nursing management

1. Ms. AMANDEEP KAUR
M.M.C.O.N

3. Definition
 Also known as:- Pyothorax Or Purulent
Pleuritis. The word Empyema comes from the
greek word Empyein, which means :pus –
producing (suppurates).
 Accumulation of Pus in the Pleural cavity.

4. ETIOLOGY EMPYEMA
STABBING
GUNSHOT
WOUNDS
ETC.
NON
TRAUMATIC
EXTRATHORACIC
SEPSIS
THORACIC
SEPSIS
OSTEOMELITIS
MEDIASTINITIS
PULMONARY
DISEASE
PNEUMONIA, TB,
BRONCHIECTASIS,
LUNG ABCESS
NON-
IATROGENIC
LUNG
RESECTION,
OESOPHAGEAL
TEARS,
PARACENTESIS,
THORACIS,
LIVER BIOPSY
IATROGENIC
TRAUMATIC
SUBPHERANIC
ABCESS,
HEPATIC
ABCESS
STERNUM
VERTEBRAE RIBS

5. ORGANISMS
The most common:
 Staph. aureus .(90% of causes in infants & children)
 Strept. pneuomonie.
 H. influenzae

6. ETIOLOGY
 Lung diseases: Pneumonia (the most common
cause) Lung abscess.
 Subphrenic abscess (accumulation of infected fluid
between the diaphragm, liver, and spleen)
 Post traumatic.
 Post-operative.
 Blood spread. (post PE)
 Iatrogenic.

7. RISK FACTOR
 Alcoholism
 Drug use
 HIV infection
 Neoplasm
 Pre-existent pulmonary disease

8. 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

9. Cont…
 Attracts more WBCs to the site.
 Extensive purulent exudate production.
 Initiation of fibroblastic (collagen and other proteins)
activity (Stage II)
 Adherence of the two pleural membranes (Stage III)
 Formation of a “Peel”

10. CLINICAL STAGES
 Acute stage :
within the first 2 weeks of the onset.
 Chronic Stage :
after 2 weeks or with the formation of the thick peel
and loculations.

11. Causes of Chronicity:
 Inadequate Tube Drainage.
 Chronic pulmonary Disease( T.B. or Fungal Infection)
 Immuno-supressed patients.
 Presence of Foreign body within the pleural space.

12. SYMPTOMS & SIGNS
 Fever
 Cough & Expectoration.
 Pleuretic chest pain.
 Easy fatiguability.
 Loss of weight.
 Night sweating.

13. COMPLICATIONS
 Rupture into the lung;
Broncho-Pleural fistula
 Spread to the subcutaneous tissue;
Empyema Necessitasis) (extension of an empyema
outward the pleural cavity.)
 Septicaemia & septic shock.

14. INVESTIGATIONS
 Chest X-ray.
 C-T scan.
 Ultrasonography
 Thoracentesis

15. Light’s criteria
 Pleural fluid protein: serum protein > O.5 (1-2 g/dL)
 Pleural fluid : serum LDH >0.6 (Lactate dehydrogenase
less than 50% of plasma)

16. Other minor criteria
 Cholesterol > 45mg/dl (< 45 mg/dL).
 pH <7.2 (7.60-7.64)
 Glucose < 50% serum (similar to that of plasma)

17. Goals of the treatment
 Treat the infection
 Drain the purulent effusion adequately and
completely
 Re-expand the lung to fill the pleural space
 Eliminate complications and avoid chronicity

18. Antibiotic treatment
 As soon as the bacteriologic sample are recovered
 Pneumonia
 Amoxicillin, Metronidazole
 Amox-clavulanic acid
 Nosocomial
 Tazobactam or Imipenem
 Aminoglycoside or Quinolone
 Adapted to the laboratory results

19. British Thoracic Society.

20. Available techniques

21. Primary treatment options
 Antibiotics alone;
 Récurrent thoracocentèsis
 Insertion of chest drain alone or in combination with
fibrinolytics
 VATS(Video-Assisted Thoracic Surgery).
 Open decortication:- the operation of removing fibrous
scar tissue that prevents expansion of the lung.

22. Thoracocentesis
 Big caliber needle
 Mostly diagnosis technique
 Therapeutically used if the liquid remains.
 Theoretically allows pleural lavage

23. Chest Tube
 As soon as the liquid is thick
 Localization
 free: axillary
 loculated: Chest imaging using
ultrasonography and/or computed
tomography
 Size: 20 à 24
 Bedside

24. Pleural Lavage
 Isotonic saline
 Modalités
 3 way stopcock
 Directly through the CT: 250 to 500 ml
 Cautiously if suspicion of broncho-pleural fistula
 Timing:
 Immediately after CT placement
 Once a day until the liquid is clear

25. NOXYFLEX (noxytioline)
 Local disinfectant (formaldéhyde)
 2,5 g diluted in at least 100ml isotonic saline
 Maximum: 5g/day
 Incompatible with iodine polyvidone,chlorhexidin,
chlorine solution, lactic acid

26. Fibrinolytics
 Urokinase: 100 000 or 300 000 IU conditioning
 Streptokinase: 250000 IU conditioning
 250.000 IU in 10-20 ml isotonic saline
 Don’t evacuate before 24 to 48 heures
 Constantly associated with fever (38-39°C)
 Then evacuate
 Pleural lavage
 clamp 4h ( Chest 1996)

27. Video-assisted thoracic surgery
 Collection<10 cm: unusual
 Visual control of the CT position
 5 mm introducer, 4 mm optical
 Collection>10 cm
 10 mm introducer
 Two or three ports are made in the chest
 One port is utilised for the camera and the others for
grasping instruments
 Free fluid is evacuated and loculations drained under
thoracoscopic visualisation.
 Fibrinous adhesions are separated and the pleural debris
removed from the pleural lining using endoscopic
grasping forceps or by extensive irrigation and suction.
 Following the procedure, one or two chest drains are then
placed in the portholes.

28. Local antibiotics
 Usually Rifampin or Colimycin
 Still debated
 Do not replace systemic treatment

29. Physiotherapy
 Key to a correct evolution
 After CT removal
 Often and for a long time…..
 Decrease surgery
 Decrease long term pain and functionnal limitations

30. Complications
 Pleural thickening
 Reduced lung function

31. 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