eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Pleural Effusion: Differential Diagnoses & Workup

Author: Ibrahim Abdulhamid, MD, Assistant Professor of Pediatrics, Wayne State University; Director of Pediatric Pulmonary Medicine, Clinical Director of Pediatric Sleep Laboratory, Children's Hospital of Michigan
Coauthor(s): Debbie S Toder, MD, Director of Cystic Fibrosis Center, Department of Pediatrics, Division of Pulmonary Medicine, Assistant Professor, Wayne State University and Children's Hospital of Michigan; Vandana Batra, MD, Consulting Staff, Baybees Pediatrics
Contributor Information and Disclosures

Updated: Apr 22, 2008

Differential Diagnoses

Pneumonia

Other Problems to Be Considered

Chest mass
Pneumonia with pleurisy
Pleural thickening

Workup

Laboratory Studies

  • Initial studies
    • Initially obtain a CBC count, differential WBC count, and blood culture in a patient with a suspected pleural effusion.
    • Although nonspecific, the erythrocyte sedimentation rate (ESR) is often elevated in children with empyema and may be useful for comparison during follow-up.
    • However, these investigations, along with other acute-phase reactants such as ESR, C-reactive protein (CRP) levels, and procalcitonin levels, have not helped in differentiating bacterial from viral infections.
    • CRP levels tend to drop faster than the ESR and may be a good marker of adequate treatment. 
  • Other studies: Studies helpful in interpreting results of pleural-fluid analysis (described below) include measurements of pH and/or serum glucose, lactate dehydrogenase (LDH), protein, triglycerides, and electrolyte levels.
  • Serologic studies: These may be helpful if specific organisms, such as Mycoplasma species, Legionella species, or adenovirus, are suspected.
  • Pleural-fluid analysis
    • Unless frank pus is obtained, fluid should be sent for Gram staining and culture; acid-fast staining and culture; cell counts; cytology; and determination of pH, protein, glucose, LDH, and triglyceride levels. Stains and cultures may be adequate studies if frank pus is collected.
    • Obtain pleural fluid hematocrit if hemothorax is suspected.
    • Counterimmunoelectrophoresis of urine and pleural fluid can help in identifying some common bacterial organisms when no pathogens are isolated.
    • Measurement of adenosine deaminase activity in the pleural fluid can be helpful if TB is suspected.
    • Pleural effusions are usually classified as transudates or exudates. Examination of the pleural fluid facilitates diagnosis, although criteria for distinguishing transudates and exudates, often called Light criteria, are based on studies in adults. Alkrinawi and Chernick have challenged the usefulness of these criteria, finding that 4-12 of 26 children with parapneumonic effusion had transudative instead of exudative biochemistries.16
      • An exudate has one or more of the following characteristics: pleural protein–systemic protein ratio higher than 0.5, pleural LDH–systemic LDH ratio higher than 0.6, and pleural LDH higher than two thirds of the upper limit of the normal serum LDH value.
      • In general, exudates generally have protein concentration higher than 3 g/dL or a specific gravity of 1.020 on a refractometer.
