This document defines empyema as the accumulation of pus in the pleural cavity. It is most commonly caused by pneumonia or other lung infections. Key symptoms include fever, chest pain, and cough. Diagnosis involves chest x-ray and thoracentesis. Treatment involves antibiotics, chest tube placement to drain pus, and sometimes fibrinolytics or surgery. Goals are to treat the infection, drain the pleural space, and allow lung re-expansion to prevent chronic issues. Physiotherapy after treatment is important for full recovery.

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