Empyema in Children: Causes, Symptoms, and Care

When a child develops pneumonia, parents often breathe a sigh of relief once antibiotics begin working. But sometimes, the infection takes a concerning turn. Fluid accumulates in the space between the lungs and chest wall, and if that fluid becomes infected with pus, the child has developed empyema-a serious complication that requires prompt medical intervention. Understanding this condition helps nurses provide better care and helps families navigate what can be a frightening diagnosis.

What is empyema? 🔗

Empyema is an infection of the fluid in the pleural space-the thin gap between the lungs and the inner chest wall. Under normal circumstances, this space contains only a small amount of clear, sterile fluid that helps the lungs move smoothly during breathing. When bacteria invade this space, the fluid becomes thick, purulent, and filled with immune cells, dead cells, and bacteria. Unlike a simple cough that children can expel, this pus cannot be cleared naturally. It must be drained through medical procedures.

The condition is also called pyothorax or purulent pleuritis. While empyema has become less common since the widespread use of antibiotics, it remains a significant cause of illness in children worldwide, particularly among infants and young children aged 1-4 years.

Causes and risk factors 🔗

The most common cause of empyema in children is parapneumonic effusion-fluid accumulation that develops as a complication of bacterial pneumonia. Studies show that parapneumonic effusions occur in 50-70% of patients admitted with complicated pneumonia. While most of these effusions resolve with proper antibiotic treatment, some progress to empyema.

Common causative organisms 🔗

The bacteria responsible for empyema in children differ from those typically seen in adults. The primary organisms include Streptococcus pneumoniae, which accounts for approximately 40-50% of cases, followed by Staphylococcus aureus (including methicillin-resistant strains or MRSA), and Streptococcus pyogenes. Staphylococcus aureus is particularly common in infants. Anaerobic empyema, while common in adults, is rare in children.

Other contributing factors 🔗

Beyond pneumonia, empyema can develop from penetrating chest trauma, bloodstream infections that reach the pleural space, complications following thoracic surgery, or rarely, spread from abdominal infections. Interestingly, research suggests that NSAID use during acute viral infections may increase the risk of empyema in children, making this an important consideration during treatment of respiratory illnesses.

Signs and symptoms in children 🔗

Recognizing empyema early is crucial because treatment outcomes are significantly better when the condition is detected at an initial stage. However, distinguishing empyema from uncomplicated pneumonia can be challenging since many symptoms overlap.

Common clinical features 🔗

Children with empyema typically present with persistent or worsening fever despite being on appropriate antibiotic therapy for pneumonia. Other symptoms include difficulty breathing (dyspnea), rapid breathing (tachypnea), decreased appetite, chest pain that worsens with breathing, and general malaise. Severe respiratory distress may be observed particularly in infants, who may struggle to feed and appear more ill than older children.

An important clinical clue is when a child being treated for pneumonia shows worsening symptoms or fails to improve as expected. Nurses and caregivers should remain alert to these signs as they often indicate fluid accumulation in the pleural space.

Physical examination findings 🔗

During examination, healthcare providers typically find reduced chest movement on the affected side, decreased breath sounds when listening with a stethoscope, and dullness when tapping (percussing) the chest over the fluid collection. In chronic cases that develop due to delayed diagnosis or inadequate treatment, children may show signs of prolonged illness including anemia, finger clubbing, weakness, and even chest wall deformities or scoliosis.

The three stages of empyema 🔗

Understanding the stages of empyema helps guide treatment decisions. The condition progresses through three distinct phases, though these represent a continuous spectrum rather than discrete categories.

Stage 1: Exudative stage (days 1-3) 🔗

In the earliest stage, the pleural fluid is thin, clear, and often sterile. The fluid contains neutrophils but maintains normal glucose and pH levels. At this point, antibiotics alone may be sufficient for treatment. This stage offers the best opportunity for resolution without invasive procedures.

Stage 2: Fibrinopurulent stage (days 4-14) 🔗

As bacteria invade and multiply, the fluid becomes thick and cloudy. Fibrin deposits form partitions or loculations-walled-off pockets of pus within the pleural space. The pleural fluid pH and glucose levels drop significantly while protein and lactate dehydrogenase (LDH) levels rise. Antibiotics cannot penetrate well into the empyema cavity at this stage, and drainage procedures become necessary. This is the most common stage at the time of diagnosis.

Stage 3: Organizing stage (after 14 days) 🔗

In the final stage, fibroblasts grow into the pleural membranes, depositing collagen and creating a thick, fibrous “peel” over the lung surface. This peel can trap the lung and prevent it from expanding properly. Surgical intervention is often required at this stage to remove the thickened tissue and free the lung.

Diagnosis 🔗

Accurate diagnosis of empyema involves imaging studies and analysis of the pleural fluid.

Imaging studies 🔗

Chest X-ray is typically the first imaging study performed. It can show fluid accumulation appearing as opacity in the hemithorax, and in large effusions, the heart and mediastinum may be pushed toward the healthy side. However, X-rays have limited specificity, especially in early stages.

Ultrasonography is particularly valuable and is recommended as the preferred initial imaging modality after chest X-ray. The Canadian Paediatric Society recommends chest radiograph followed by chest ultrasound for diagnostic imaging. Ultrasound can distinguish between free-flowing and loculated fluid, detect septations characteristic of empyema, and guide safe needle placement for fluid sampling.

