Empyema

An accumulation of thick,

purulent fluid within the
pleural space, often with
fibrin development & a
loculated (walled-off) area
where infection is located
Causes/Risk Factors:
Presence of bacterial pneumonia or
lung abscess
Penetrating chest trauma
Hematogenous infection of the
pleural space
Nonbacterial infections
Iatrogenic causes (after thoracic
surgery or thoracentesis)
Assessments with
PE & NHH
Signs & Symptoms:
Assessments with
PE & NHH
Physical Exams:
 or absent breath
sounds over affected area
 dullness on chest
percussion
 fremitus
Diagnostic & Lab Studies
Computed Tomography
(CT) scan – reveals large
empyema collection with
atelectic lobe and
consolidation
CT scan of chest showing empyema
necessitans (long arrow), a chronic
untreated empyema that has eroded
through the thoracic cage and formed a
subcutaneous abscess (short arrow)
CT scan showing empyema with split pleura
sign (enhancement of the thickened inner
visceral and outer parietal pleura separated by
a collection of pleural fluid)
Diagnostic & Lab Studies
Diagnostic Thoracentesis,
under ultrasound guidance –
extraction of a cloudy or
frankly purulent fluid; little
or no offense odor (aerobic
pus); foul smelling
(anaerobic pus)
Diagnostic & Lab Studies
Diagnostic Thoracentesis,
under ultrasound guidance –
fluid analysis
Diagnostic
Thoracentesis
Pathophysiology
Presence of
Parapneumonic Effusion

Release of inflammatory
mediators

 
↑permeability of the
capilliaries
 
Attracts WBCs to the site
Escape of albumin & other
protein from the capillaries

 
↑ Pleural fluid

Presence of free-flowing,
protein rich pleural fluid
(Stage I)

 
Inflammation worsens

Attracts more WBCs to the
site

 
Extensive purulent
exudate production

Initiation of fibroblastic
activity
(Stage II)

 
Adherence of the two
pleural membranes
(Stage III)

Formation of a “peel”
Nursing Diagnosis
Impaired Gas Exchange r/t
compressed lung
Acute Pain r/t infection of the
pleura
Risk for Activity Intolerance
r/t hypoxia secondary to
empyema
Principles of Management
Help the patient cope with
the condition
Instruct patient in lung-
expanding breathing exercises
to restore normal respiratory
function
Principles of Management
Provide care specific to the
method of drainage
Instruct the patient & family on
care of the drainage system &
drain site, measurement &
observation of drainage, s/sx of
infection, and how & when to
contact a health care provider
 Pharmacology
Antibiotic, cephalosporin (second
generation) – for bacterial
infections;
Cefuroxime (Zinacef) – for
staphylococcal & streptococcal
organisms; most often selected
initial antibiotic (Adult: 750-1500mg
IV q8h; Pedia: 150mg/kg/d IV
divided q8h)
 Pharmacology
Antibiotics,anaerobic infections –
an aspiration or likely anaerobic
infection is the cause of the
pneumonia
Clindamycin (Cleocin) – for gram-
positive organisms & anaerobes
(Adult: 600-1200mg/d IV/IM
divided q6-8h; Pedia: 25-40mg/kg/d
IV divided q6-8h)
 Pharmacology
Antibiotic, Miscellaneous – when
methicillin-resistant S.aureus is
suspected.
Vancomycin (Vancocin, Vancoled) –
a glycopeptide agent for gram-
positive (Adult: 500mg IV q6h or 1g
IV q12h- not to exceed infusion rate
of 10mg/min; Pedia: 40mg/kg/d IV
divided tid/qid)
 Pharmacology
Thrombolytic Agents – convert
plasminogen to plasmin, leading to
clot lysis.
Alteplase (Activase) – binds to fibrin
in a thrombus & converts the
entrapped plasminogen to plasmin,
initiating local fibrinolysis.
(administered intrapleural via chest
tube)
Surgery/Special Procedures
AntibioticTherapy – prescribed
in large doses based on the
causative organism
Thoracentesis – for small fluid
volume w/c is not too purulent
or thick
Surgery/Special Procedures
Tube Thoracostomy – for
loculated or complicated pleural
effusions
Open Chest Drainage via
Thoracotomy, including potential
rib resection – for thickened
pleura & removal of the underlying
diseased pulmonary tissue
BioEthics

Is open thoracotomy

still a good treatment
option for the
management of
empyema in children?
 Open thoracotomy remains an
excellent option for management
of stage II–III empyema in
children. When open
thoracotomy is performed in a
timely manner there is low
morbidity and it provides rapid
resolution of symptoms with a
short hospital stay.
 However, delayed referrals may
result in advanced pulmonary
sepsis and a protracted clinical
course. The late results are
encouraging. Use of thoracoscopy
or fibrinolysis should be considered
on the basis of their own merit, not
on the assumption of probable
adverse outcomes after
thoracotomy.
THAT’S ALL,
THANK
YOU!!!