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Empyema

G
GAMANDEEP

nursing management

1 of 33
Ms. AMANDEEP KAUR
M.M.C.O.N
Empyema
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.
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
ORGANISMS
The most common:
 Staph. aureus .(90% of causes in infants & children)
 Strept. pneuomonie.
 H. influenzae
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.

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Empyema

  • 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
  • 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
  • 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