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PLEURISY IN CHILDREN
Dr.p.natarajan
 Pleura
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1. The pleura is a two layered sac that holds the lungs and
separates them from the chest wall, diaphragm,
and heart.
2. The pleura that lines the inside of the chest is called
the parietal pleura.
3. The pleura that covers the lungs is called
the visceral pleura.
4. The pleura is separated by a thin layer of fluid. This lets
the lungs expand and contract easily during breathing.
5. Pleural cavity has negative pressure that helps in
inspiration
 Pleurisy
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1. Inflammation of pleura
2. Inflammatory process is divided into 3
types:
1. Dry or plastic
2. Serofibrinous or serosanguinous
3. Purulent
 Dry or Plastic pleurisy
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Etiology
1. Bacterial
2. Viral
3. Tuberculous
4. Connective tissue: Rheumatic
fever
 Pathology
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1. Pathology is usually limited to visceral

pleura
2. Small amounts of yellow serous fluid
collection
3. Adhesions between pleural surfacces
4. Deposition of fibrin in the space
5. Fibrothorax
 Clinical manifestations
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1. Stabbing Pain exaggerated by deep breathing, coughing and

straining
2. It is a dull aching pain in some
3. Localized over the chest and also referred to shoulder or back
4. Grunting and guarding of respiration
5. Child lies on affected side to reduce respiratory movement
6. Audible friction rub may be present
7. Dull percussion note
8. There may be no symptoms in some cases; seen only CXR as
haziness
 DD
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1. Epidemic pleurodynia: Bornholm disease; Coxsackie B

2. Trauma to the rib cage
3. Lesions of dorsal root ganglia
4. Tumors of spinal cord
5. Herpes zoster
6. Gall bladder disease
7. Trichinosis : Infection with the roundworm Trichinella
spiralis. Fever; Muscle pain with breathing, chewing,
or using large muscles
8. Tuberculosis
 Treatment
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1. Treat primary cause

2. Immobilize the chest with adhesive
plaster
3. Suppress cough
4. Analgesia with NSAID
 Serofibrinous pleurisy
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Etiology:
1. Lung infections

2. Inflammatory bowel disease

3. SLE

4. Periarteritis

5. Rheumatic fever

6. Neoplasm
 Clinical manifestations
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1. As fluid accumulate pain may disappear

2. Large fluid collection leads to cough, dyspnea, retraction,
tachypnea, orthopnea and cyanosis
3. Signs:
1. Dull percussion note
2. Decrease of breath sounds
3. Diminished tactile fremitus
4. Mdiastinal push to opposite side
5. Intercostal fullness
6. Rales and ronchi due to lung infection
7. Bronchial breathing
8. Friction rubs
9. Shifting dulness
 Work up
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1. CXR:
1. Homogeneous density
2. Absent lung markings
3. Absent air bronchogram
4. Obliteration of costo and cardio phrenic angles
5. Widening of interlobar septa
2. Ultrasonography
3. Diagnostic pleural tap:
1. Increase in protein; minimal leukocytosis; increase in
LDH
2. AFB and gram stain
 CXR at 1 day interwal- 3 yr old child
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 DD
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1. Hydrothorax
2. Chylothorax
3. Hemorrahge
4. Pyothorax
5. Pleural thickening
 Complications
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1. Fluid may resolve with treatment of

pneumonia
2. May turn purulent if untreated
3. Adhesions may develop between pleural
layers
4. Pleural thickening may develop
5. Usual to resolve completely over time
 Treatmrnt
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1. Treat underlying disease

2. Drain large collection; rapid draining may
produce re expansion pulmonary edema
3. Chest tube for re accumulation
4. Indication for thoracostomy: pleural fluid has:
1. pH < 7.2
2. Glucose < 50 mg/dL
3. Purulent fluid
 Purulent pleurisy or Empyema
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Definition: accumulation of pus in pleural space