      • In exudative effusion, the pleural glucose level is usually less than 60 mg/dL. A pleural glucose–serum glucose ratio less than 0.5 can be seen in several conditions, such as parapneumonic effusion, TB, malignancy, esophageal rupture, or rheumatoid effusions.
      • Arterial pH affects pleural pH. Simultaneous pH measurement may be needed to ensure that systemic acidosis is not the cause of low pleural pH. In measuring pleural pH, the fluid should be collected anaerobically in a heparinized syringe and transported on ice (which may keep the pH constant for 12 h if the temperature is kept at 0°C). Low fluid pH is usually associated with low glucose and high LDH levels, and any discrepancy in these measures may indicate laboratory error. Pleural fluid pH less than 7.2 is usually observed in exudative effusions, urinothorax, and systemic acidosis. A complicated parapneumonic effusion with a pH less than 7 is most likely to require chest-tube drainage, whereas an effusion with a pH of 7-7.2 may or may not need drainage. Production of ammonia by urea-splitting bacteria (eg, Proteus species) may increase and not decrease pleural fluid pH.
      • Exudates are caused by infection, pancreatitis (left-sided), systemic lupus erythematosus and other rheumatologic diseases, chylothorax, malignancy, or trauma. In chylothorax, the lipid level is typically 1-4 g/dL, but it may be lower in unfed patients, particularly newborns. Lymphocytes are the predominant cell.
      • Hemorrhagic effusion can be caused by malignancy, trauma, vascular erosion, or coagulopathy. In malignancy, cytologic studies may be diagnostic if results are positive, but negative cytology does not rule out malignancy. In a retrospective study, Chaignaud et al found that cytologic examination and immunotyping of the cells in the pleural fluid were diagnostic in 71% of children with lymphoblastic lymphoma, obviating general anesthesia and open biopsy of the mediastinal masses.17
      • A transudate has none of the chemical characteristics of an exudate. The protein concentration is usually less than 3 g/dL, pleural LDH is less than two thirds the upper level of normal serum LDH, and pleural protein and LDH concentrations and serum levels are less than 0.5 and less than 0.6, respectively. A pH of 7.45 or a pH higher than the patient's blood pH is consistent with transudative effusion.
      • Transudates are caused by congestive heart failure, hypoalbuminemia, nephrosis, hepatic cirrhosis, and iatrogenic causes (eg, misplaced central line, complication of ventriculopleural shunt).
  • Pleural fluid cultures are usually negative because of the common practice of using antibiotics before fluid samples are cultured. For example, in a multicenter British study, only 17% of the cases had positive culture findings.
  • New techniques, such as pneumococcal or broad-range 16S polymerase chain reaction (PCR), may be helpful in identifying possible infectious agents in culture-negative samples. In a study by Menezes-Martins et al (2005), PCR was compared with traditional bacterial fluid cultures in 37 children.18 PCR and bacterial cultures revealed a bacterial organism in 95.2% and 33.3% of the cases of complicated effusions, respectively. PCR revealed a bacterial agent in 31.3% of uncomplicated effusions. According to PCR results, most effusions were caused by MRSA and S pneumoniae.
  • TB or malignancy may proportionally increase the number of lymphocytes in pleural fluid samples.