Computed tomography (CT) provides the most detailed visualization and is considered the gold standard for evaluating empyema. It shows pleural thickening, loculations, and the characteristic “split pleura sign.” However, due to radiation exposure, CT should not be used routinely in children and is reserved for complex cases or when ultrasound findings are inconclusive.

Pleural fluid analysis 🔗

Thoracentesis-drawing fluid from the pleural space with a needle-is the most specific diagnostic method. The presence of frank pus is diagnostic of empyema and requires no further fluid analysis. When the fluid is not clearly purulent, laboratory analysis helps determine the need for drainage. Key indicators of complicated effusion include pH below 7.2, glucose below 40 mg/dL, LDH greater than 1000 IU/L, and positive bacterial cultures. Gram staining and culture help identify the causative organism, though cultures may be negative if antibiotics were started before fluid sampling.

Management approaches 🔗

The primary goals of empyema treatment are to drain the infected fluid, allow the compressed lung to re-expand, treat the underlying infection, and prevent complications.

Antibiotic therapy 🔗

All children with empyema require antibiotic treatment. Initial antibiotic selection should cover the most common pathogens based on the child’s age and local resistance patterns. The total antibiotic duration typically ranges from three to four weeks if there is adequate drainage and no additional complications. Transition from intravenous to oral antibiotics is appropriate when drainage is complete and the child shows clinical improvement. Parents should know that persistent fever for more than 72 hours on appropriate therapy is common with empyema and does not necessarily indicate treatment failure if the child is otherwise improving.

Drainage procedures 🔗

Chest tube thoracostomy is the primary drainage method. A tube is inserted into the pleural space and connected to an underwater seal drainage system. Early initiation of chest drainage promotes recovery and lung expansion in up to 86% of cases. In some cases, fibrinolytic agents such as tissue plasminogen activator (tPA) or urokinase may be instilled through the chest tube to break up loculations and improve drainage.

Video-assisted thoracoscopic surgery (VATS) offers an alternative approach, particularly when chest tube drainage is unsuccessful or when the empyema is advanced. This minimally invasive procedure allows direct visualization and removal of fibrin deposits and loculations. Studies show similar outcomes between VATS and chest tube drainage with fibrinolytics, with the choice often depending on local expertise and resources.

Open thoracotomy with decortication is reserved for cases where less invasive methods fail or for chronic empyema with thick pleural peel. Due to the potential for causing skeletal deformities in growing children, open drainage is avoided when possible.

Nursing care responsibilities 🔗

Nurses play a critical role in the ongoing management of children with empyema, from monitoring respiratory status to supporting the child and family through what can be an extended hospitalization.

Respiratory monitoring 🔗

Careful assessment of respiratory status is essential. Nurses must monitor respiratory rate, oxygen saturation, work of breathing, and breath sounds regularly. Any sudden deterioration in respiratory status-increased dyspnea, tachypnea, decreased oxygen saturation, or signs of tension pneumothorax-requires immediate escalation to the medical team.

Chest tube management 🔗

For children with chest drains, nurses ensure the drainage system remains below chest level, monitor for air leaks by observing the water seal chamber for bubbling, and document the volume, color, and consistency of drainage output. Dressing changes at the insertion site must be performed using aseptic technique, and the site should be monitored for signs of infection including redness, swelling, or purulent discharge.

Hydration and nutrition 🔗

Children with empyema often have poor appetite due to fever and respiratory distress. Maintaining adequate hydration and nutritional intake supports healing and immune function. Nurses should monitor fluid balance, encourage oral intake when appropriate, and collaborate with the nutritional team as needed.

Pain management 🔗

Chest pain from pleural inflammation and discomfort from chest tubes can be significant. Effective pain control improves the child’s ability to breathe deeply, cough, and participate in lung-expanding exercises, all of which promote recovery.

Preparation for procedures 🔗

When surgical intervention is planned, nurses prepare both the child and family by explaining what to expect, addressing concerns, and ensuring pre-operative requirements are met. Post-operatively, close monitoring continues with attention to wound healing and respiratory recovery.

Prognosis and follow-up 🔗

The good news is that children generally have excellent outcomes from empyema when treated appropriately. Due to rapid tissue regeneration in childhood, healing often occurs without aggressive treatment and without long-term lung function impairment. Follow-up chest X-rays and pulmonary function tests are typically performed to confirm resolution of pleural and lung changes. Most children return to normal activities within a few months of treatment completion.

What do you think? How can nurses best support families during the extended hospitalization that empyema often requires? What strategies have you found effective for managing pain and anxiety in children with chest tubes?

References

1. https://pmc.ncbi.nlm.nih.gov/articles/PMC10995679/
2. https://emedicine.medscape.com/article/1001747-overview
3. https://www.ncbi.nlm.nih.gov/books/NBK544279/
4. https://cps.ca/en/documents/position/complicated-pneumonia-empyema
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3200394/
6. https://pmc.ncbi.nlm.nih.gov/articles/PMC6568155/
7. https://www.ncbi.nlm.nih.gov/books/NBK556088/