Etiology:
1. Pneumonia: Strepto, staphylo, Pneumo

2. Rupture of lung abscess

3. Thoracic surgery

4. Extension of mediastinitis

5. Extension of intra abdominal abscess

Epidemiology:
5-10% bacterial pneumonia may develop empyema
 Pathology
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3 stages:
1. Exudative: fibrinous exudate forms on the pleural
surface
2. Fibrinopurulent: fibrinous septae forms
loculations of fluid and thickening of parietal
pleura
3. Organizational stage: fibroblast proliferation and
thickening of pleura; lung collapse
 Clinical manifestations
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1. Presents as bacterial pneumonia

2. High fever and chills
3. Respiratory distress
4. Toxemia
5. Frontal sweating
 Work up
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1. CXR
2. CT scan
3. Ultrasound
4. Thoracentesis :
1. gram stain and culture
2. pH < 7.2
3. >10 000 wbcs
5. High ESR
6. Leukocytosis
 Complications
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1. Bronchopleural fistula → pyopneumothorax

2. Pyopericardium
3. Lung abscess
4. Peritonitis
5. Rib osteomyelitis
6. Rupture into subcutis
7. Meningitis
8. Orthritis
9. Osteomyelitis
10. Septicemia
11. Pleural thickening → persistent fever
 Treatment
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1. Thoracenetsis
2. Chest tube drainage- fibrinolytics
(strptokinase)
3. Antibiotics- 3-4 weeks
4. Decortication through video assisted
thoracoscopy
 Pneumothorax
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1. Definition: accumulation of extrapulmonary air

within the chest
2. Most often it is due to leakage of air from lung
3. Not so common in childhood
4. Types :
1. Primary spontaneous

2. Secondary spontaneous

3. Traumatic

4. Iatrogenic

5. Catamenial
 Primary
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Eetiology
1. Pneumonia : high in staph pneumonia
2. Bronchiolitis
3. Tuberculosis
4. Cystic fibrosis
5. Lung abscess
6. Pulmonary infarct
7. Rupture of cyst
8. Rupture of emphysematous bleb (asthma)
9. Foreign body in lung
10. Lymphoma
 Secondary
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Etiology
1. Traumatic:
1. Penetrating injury
2. Blunt trauma
3. Loud music
2. Iatrogenic:
1. Thoracotomy
2. Tracheostomy
3. Needle punctutre
4. Mechanical ventilation
5. Resuscitation
3. Catamenial: during menstruation
 Pathophysiology
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1. Air in pleural space abolishes negative

pressure
2. Lung collapses upto 30%
3. In tension pneumothorax:
1. mediastinal shift
2. Decreased venous return
3. Decreased cardiac output
4. Hypoxemia

5.
 Clinical manifestations
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1. Abrupt onset of symptoms

2. Dyspnea, chest pain, cyanosis
3. Chest retraction
4. Signs:
1. Decreased breath sounds
2. Tympanitic percussion note
3. Tracheal shift
 DD
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1. Diaphragmatic hernia
2. Emphysema
3. Large cyst or cavity
4. Compensatory expansion
5. Distended stomach
 Treatment
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1. Tension pneumothorax: emergency needle

thoracostomy
2. Small and medium pneumothorax may resolve
spontaneously
3. 100% O2 helps resolution
4. For collapse lung: chest tube drainage
5. Chemical pleurodesis (doxycyclin in pleural
space)
6. Thoracoscopic blebectomy
 Intercostal drainage
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1. 4th or 5th intercostal space; between the mid- to anterior

axillary line
2. 2nd intercostal space at mid-clavicular line
3. Advaantage of first site:
◼ The heart, great vessels, and internal mammary artery are out of reach
of the device.
◼ Dome of the liver or spleen and the brachial plexus in the axilla are
distant from the entrance site and unlikely to be injured.
◼ The chest wall is thinner laterally than anteriorly, where the pectoral
muscle (and in a female teenager, breast tissue) is present
◼ Anterior chest wall remains free for auscultation, ekg leads, etc.
◼ Cosmetic result is superior
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