Imaging Studies

  • Chest radiography
    • A chest radiograph may reveal underlying pneumonia before pleural fluid starts accumulating (see Media file 1). Most effusions are found on anteroposterior (AP) and lateral chest radiographs. On an upright image, and even on lateral decubitus images, the costophrenic angle is lost (see Media files 2-6).
    • As the size of the pleural effusion increases, the hemidiaphragm is obscured, and a mass effect with shift of the mediastinum away from the affected side is seen (see Media file 9). If an image is obtained with the patient supine, one may see only a nonspecific haze over the affected hemithorax, as the fluid layers in the posterior area.
    • To confirm that the fluid is free flowing, posteroanterior and lateral decubitus images obtained with the affected side down are often obtained (see Media files 7-8, 10-11). Conventional wisdom holds that, if a 10-mm layer of fluid is visible, sufficient fluid is present for thoracentesis to be successful. In large effusions, the affected side is opacified, and the decubitus image is not helpful (see Media file 9).
    • In adults, the minimum amount of fluid required before it is observed on an upright radiograph film is approximately 400 mL, whereas lateral decubitus images (obtained with the affected side down) may reveal as little as 50 mL of accumulated fluid.
    • A lateral decubitus image obtained with the affected side up may facilitate the evaluation of the underlying lung for atelectasis or infiltrates.
  • Ultrasonography
    • Ultrasonography is effective for visualizing an effusion and determining if fluid is free flowing or loculated. It may also be used to guide thoracentesis (see Media files 12-13). Ultrasonography may also help in distinguishing a large solid chest mass from an effusion.
    • In a retrospective study, Ramnath et al suggested a beneficial role for early use of ultrasonography to identify effusions with evidence of organization.19 Patients with complicated effusions had significantly shortened hospital stays when aggressively treated with decortication rather than tube thoracostomy. Children who had no evidence of organization on chest ultrasonography and who were treated with intravenous (IV) antibiotics and thoracentesis or a chest tube had a hospitalization course similar to that of children who had comparable ultrasonography findings but who were treated aggressively with thoracoscopy or decortication.
    • In a series of 81 children with complicated parapneumonic effusion, Chiu et al used ultrasonography to monitor, classify, and guide the surgical intervention of these patients.15 The effusions were classified into 3 stages based on fibrin deposition and formation of fibrin septae. These fluid characteristics were used to guide the use of chest tube versus video-assisted thoracoscopic surgery (VATS). Early chest tube drainage of effusion with fibrin deposits eliminated the need for further surgical treatment, whereas initial use of VATS for effusion with fibrin septae lead to shortening of fever and hospital stay.  
  • CT scanning
    • CT, especially contrast-enhanced CT, can provide additional information about the effusion and the pleural surfaces around it (see Media file 14).
    • In adults, parietal pleural thickening on a contrast-enhanced CT scan is a specific but nonsensitive indicator of an exudate.
    • Unless an underlying mass is a concern, chest CT scanning may not be necessary to diagnose a simple pleural effusion. However, it is useful in identifying purulent and loculated effusions.
    • Enhanced and nonenhanced chest CT scans are helpful in identifying underlying lung parenchymal conditions, necrotizing pneumonias, lung abscesses, and hilar lymphadenopathy (see Media file 14).
    • In addition, chest CT scanning (especially contrast-enhanced CT scanning) is valuable in making management decisions in cases of complicated effusions and in cases that do not respond to therapy.

Other Tests

  • A purified protein derivative (PPD) test should be performed, particularly if risk factors for TB are present.
  • Merino et al reported a sensitivity of 97.4% for TB pleural effusion in 39 children with a PPD induration of more than 5 mm.6

Procedures

  • Thoracentesis
    • Thoracentesis is recommended for diagnosing most pleural effusions of sufficient size; however, prospective studies in children are lacking.
    • Thoracentesis is often not performed if the diagnosis is thought to be certain, and the likelihood of empyema or malignancy is low. Such circumstances include small bilateral infiltrates in congestive heart failure or nephrosis or a small parapneumonic effusion in an afebrile child recovering from pneumonia.
    • Thoracentesis should be performed when pleural effusion compromises the patient's respiratory status, in patients with empyema or malignancy, or in newborns.
  • Pleural biopsy: This may be needed in cases of unexplained inflammatory effusion, suspected TB, or malignancy.

More on Pleural Effusion

Overview: Pleural Effusion
Differential Diagnoses & Workup: Pleural Effusion
Treatment & Medication: Pleural Effusion
Follow-up: Pleural Effusion
Multimedia: Pleural Effusion
References
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References

  1. Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. Feb 15 2002;34(4):434-40. [Medline].

  2. Byington CL, Korgenski K, Daly J, Ampofo K, Pavia A, Mason EO. Impact of the pneumococcal conjugate vaccine on pneumococcal parapneumonic empyema. Pediatr Infect Dis J. Mar 2006;25(3):250-4. [Medline].

  3. Asmar BI, Slovis TL, Reed JO, Dajani AS. Hemophilus influenzae type b pneumonia in 43 children. J Pediatr. Sep 1978;93(3):389-93. [Medline].

  4. Murphy D, Lockhart CH, Todd JK. Pneumococcal empyema: outcome of medical management. Am J Dis Child. Jul 1980;134(7):659-62. [Medline].

  5. Chartrand SA, McCracken GH. Staphylococcal pneumonia in infants and children. Pediatr Infect Dis. Jan-Feb 1982;1(1):19-23. [Medline].

  6. Merino JM, Carpintero I, Alvarez T, et al. Tuberculous pleural effusion in children. Chest. Jan 1999;115(1):26-30. [Medline].

