ABSTRACT
Q1 An otherwise healthy 3-year-old male presented to the hospital 7 days ago with a diagnosis of right lower lobe pneumonia. He has been treated with intravenous antibiotics and continues to have a fever. The patient is on room air. An ultrasound is performed which shows a pleural effusion that layers in the decubitus position. What is the most appropriate management at this point? A chest physiotherapy and extending the coverage of the antibiotics B thoracoscopic debridement and pleurodesis C continue to observe and complete 14 days of intravenous antibiotics D thoracostomy tube placement E thoracotomy and debridement of empyema
A1 D Primary therapy for empyema is the administration of high-dose intravenous antibiotics. However, failure to respond to the initial treatment such as the presence of persistent fevers requires effective drainage of the pleural space. Fluid that layers in the decubitus position may be treated with chest tube drainage alone. Loculated fluid collections may not be sufficiently drained in such a way, and the optimal management of these patients is still debated. This patient probably has an empyema in its exudative phase given the fact that there are no loculations on ultrasound. Thoracoscopy or thoracotomy is not indicated at this time, and postural drainage alone has not shown to be effective in treating empyema. If fevers persist despite 7 days of antibiotic treatment, it is unlikely that the empyema will resolve by extending coverage or treatment time.
