Change in the management of pneumonia with pleural effusion in children following implementation of a new decision tree

Abstract

Introduction: Optimal management of parapneumonic pleural effusion in children is a mater of controversy. To unify the care strategy at our institution, a multidisciplinary standardised protocol was elaborated.

Aim: To evaluate the change in management after implementation of our decision-tree (DT).

Method: Case control retrospective study of children 2 months to 18 years old admitted for pneumonia with pleural effusion before and after introducing the DT to compare management and outcome.

Results: 81 patients eligible for complete chart review, 52 before DT (group I, median age 4.5y, IQR 1.7-14.3) and 29 after (group II, median age 4.4y, IQR 0.8-16.8). Proportion of patients undergoing chest tube insertion did not change between groups (21% vs. 17%, p=0.6) and was low. Number of chest CT decreased without statistical significance (13 vs 6, p=0.4). Duration of antibiotic treatment (15d, IQR 11-32 vs. 14d, IQR 12-21) and hospital stay (6d, IQR 2-12 vs. 6.2d, IQR 3-13.5) did not significantly alter. There was a significant increase in pain control in group II compared to group I (69% vs. 31%, p<0.001), including the prescription of patient controlled analgesia (11 vs 0, p=0.03). Likewise, significant decrease in weight loss in group II during admission (-0.3kg, IQR -2.6-2.3 vs. -3kg, IQR -5.4-2, p=0.01).

Conclusion: The implementation of a multidisciplinary DT for the management of parapneumonic effusion has not decreased the number of invasive procedures, which is overall low. However, it led to a significant improvement in pain control and nutritional outcome. As the incidence of complicated pneumonia is rising, it is of great interest to improve patient care.