  7. Ampofo K, Byrington C. Management of Parapneumonic Empyema. Pediatr infec Dis J. 2007;26:445-446.

  8. Wolfe WG, Spock A, Bradford WD. Pleural fluid in infants and children. Am Rev Respir Dis. Dec 1968;98(6):1027-32. [Medline].

  9. Alkrinawi S, Chernick V. Pleural infection in children. Semin Respir Infect. Sep 1996;11(3):148-54. [Medline].

  10. Hardie W, Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas in children. Clin Infect Dis. Jun 1996;22(6):1057-63. [Medline].

  11. Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis. Nov-Dec 1984;3(6):578-91. [Medline].

  12. Brook I. Microbiology of empyema in children and adolescents. Pediatrics. May 1990;85(5):722-6. [Medline].

  13. Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin- nonsusceptible Streptococcus pneumoniae. Pediatrics. Mar 1998;101(3 Pt 1):388-92. [Medline].

  14. Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics. Jun 2004;113(6):1735-40. [Medline].

  15. Chiu CY, Wu JH, Wong KS. Clinical spectrum of tuberculous pleural effusion in children. Pediatr Int. Jun 2007;49(3):359-62. [Medline].

  16. Alkrinawi S, Chernick V. Pleural fluid in hospitalized pediatric patients. Clin Pediatr (Phila). Jan 1996;35(1):5-9. [Medline].

  17. Chaignaud BE, Bonsack TA, Kozakewich HP, Shamberger RC. Pleural effusions in lymphoblastic lymphoma: a diagnostic alternative. J Pediatr Surg. Sep 1998;33(9):1355-7. [Medline].

  18. Menezes-Martins LF, Menezes-Martins JJ, Michaelsen VS, et al. Diagnosis of parapneumonic pleural effusion by polymerase chain reaction in children. J Pediatr Surg. Jul 2005;40(7):1106-10. [Medline].

  19. Ramnath RR, Heller RM, Ben-Ami T, et al. Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics. Jan 1998;101(1 Pt 1):68-71. [Medline].

  20. Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax. Feb 2005;60 Suppl 1:i1-21. [Medline]. [Full Text].

  21. Baranwal AK, Singh M, Marwaha RK, Kumar L. Empyema thoracis: a 10-year comparative review of hospitalised children from south Asia. Arch Dis Child. Nov 2003;88(11):1009-14. [Medline].

  22. Redding GJ, Walund L, Walund D, et al. Lung function in children following empyema. Am J Dis Child. Dec 1990;144(12):1337-42. [Medline].

  23. Ginsburg CM, Howard JB, Nelson JD. Report of 65 cases of Haemophilus influenzae b pneumonia. Pediatrics. Sep 1979;64(3):283-6. [Medline].

  24. Chan W, Keyser-Gauvin E, Davis GM, Nguyen LT, Laberge JM. Empyema thoracis in children: a 26-year review of the Montreal Children's Hospital experience. J Pediatr Surg. Jun 1997;32(6):870-2. [Medline].

  25. Barbato A, Panizzolo C, Monciotti C, et al. Use of urokinase in childhood pleural empyema. Pediatr Pulmonol. Jan 2003;35(1):50-5. [Medline].

  26. Maskell NA, Davies CW, Nunn AJ, Hedley EL, Gleeson FV, Miller R. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. Mar 3 2005;352(9):865-74. [Medline].

  27. Hawkins JA, Scaife ES, Hillman ND, Feola GP. Current treatment of pediatric empyema. Semin Thorac Cardiovasc Surg. 2004;16(3):196-200. [Medline].

  28. Hope WW, Bolton WD, Stephenson JE. The utility and timing of surgical intervention for parapneumonic empyema in the era of video-assisted thoracoscopy. Am Surg. Jun 2005;71(6):512-4. [Medline].

  29. Doski JJ, Lou D, Hicks BA, et al. Management of parapneumonic collections in infants and children. J Pediatr Surg. Feb 2000;35(2):265-8; discussion 269-70. [Medline].

