eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Pleural Effusion: Treatment & Medication

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

Treatment

Medical Care

Treatment of the underlying disorder is generally all that is required for effusions caused by renal, cardiac, or rheumatologic diseases.

  • Parapneumonic effusion usually progresses through 3 stages: exudative, fibrinopurulent, and organizational.20
    • The exudative stage is associated with capillary leak during the first 3 days.
    • The fibrinopurulent stage is associated with bacterial invasion of the pleura at 3-7 days.
    • The organizational stage is characterized by fibroblast growth occurring at 2-3 weeks if the effusion is not treated properly.
  • Parapneumonic effusion and empyema are initially treated with empiric antibiotics based on the patient's age and the organisms and sensitivities commonly present in the community. As stated above, the most common cause is S pneumoniae.
    • Antibiotics can be changed if a positive culture is obtained.
    • In a hospitalized patient with complicated parapneumonic effusion, antibiotics are administered IV while a thoracostomy tube is present until the patient is afebrile and clearly improving clinically. Oral (PO) antibiotics are frequently continued for weeks following these procedures.

Surgical Care

Prospective studies in pediatric parapneumonic effusion and empyema are lacking. Much of current practice is based on studies in adults and retrospective analysis of series of children. Technologic and pharmacologic advances have provided options and changes in approach. In the early exudative stage, thoracentesis and antibiotics may be effective.21

  • Chest-tube placement is necessary to drain fluid causing respiratory distress.
    • Some clinicians believe that unorganized parapneumonic effusion or empyema can be treated with antibiotics alone, without chest-tube placement.
    • In the late 1960s, Walter et al reviewed their experience in treating 38 children with pleural effusion and 60 with empyema over 15 years. None of the patients with nonempyemic effusions required chest-tube drainage, and 13 of 60 patients with empyema needed only thoracentesis, without placement of a chest tube.
    • Murphy et al described 9 children with empyema secondary to S pneumoniae, and 3 of these patients had thoracentesis but did not require chest tubes.4
    • Redding et al treated 8 of 15 children with empyema without chest-tube drainage.22 The 7 patients who had chest-tube drainage had hospital stays and durations of parental antibiotic therapy longer than those of patients who did not have chest tubes.
    • Ginsburg et al reported that 49 of 65 children with H influenza pneumonia had pleural effusion.23 Only 20 of the 49 children required chest-tube placement; 1 required open chest drainage, and the rest did not need chest-tube drainage.
    • Chan et al reviewed their experience of treating 47 children with empyema over 26 years in a Canadian institution.24 The empyema was divided into acute, fibropurulent, and chronic effusions. Of the patients who had acute empyema, 3 out of 7 did well without chest-tube placement. Most of the 39 children with fibropurulent effusions were successfully treated with chest tubes, and only 7 required decortication for persistent loculation.
    • Criteria for chest-tube placement based on pleural fluid characteristics derive mainly from experience in adults and include the following:
      • Frank pus on thoracentesis
      • Organisms seen on Gram stain
      • Pleural fluid pH less than 7 or glucose concentration less than 40 mg/dL.
    • As the effusion becomes fibrinopurulent and subsequently organizes, chest tubes often become ineffective because fibrinous strands and loculations divide the pleural space into compartments.
      • Chest ultrasonography and CT scanning may demonstrate this process (see Media files 12-14).
      • To avoid or treat this condition, fibrinolytic agents have been instilled by means of the thoracostomy tube.
      • Streptokinase, urokinase, and alteplase have been safely used in children, with good results and without surgery in 90%.
      • Urokinase (10,000-100,000 units once or twice a day, based on the child's age) was used in 2 pediatric studies.25
      • In a large double blind study in the UK, Maskell et al reported that use of intrapleural streptokinase did not improve mortality, the rate of surgery, or the length of the hospital stay.26
      • Recombinant tissue plasminogen activator (tPA) may prove useful, but studies are lacking. Hawkins et al instilled tPA via chest tubes in 58 children with empyema.27  Fifty four (93%) improved without further surgical intervention, 3 needed VATS, and one had open thoracotomy with decortication.
      • According to Ampofo, use of VATS in children with empyema in a tertiary pediatric care facility in Utah has decreased from 77% in the late 1990s to 20% in the early 2000s after implementing a protocol that combines early chest tube placement with tPA.7  
      • Alteplase (0.1 mg/kg once a day) has been used.
      • Concerns about these agents (allergy [in the case of streptokinase], fever, bleeding, local discomfort, and possible transmission of viral agents from human neonatal kidney cells used to produce urokinase) have dampened enthusiasm for the use of these drugs.
  • VATS allows visualization of the pleural space and is less invasive than open thoracotomy. VATS has made early surgical intervention more attractive than before.
    • In a retrospective analysis, early VATS in children decreased the number of procedures and hospital days compared with the previous practice of thoracentesis, fibrinolytic therapy, and failed thoracotomy or VATS.28,29
    • Several authors have reported that early VATS is safe and effective and that it shortens hospital stay in the management of empyema in children and adults.30,31
    • In a retrospective 10-year study, Padman et al reported their experience and clinical course of 109 children; 50 patients had VATS, and 59 did not.32  The use of VATS within 48 hours of admission lead to significant reduction of hospital stay by 4 days, compared with delayed use of VATS after 48 hours of admission.
  • Gates et al reviewed the results of various therapeutic interventions for empyema, including chest-tube placement, fibrinolysis, VATS, and thoracotomy.33 Early VATS or thoracotomy shortened hospital stay compared with other interventions. The use of antibiotics and duration of chest-tube placement was not correlated with any of the intervention methods.
  • Open thoracotomy with lysis of adhesions should be reserved for late-manifesting or complicated cases of empyema, chronic empyema, and cases with severe pleural fibrous changes.
  • Pleural biopsy may be needed in cases of unexplained inflammatory effusion, suspected TB, or malignancy.

