References:
- Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 15th Edition, ISBN 978-197-51-6103-3, by Janice L. Hinkle, Kerry H. Cheever, and Kristen J. Overbaugh (Ch. 19, pp. [ebook] 1598–1599)
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Empyema is an accumulation of thick, purulent fluid within the pleural space, often with fibrin development and a loculated (walled-off) area where infection is located.
Pathophysiology
Most empyemas occur as complications of bacterial pneumonia or lung abscess. They also result from penetrating chest trauma, hematogenous infection of the pleural space, nonbacterial infections, and iatrogenic causes (after thoracic surgery or thoracentesis).
At first the pleural fluid is thin, with a low leukocyte count, but it frequently progresses to a fibropurulent stage and, finally, to a stage where it encloses the lung within a thick exudative membrane: loculated empyema
Clinical Manifestations
The patient is acutely ill and has signs and symptoms similar to those of an acute respiratory infection or pneumonia—fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss. If the patient is immunocompromised, the symptoms may be vague. If the patient has received antimicrobial therapy, the clinical manifestations may be less obvious.
Assessment and Diagnostic Findings
- Auscultation: decreased or absent breath sounds over the affected area
- Percussion, Palpation: dullness and decreased fremitus
- Diagnosis is established by Chest CT.
- Usually, a diagnostic thoracentesis is performed, often under ultrasound guidance.
Medical Management
The objectives of treatment are to drain the pleural cavity and to achieve complete expansion of the lung. The fluid is drained, and appropriate antibiotics (usually begun by the IV route) in large doses are prescribed based on the causative organism (determined from the diagnostic thoracentesis).
- Sterilization of the empyema cavity requires 4 to 6 weeks of antibiotics.
- Drainage of the pleural fluid depends on the stage of the disease and is accomplished via:
- Thoracentesis (needle aspiration) with a thin percutaneous catheter, if the volume is small and the fluid is not too purulent or too thick.
- Tube thoracostomy (chest drainage using a large-diameter intercostal tube attached to water-seal drainage) with thrombolytic agents instilled through the chest tube in patients with loculated or complicated pleural effusions.
- Open chest drainage via thoracotomy, including potential rib resection, to remove the thickened pleura, pus, and debris and to remove the underlying diseased pulmonary tissue.
- Exudate formation: long-standing inflammation can result in an exudate forming over the lung, trapping it and interfering with its normal expansion. This requires surgical removal via decortication. After, the drainage tube is left in place until the pus-filled space is obliterated completely. The complete obliteration of the pleural space is monitored by serial chest x-rays, and the patient should be informed that treatment may be long term (weeks to months). Patients are often discharged with a chest tube in place, with instructions to monitor fluid drainage at home.
Nursing Management
Resolution of empyema is a prolonged process.
- The nurse helps the patient cope with the condition and instructs the patient in lung-expanding breathing exercises to restore normal respiratory function.
- The nurse also provides care specific to the method of drainage of the fluid—needle aspiration, closed chest drainage, rib resection, and drainage.
- Instruct the family on care of the drainage system and drain site, measurement and observation of drainage, signs and symptoms of infection, and how and when to contact the primary provider.