  30. Kim BY, Oh BS, Jang WC, et al. Video-assisted thoracoscopic decortication for management of postpneumonic pleural empyema. Am J Surg. Sep 2004;188(3):321-4. [Medline].

  31. Petrakis IE, Kogerakis NE, Drositis IE, et al. Video-assisted thoracoscopic surgery for thoracic empyema: primarily, or after fibrinolytic therapy failure?. Am J Surg. Apr 2004;187(4):471-4. [Medline].

  32. Padman R, King KA, Iqbal S, Wolfson PJ. Parapneumonic effusion and empyema in children: retrospective review of the duPont experience. Clin Pediatr (Phila). Jul 2007;46(6):518-22. [Medline].

  33. Gates RL, Caniano DA, Hayes JR, Arca MJ. Does VATS provide optimal treatment of empyema in children? A systematic review. J Pediatr Surg. Mar 2004;39(3):381-6. [Medline].

  34. McLaughlin FJ, Goldmann DA, Rosenbaum DM, et al. Empyema in children: clinical course and long-term follow-up. Pediatrics. May 1984;73(5):587-93. [Medline].

  35. Beers SL, Abramo TJ. Pleural effusions. Pediatr Emerg Care. May 2007;23(5):330-4; quiz 335-8. [Medline].

  36. Byington CL, Samore MH, Stoddard GJ, Barlow S, Daly J, Korgenski K. Temporal trends of invasive disease due to Streptococcus pneumoniae among children in the intermountain west: emergence of nonvaccine serogroups. Clin Infect Dis. Jul 1 2005;41(1):21-9. [Medline].

  37. Byington CL, Spencer LY, Johnson TA, Pavia AT, Allen D, Mason EO. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. Feb 15 2002;34(4):434-40. [Medline].

  38. Chiu CY, Wong KS, Huang YC, Lai SH, Lin TY. Echo-guided management of complicated parapneumonic effusion in children. Pediatr Pulmonol. Dec 2006;41(12):1226-32. [Medline].

  39. Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med. Jun 1998;19(2):363-71. [Medline].

  40. Hendren WH, Haggerty RJ. Staphylococcic pneumonia in infancy and childhood; analysis of seventy-five cases. J Am Med Assoc. Sep 6 1958;168(1):6-16. [Medline].

  41. Hilliard TN, Henderson AJ, Langton Hewer SC. Management of parapneumonic effusion and empyema. Arch Dis Child. Oct 2003;88(10):915-7. [Medline].

  42. Jaffe A, Cohen G. Thoracic empyema. Arch Dis Child. Oct 2003;88(10):839-41. [Medline].

  43. Knudtson J, Grewal H. Pediatric empyema--an algorithm for early thoracoscopic intervention. JSLS. Jan-Mar 2004;8(1):31-4. [Medline].

  44. Krishnan S, Amin N, Dozor AJ, Stringel G. Urokinase in the management of complicated parapneumonic effusions in children. Chest. Dec 1997;112(6):1579-83. [Medline].

  45. [Best Evidence] Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics. Sep 2006;118(3):e547-53. [Medline].

  46. Laisaar T, Pullerits T. Effect of intrapleural streptokinase administration on antistreptokinase antibody level in patients with loculated pleural effusions. Chest. Feb 2003;123(2):432-5. [Medline].

  47. McAdams HP, Erasmus J, Winter JA. Radiologic manifestations of pulmonary tuberculosis. Radiol Clin North Am. Jul 1995;33(4):655-78. [Medline].

  48. Montgomery M. Air and liquid in the pleural space. In: Chernick V, Boat TF, Kendig EL, eds. Kendig's Disorders of the Respiratory Tract. 1998:389-411.

  49. Ozcelik C, Ulku R, Onat S, et al. Management of postpneumonic empyemas in children. Eur J Cardiothorac Surg. Jun 2004;25(6):1072-8. [Medline].