Consultations

  • Pediatric surgeon
  • Pediatric pulmonologist
  • Pediatric infectious disease specialist

Diet

A dietician should be consulted early in patients with chylothorax and in those with complicated pleural effusion and empyema, for whom the course may be prolonged.

  • Chylothorax may respond to a diet with fat supplied as medium-chain triglycerides (MCT) with a resolution of the chylous effusion at the end of 2 weeks. MCT oil is absorbed directly into the portal circulation and does not contribute to chylomicron formation. Its use may decrease lymph flow as much as 10-fold.
  • If chylothorax persists, a trial of IV alimentation for 4-5 weeks may be considered.
  • Children with complicated pleural effusion and empyema may have clinically significant anorexia and increased needs. High-calorie high-protein foods that appeal to the child should be provided early, and nasogastric feeds should be considered early, particularly in young children.

Activity

  • Pain and chest-tube placement may limit the patient's motility.
  • Analgesia can facilitate cough and clearance of the airway, especially in the presence of an underlying pneumonic process.

Medication

Antibiotics are administered for parapneumonic effusions caused by aerobic and anaerobic organisms. Specific agents should be based on the patient's age and the types of organisms and sensitivities common in the community. Therefore, the list of antibiotics below is only a guide. More than 1 agent may be used for synergy and for polymicrobial infections. Antibiotics may be changed if the organisms and their sensitivities are identified. Initially administer antibiotics IV while a thoracostomy tube is present and until some arbitrary time after the child is afebrile and improving clinically; then, the IV drugs can be switched to PO medications for 1-3 weeks.

Empyema usually requires prolonged antimicrobial therapy.

Anti-TB drugs for TB-associated effusion should be administered for 6-9 months. Chemotherapeutic agents are used for malignancy. Steroids are indicated for connective-tissue disorders and may be useful for TB effusion.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Nafcillin (Nafcil, Unipen, Nallpen)

Broad-spectrum penicillin. Used for methicillin-sensitive S aureus. Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. In severe infections, start with parenteral therapy. Change to PO as condition warrants. Because of thrombophlebitis, particularly in elderly, administer parenterally for only 1-2 d; change to PO as indicated clinically.

Adult

250 mg to 1 g PO q4-6h
Alternatively, 500 mg to 1 g IV/IM q4-6h

Pediatric

0-1 wk: 40 mg/kg/d IV/IM divided q8-12h
1-4 wk: 60 mg/kg/d IV/IM divided q8-12h
Older children: 100-200 mg/kg/d IV/IM divided q4-6h; alternatively, 50 mg/kg/d PO divided qid

Probenecid decreases elimination; associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Use caution in hypersensitivity to cephalosporins and in severe renal impairment; to optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); obtain cultures after treatment to confirm that infection is eradicated


Oxacillin (Bactocill, Prostaphlin)

Bactericidal antibiotic that inhibits cell-wall synthesis. Used to treat infections caused by penicillinase-producing staphylococci. May be used to start therapy when a staphylococcal infection is suspected.

