Management of Complicated Pneumonia in Children: Evidence Beyond Guidelines

What is already known? Complicated pneumonia is an area of debate, and a rapid diagnosis is essential for patient survival. Due to the importance of stage-adapted therapeutic decisions, different classification systems have been established. Depending on the stage of the disease, both antimicrobial and interventional approaches are indicated. Conservative management remains the mainstay for the management of parapneumonic effusion, and continuous pleural fluid drainage is not necessary in some children. However, an established consensus worldwide for the management of complicated pneumonia and thoracic empyema with different therapeutic algorithms lacks clear evidence to evaluate complex cases with minimally invasive intervention versus open decortication. Such controversy concerning the best surgical approach persists, especially for sick patients in intensive care who are not doing well despite chest tube or fibrinolytic agents. This article aimed to review current treatment standards for children with different phases of thoracic empyema and complicated pneumonia, this review article will discuss the usefulness of different diagnostic methods and most recent updates on management. 1. Outline the definition, pathophysiology and common causes 2. Review the diagnosis and current treatment standards for complicated pneumonia 3. Review different surgical approaches and their outcomes 4. Provide an update on the recent utilization of video-assisted thoracoscopy (VATS) 5. Review evidence regarding the best fibrinolytic agent 6. Review evidence concerning when to indicate decortication 7. Provide a simplified pathway for the management of complicated pneumonia (figure 9).