Children Case Reports

Hepatitis A: A Case Report

Perinatal management of extreme preterm birth before 27 weeks of gestation: a framework for practice

Steroid treatment for premature babies

Hemophilia A(Factor 8 deficiency) treatment in children 

          

                Antihemophilic Factor Dosage

Childhood pneumonia(WHO)

Empyema thoracis in children

        The indications for chest tube drainage in empyema thoracis in children

Empyema thoracis, a condition characterized by the accumulation of pus in the pleural cavity, often requires chest tube drainage. The indications for chest tube drainage in empyema thoracis include:

1. Persistent or Significant Pleural Effusion:

   • Description: Large amounts of pus or fluid in the pleural space that do not resolve with antibiotic therapy.
   • Indication: To remove the infected fluid and reduce symptoms.

2. Loculated Empyema:

   • Description: Presence of pockets of pus within the pleural cavity.
   • Indication: To ensure effective drainage of all loculated areas.

3. Complicated Parapneumonic Effusion:

   • Description: Infected pleural effusion that does not respond to initial antibiotic treatment.
   • Indication: To prevent the progression to frank empyema.

4. Failure of Medical Management:

   • Description: Lack of clinical improvement despite appropriate antibiotic therapy.
   • Indication: To mechanically remove the pus and allow lung re-expansion.

5. Respiratory Compromise:

   • Description: Significant respiratory distress or difficulty breathing due to the pleural effusion.
   • Indication: To relieve pressure on the lung and improve respiratory function.

6. Diagnostic Confirmation:

   • Description: Need to confirm the diagnosis of empyema and assess the characteristics of the pleural fluid.
   • Indication: To obtain pleural fluid samples for analysis (e.g., culture, Gram stain).

7. Septation or Fibrin Strands on Imaging:

   • Description: Imaging studies (e.g., ultrasound, CT scan) show septations or fibrin strands within the pleural cavity.
   • Indication: To ensure adequate drainage of all compartments and prevent complications.

8. Preventing Fibrothorax:

   • Description: Risk of fibrothorax (thickened pleura leading to restricted lung expansion) due to untreated empyema.
   • Indication: To promote full expansion of the lung and prevent long-term complications.

9. Empyema in Immunocompromised Patients:

   • Description: Increased risk of complications and poor response to antibiotics alone in immunocompromised individuals.
   • Indication: To promptly control the infection and reduce morbidity.

10. Persistent Fever and Systemic Symptoms:

    • Description: Continued fever, malaise, and other systemic signs of infection despite antibiotic therapy.
    • Indication: To control the source of infection and improve clinical symptoms.

Chest tube drainage helps to evacuate the infected pleural fluid, allows the lung to re-expand, and facilitates the healing process. In some cases, additional interventions such as fibrinolytic therapy, video-assisted thoracoscopic surgery (VATS), or open thoracotomy may be required for effective management.

The specific amount of pus or fluid in the pleural space that warrants chest tube drainage can vary, but some general guidelines can be provided:

1. Volume Thresholds:

   • Description: While there is no universally agreed-upon exact volume, significant pleural effusion often means more than 500 mL.
   • Indication: Chest tube drainage is commonly indicated when pleural fluid exceeds 500 mL, particularly if it is accompanied by symptoms or signs of infection.

2. Clinical Judgment:

   • Description: The decision to drain can depend on the clinical presentation and the patient's symptoms rather than a strict volume measurement.
   • Indication: Even smaller volumes may require drainage if the patient is experiencing severe symptoms such as dyspnea, fever, or pain.

3. Radiologic Evidence:

   • Description: Imaging studies such as chest X-rays or CT scans can provide a more accurate assessment of the effusion size.
   • Indication: A chest tube may be indicated if imaging shows a large, loculated, or compressive pleural effusion, even if the exact volume is not quantified.

4. Physiological Impact:

   • Description: The impact of the effusion on lung function and overall respiratory status is crucial.
   • Indication: If the effusion is causing significant respiratory compromise, chest tube drainage may be necessary regardless of the precise volume.

In practice, clinicians consider a combination of factors including the volume of pleural fluid, clinical symptoms, and radiologic findings to decide on the need for chest tube drainage in empyema thoracis.

          difference between Parapneumonic Effusion and sympneumonic effusion?

Parapneumonic effusion and sympneumonic effusion are terms used in the context of pleural effusions associated with pneumonia, but they have distinct meanings and implications:

1. Parapneumonic Effusion:

   • Definition: A parapneumonic effusion is any pleural effusion that is associated with pneumonia, lung abscess, or bronchiectasis. It is a general term that encompasses all types of pleural effusions related to these infections.
   • Classification: Parapneumonic effusions can be classified into three types:
     • Uncomplicated Parapneumonic Effusion: Fluid in the pleural space that is not infected. It is usually a sterile exudate resulting from the inflammatory process of pneumonia. These effusions typically resolve with appropriate antibiotic treatment of the underlying pneumonia.
     • Complicated Parapneumonic Effusion: Fluid in the pleural space that becomes infected but not purulent. This type often requires more than just antibiotics and may necessitate drainage to prevent progression to empyema.
     • Empyema: The most severe form of parapneumonic effusion, characterized by the presence of frank pus in the pleural space. This condition requires prompt drainage and often additional therapeutic interventions.

2. Sympneumonic Effusion:

   • Definition: The term "sympneumonic effusion" is less commonly used and not widely recognized in the medical literature. It generally refers to a pleural effusion that occurs concurrently with pneumonia, similar to a parapneumonic effusion.
   • Usage: In practice, "sympneumonic effusion" is often used interchangeably with "parapneumonic effusion," but the latter is the more accepted and standardized term in medical contexts.
   • Implications: If "sympneumonic effusion" is used, it would typically imply an effusion associated with pneumonia, but it does not provide specific details about the nature of the effusion (i.e., whether it is uncomplicated, complicated, or empyema).

In summary, while "parapneumonic effusion" is a well-defined and commonly used term to describe pleural effusions associated with pneumonia, "sympneumonic effusion" is less specific and widely used. "Parapneumonic effusion" is preferred for clarity and classification purposes.

Latest treatment protocol for Nephrotic syndrome

Pediatric idiopathic steroid-sensitive nephrotic syndrome:diagnosis and therapy —short version of the updated German best practice guideline (S2e) — AWMF register no. 166-001, 6/2020(Link click here)