Empyema

1. Empyema
Anees.A
Assistant professor,
Govt college of nursing , Alappuzha

2. Pleural effusion
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It is the collection of fluid with in the pleural space
Transudate and exudate
Transudate :
increased hydrostatic pressure ( Heart failure )
decreased oncotic pressure ( liver disease – hypoalbuminimea )
Exudate :
Inflammation ( pneumonia, lung abscess, chest trauma, pulmonary malignancies,
infarction ,emboli, pancreatitis )

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Transudate
It is due to increased hydrostatic
pressure or due to decreased
oncotic pressure
Pleural fluid analysis
Low cell count
Low protein count
Fluid is clear/ pale yellow
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Exudate
It is due to inflammation
Pleural fluid analysis
High cell count
high protein count
Fluid is dark yellow

7. Empyema
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Accumulation of pus with in the pleural space
Etiology
Pneumonia
TB
Lung abscess

8. Pathophysiology
Infection, inflammation
Release of inflammatory mediators
Capillary permeability
Release of WBC and proteins
Increase pleural fluid/ exudate
Initiation of fibroblast ( collagen and other proteins ) activity
Adherence of the two pleural membranes ( adhesion)/ thickening/ fibrosis )

9. Phases
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Exudate phase ( 1-3 days )
(Infection and inflammation- capillary permeability- leakage of fluids in to
pleural space)
Fibro purulent phase ( 4-14 days )
Neutrophil accumulation and development of empyema
Organizing stage ( after 14 days )
Fibroblasts grow in to the exudate , collagen formation and adhesion
formation
thickened pleura, fibrotic changes

10. Clinical manifestations
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Fever, chills
Pleuritic pain
Features of respiratory distress
Dyspnea
Tachypnea
hypoxemia
Decreased movement of the chest wall on the affected side
Decreased breath sounds on the involved lung segments
Tracheal deviation
Hypotension, tachycardia

11. Diagnosis
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X- ray
CT
Thoracentesis
Pleural fluid analysis :
Bacterial culture, Gram stain
AFB stain ( TB)
red and white blood cell counts,
chemistry studies ( glucose, amylase, LDH)
cytogenic studies ( malignant cells , PH)
Pleural biopsy

16. Management
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Identify the underlying cause of the pleural effusion
Prevent re accumulation of fluid
To relieve dyspnea
Thoracentesis is performed
To remove fluid
To obtain a specimen for analysis
To relieve dyspnea
Repeated thoracentesis may results in depletion of protein, electrolytes,
hypovolemia, hypotension

17. Pleurodesis
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It is performed to obliterate the pleural space and prevent the
accumulation of fluid
It may be performed using a thoracoscopic approach or using a
chest tube
A chemically irritating agent ( talc, bleomycin, doxycycline) is
instilled in to the pleural space
After the agent is instilled, chest tube is clamped for 60-90 minutes
and patient is assisted to assume various positions to promote
uniform distribution of the agent and to maximize its contact with
the pleural surfaces
To promote adhesions between the visceral and parietal pleura
surfaces

23. Decortication
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It is the surgical removal of fibrous tissue in the pleural surface
This procedure is called PLEURAL PEEL