surgery plus IV antibiotics.
- Watch for worsening symptoms despite treatment (fever, breathing issues, chest pain).
- Early imaging and intervention improve outcomes.
- Vaccines and prompt pneumonia treatment help reduce the risk of this condition.
Pleural Empyema – Frequently Asked Questions
What is pleural empyema?
Pleural empyema is a pus-filled collection in the pleural space around the lung, often following pneumonia and requiring drainage.
What causes pleural empyema and who is at risk?
It’s typically caused by bacteria such as Streptococcus pneumoniae, Staphylococcus aureus, or group A strep. Children with weakened immune systems, malnutrition, or insufficient vaccination are more vulnerable.
What are the symptoms of empyema in children?
Look for persistent fever that doesn’t respond to antibiotics, chest pain that worsens with deep breathing or coughing, difficulty breathing, poor appetite, fatigue, and sometimes abdominal discomfort.
How is it diagnosed?
Diagnosis typically involves a medical evaluation, chest X-ray, ultrasound to detect fluid pockets, and, if needed, CT imaging. Sampling pleural fluid is less common in children but may be used to guide treatment.
How is pleural empyema treated?
Treatment includes antibiotics, drainage via a chest tube (sometimes using fibrinolytic medication), and minimally invasive surgery (VATS) if necessary.
What is the outlook for children with empyema?
With early and appropriate treatment, most children recover fully. Follow-up involves imaging and regular check-ups to ensure there are no long-term complications.
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