Adult

500-1000 mg PO q4-6h
4-12 g/d IV/IM divided q6h

Pediatric

50-100 mg/kg/d PO divided q6h
150-200 mg/kg/d IV/IM divided q6h

Decreases effects of contraceptives and tetracycline; may increase levels of disulfiram and probenecid when administered concomitantly; effect of anticoagulants increase when large IV doses given

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hypersensitivity to cephalosporins and in severe renal impairment


Vancomycin (Lyphocin, Vancocin, Vancoled)

Can be used for MRSA and S pneumoniae. Potent antibiotic against gram-positive organisms and active against Enterococcus species. Indicated for patients who cannot receive or whose conditions fail to respond to penicillins and cephalosporins or those with infections with resistant staphylococci. To avoid toxicity, current recommendation is to assay vancomycin trough levels 30 min before fourth dose. Use creatinine clearance (CrCl) to adjust dose in renal impairment.

Adult

500 mg to 2 g/d IV divided tid/qid

Pediatric

40-45 mg/kg/d IV in divided doses q6h

Erythema, histaminelike flushing and anaphylactic reactions may occur when administered with anesthetics; with concurrent aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced, when coadministered with nondepolarizing muscle relaxants

Documented hypersensitivity; patients with previous hearing loss

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure, neutropenia; red man syndrome caused by too-rapid IV infusion (dose given over few min) but rare when given IV over 2 h or as PO or IP; red man syndrome not an allergic reaction


Penicillin G (Pfizerpen)

Used to treat S pneumoniae infection or anaerobic bacteria. Interferes with synthesis of cell-wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Adult

2-24 million U/d IV divided q4-6h

Pediatric

250,000-400,000 U/d or 150-240 mg/kg/d IV divided q4-6h

Probenecid can increase effects; coadministration of tetracyclines can decrease effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in impaired renal function; possible cross-allergy to cephalosporins


Cefotaxime (Claforan)

Third-generation cephalosporin. Can be used for S pneumoniae or H influenzae infection. Arrests bacterial cell-wall synthesis, which inhibits bacterial growth.

Adult

Moderate-to-severe infections: 1-2 g IV/IM q6-8h
Life-threatening infections: 1-2 g IV/IM q4h

Pediatric

Infants and children: 50-180 mg/kg/d IV/IM divided q4-6h
>12 years: Administer as in adults

Probenecid may increase levels; coadministration with furosemide and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in history of renal impairment and colitis


Ceftriaxone (Rocephin)

Third-generation cephalosporin; can be used for S pneumoniae or H influenzae. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Adult

1-2 g IV q12-24h

Pediatric

Neonates >7 days: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d
Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Documented hypersensitivity; hyperbilirubinemic neonates, especially prematurely born neonates

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding women and in allergy to penicillin


Clindamycin (Cleocin)

Can be used for S pneumoniae infection, anaerobes, and as alternative drug for MRSA. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl transfer RNA (tRNA) from ribosomes causing RNA-dependent protein synthesis to arrest.

Adult

150-450 mg/dose PO q6-8h; not to exceed 1.8 g/d
600-1200 mg/d IV/IM divided q6-8h, depending on degree of infection

Pediatric

25-40 mg/kg/d IV divided q6-8h
8-20 mg/kg/d PO as hydrochloride or 8-25 mg/kg/d PO as palmitate divided tid/qid

Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile

Antituberculous Drugs

For treatment of drug-susceptible TB infection. Recent recommendations include 6-9 months of therapy. Six-month regimen includes 2 months of isoniazid (INH), rifampin, and pyrazinamide once per day followed by 4 months of INH and rifampin daily or 2 months of INH, rifampin, and pyrazinamide daily, followed by 4 months of INH and rifampin twice a week under directly observed therapy (DOT). For drug-resistant TB, initial treatment should include 4 drugs until susceptibility is determined. Therapy should last 12-18 months.