  50. Panitch HB, Papastamelos C, Schidlow DV. Abnormalities of the pleural space. In: Taussig LM, Landau LI, eds. Pediatric Respiratory Medicine. 1999:1178-96.

  51. Satish B, Bunker M, Seddon P. Management of thoracic empyema in childhood: does the pleural thickening matter?. Arch Dis Child. Oct 2003;88(10):918-21. [Medline].

  52. Schaaf HS, Beyers N, Gie RP, et al. Respiratory tuberculosis in childhood: the diagnostic value of clinical features and special investigations. Pediatr Infect Dis J. Mar 1995;14(3):189-94. [Medline].

  53. Shoseyov D, Bibi H, Shatzberg G, et al. Short-term course and outcome of treatments of pleural empyema in pediatric patients: repeated ultrasound-guided needle thoracocentesis vs chest tube drainage. Chest. Mar 2002;121(3):836-40. [Medline].

  54. Stringel G, Hartman AR. Intrapleural instillation of urokinase in the treatment of loculated pleural effusions in children. J Pediatr Surg. Dec 1994;29(12):1539-40. [Medline].

  55. Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax. Apr 2002;57(4):343-7. [Medline].

  56. Virkki R, Juven T, Rikalainen H, et al. Differentiation of bacterial and viral pneumonia in children. Thorax. May 2002;57(5):438-41. [Medline].

  57. Waagner DC. The clinical presentation of tuberculous disease in children. Pediatr Ann. Oct 1993;22(10):622-8. [Medline].

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Further Reading

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Keywords

pleural effusion, fluid, pleural space, congestive heart failure, nephrosis, infectious effusion, bilateral effusion, pleural infection, empyema, Mycoplasma pneumoniae, Staphylococcus aureus pneumonia, Haemophilus influenzae type b, Streptococcus pneumoniae pneumonia, tuberculosis, TB, congenital effusion, chylothorax, intrathoracic lymphomas, lymphoblastic lymphoma, non-Hodgkin lymphoma, hemolytic uremic syndrome, pneumococcal empyema, bacteremia, malignant effusion, parapneumonic effusion, upper respiratory tract infection, bronchitis, pleurisy
 
subpulmonic fluid collection, abdominal distension, dyspnea, respiratory distress, systemic lupus erythematosus, pleural rub, congenital heart disease, CHD, methicillin-resistant Staphylococcus aureus, MRSA, varicella, Staphylococcus pyogenes, Hodgkin disease, Down syndrome, diaphragmatic hernia, hydrops fetalis, polyhydramnios, pulmonary hypoplasia, Lemierre syndrome, hemothorax, pulmonary infarction, postpericardiotomy syndrome

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Contributor Information and Disclosures

Author

Ibrahim Abdulhamid, MD, Assistant Professor of Pediatrics, Wayne State University; Director of Pediatric Pulmonary Medicine, Clinical Director of Pediatric Sleep Laboratory, Children's Hospital of Michigan
Ibrahim Abdulhamid, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Sleep Medicine, and American Thoracic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Debbie S Toder, MD, Director of Cystic Fibrosis Center, Department of Pediatrics, Division of Pulmonary Medicine, Assistant Professor, Wayne State University and Children's Hospital of Michigan
Debbie S Toder, MD is a member of the following medical societies: American Academy of Pediatrics and American Thoracic Society
Disclosure: Nothing to disclose.

Vandana Batra, MD, Consulting Staff, Baybees Pediatrics
Vandana Batra, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Girish D Sharma, MD, Associate Professor, Department of Pediatrics, Rush University Medical Center, Rush Children's Hospital; Director of Pediatric Pulmonary Section and Rush Cystic Fibrosis Center
Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Heidi Connolly, MD, Associate Professor of Pediatrics and Psychiatry, University of Rochester;Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center
Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of New York at Stony Brook
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, and American Thoracic Society
Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD, Attending Physician, Pediatric Pulmonary Medicine, Columbia University Medical Center; Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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