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:
of bacterial pneumonia or lung abscess €Penetrating chest trauma €Hematogenous infection of the pleural space €Nonbacterial infections €Iatrogenic causes (after thoracic surgery or thoracentesis)
€Presence

Assessments with PE & NHH
€Signs &

Symptoms: 

Fever Night sweats Pleural pain 

Cough Dyspnea Anorexia Weight loss

Assessments with PE & NHH €Physical Exams: 

r or absent breath sounds over affected area  dullness on chest percussion r 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 
Total protein > 3g/ml WBC > 15,000 cells/mm3 

pH < 7.2 Glucose < 400mg/L LDH > 1000 IU/ml

Diagnostic Thoracentesis

Pathophysiology Presence of Parapneumonic Effusion ª Release of inflammatory mediators
ª

ª permeability of the capilliaries ª ª Attracts WBCs to the site Escape of albumin & other protein from the capillaries ª

ª

Pleural fluid
ª

Presence of free-flowing, protein rich pleural fluid
(Stage I) ª

ª

Inflammation worsens
ª

Attracts more WBCs to the site
ª

ª

Extensive purulent exudate production
ª

Initiation of fibroblastic activity (Stage II)
ª

ª

Adherence of the two pleural membranes (Stage III)
ª Formation of a ³peel´

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 lungexpanding breathing exercises to restore normal respiratory function

Principles of Management
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
€Provide

Pharmacology
€Antibiotic,

cephalosporin (second generation) ± for bacterial infections; Cefuroxime (Zinacef) ± for staphylococcal & streptococcal organisms; most often selected initial antibiotic (Adult: 7501500mg 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 grampositive organisms & anaerobes (Adult: 600-1200mg/d IV/IM divided q6-8h; Pedia: 2540mg/kg/d IV divided q6-8h)

Pharmacology
€Antibiotic,

Miscellaneous ± when methicillin-resistant S.aureus is suspected. Vancomycin (Vancocin, Vancoled) ± a glycopeptide agent for grampositive (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
€Antibiotic

Therapy ± 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.

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