Isoniazid (INH, Laniazid, Nydrazid)

Best combination of effectiveness, low cost, and minor adverse effects. First-line drug unless resistance or another contraindication known. Therapeutic regimens <6 mo have unacceptably high relapse rate. Coadministration of pyridoxine recommended if peripheral neuropathies secondary to INH therapy develop. Prophylactic doses of 6-50 mg/d recommended.

Adult

5 mg/kg PO qd (usually 300 mg/d) and 10 mg/kg qd in 1-2 divided doses in disseminated disease; not to exceed 300 mg/d
DOT: 15 mg/kg twice weekly; not to exceed 900 mg/d

Pediatric

10-20 mg/kg PO qd; not to exceed 300 mg/d

Incidence of INH-related hepatitis can increase with daily alcohol ingestion; aluminum salts may decrease serum levels (administer 1-2 h before aluminum salts taken); may increase effects of anticoagulant with coadministration; may inhibit metabolic clearance of benzodiazepines
Carbamazepine toxicity or INH hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase CNS adverse effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram
Coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin

Documented hypersensitivity; previous INH-associated hepatic injury or other severe adverse reactions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Can cause hepatitis and peripheral neuritis; monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations recommended during therapy, even when visual symptoms do not occur


Rifampin (Rifadin, Rimactane)

For use in combination with at least one other anti-TB drug. Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which in turn blocks RNA transcription. Cross-resistance may occur. Treat 6-9 mo or until 6 mo have elapsed from conversion to negative sputum cultures.

Adult

600 mg/d PO

Pediatric

10-20 mg/kg/d PO; not to exceed 600 mg/d

Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin

Blood pressure may increase with coadministration of enalapril; coadministration with INH may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if liver function test [LFT] results altered)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Orange discoloration of urine and other secretions; obtain CBC counts and baseline clinical chemistries before and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interrupted and high-dose intermittent therapy associated with thrombocytopenia (reversible if therapy discontinued as soon as purpura occurs); if treatment continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur


Pyrazinamide

Pyrazine analog of nicotinamide that may be bacteriostatic or bactericidal against Mycobacterium tuberculosis, depending on concentration of drug attained at site of infection; mechanism of action unknown. Administer for initial 2 mo of 6-mo or longer regimen for drug-susceptible cases. Treat drug-resistant cases with individualized regimens.

Adult

15-30 mg/kg PO qd; not to exceed 2 g/d
DOT: 50-70 mg/kg PO 2 times/wk; not to exceed 4 g/d or 50-70 mg/kg 3
times/wk; not to exceed 3 g/d

Pediatric

20-40 mg/kg/d PO
Administer as in adults

Documented hypersensitivity; severe hepatic damage, acute gout

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Hepatotoxic effects and hyperuricemia; use only in combination with other effective anti-TB agents; inhibits renal excretion of urates; may result in hyperuricemia (usually asymptomatic); perform baseline determinations of serum uric acid levels; discontinue if signs of hyperuricemia with acute gouty arthritis; perform baseline LFTs (closely monitor in liver disease); discontinue if signs of hepatocellular damage appear; caution in history of diabetes mellitus


Streptomycin

For treatment of susceptible mycobacterial infections. Use in combination with other anti-TB drugs (eg, INH, ethambutol, rifampin). The drug available in the US from X-Gen Pharmaceuticals 866-390-4411 via several wholesalers. For more information see the X-Gen Web site.

Adult

2 times/wk dosing: 15 mg/kg/d IM; not to exceed 1 g/d
3 times/wk dosing: 25-30 mg/kg/d IM; not to exceed 1.5 g/d

Pediatric

2 times/wk dosing: 20-40 mg/kg/d IM; not to exceed 1 g/d
3 times/wk dosing: Administer as in adults

Nephrotoxicity may be increased with aminoglycosides, cephalosporins, penicillins, amphotericin B, and loop diuretics; can potentiate neuromuscular blockade of succinylcholine

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index; not intended for long-term therapy; caution in patients with renal failure not receiving dialysis; caution in myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission

Corticosteroids

These drugs may increase absorption of the pleural effusion.


Prednisone (Deltasone, Orasone)

May decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear (PMN) activity.

Adult

5-60 mg/d PO qd or divided

Pediatric

1-2 mg/kg/d PO qd or divided for 6-8 wk

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, and fungal or TB skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

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References
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References

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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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