empyema and pneumothorax (respiratory )

1. Prepared by:
Roshna Adhikari
Roll No : 1
BNS 2nd Year

2. Pneumothorax, Empyema

3. Contents
Introduction
Types
Causes
Pathophysiology
Clinical features

4. cont....
Diagnostic procedure
Treatment
Complication
Nursing management

5. EMPYEMA
An empyema is an accumulation
of which purulent(pus) fluid
within the pleural space often
with fibrin development & a
loculated(exudative,pus,fluids)
(walled- off) area where
infection. it is a type of pleural
effusion.

6. Cont…
• Empyema is usually a complication of pneumonia,
tuberculosis, or lung abscess .
• Empyema fluid is thick, opaque(not transparent),
exudative, and foul smelling.

9. cont....

10. cont.....

11. Etiology
• Infected surgical wounds of the chest.
• Penetrating chest trauma.
• Hematogenous infection of the pleural space

12. Cont….
• Non bacterial infections like viral infection (e.g.
influenza,cytomegalovirus, etc. ),fungal infection e.g.
(aspergillosis and candidiasis)
• Can develop after thoracic surgery or thoracocentesis.

13. Pathophysiology
• Infectious agent comes in contact of pleural fluid
• Defensing cells present in pleural fluid show response to
infectious agent
• There occurs edema formation and excitation of protein
and neutrophils .

14. cont..
• Deposition on visceral and parietal pleural membranes
and large number of leucocyte adhere to form pus
• Maturation of dense (thick )pus that prevent lungs to re-
expand

15. Diagnosis
• History taking ,Chest x ray
• Physical examination reveals chest auscultation demonstrates
decreased or absent breath sounds over the affected area.
• Dullness on chest percussion as well as decreased fremitus.
• Chest CT

16. cont...
• On a chest X-ray, empyema typically appears as an
accumulation of fluid (pus) in the pleural cavity, the
space between the lung and the chest wall. The fluid
collection may be dense and white, and can cause the
lung to collapse and appear smaller than normal. In
some cases, air can be seen trapped within the fluid,
leading to a characteristic "chestnut" appearance

18. Cont..
• Diagnostic thoracocentesis is performed, often under
ultrasound guidance.

19. Cont.
Laboratory analysis
• The fluid is analyzed for color, red blood cell (RBC) count,
white blood cell (WBC) count, glucose and protein levels,
lactate dehydrogenase (LDH), and pH
• Gram stains, acid-fast stains, culture and sensitivity, and
cytology studies are also performed

20. 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 are (2
to 6 week)prescribed based on the causative organism.

21. Surgical management
• Needle aspiration (Thoracocentesis )with thin percutaneous
Cather ,if volume is small and fluid is not too purulent or
too thick.
• chest tube drainage
• Tube thoracotomy ;if the pleural tapping is failed tube
thoracotomy is done for drainage of the pus in pleural
cavity

24. • Tube thoracotomy is a
procedure that involves
making a small incision in
the chest and inserting a
chest tube to drain fluid or
air from the pleural cavity

25. Cont…..
• VATS(video assisted thoracic surgery ), small incisions are
made in the chest and a thin, lighted camera (thoracoscope)
is inserted to allow the surgeon to view the inside of the
chest cavity on a video monitor. Surgical instruments are
also inserted through the incisions to remove the infected
tissue in the case of empyema.

27. Cont….
• Decortication is the surgical removal of fibrous tissue
in the pleural space; this procedure is called a pleural
peel.
• open thoracotomy

28. Complication
• Septicaemia & septic shock.
• Broncho-Pleural fistula

30. Introduction
• Accumulation of air or gas in the pleural space is called
pneumothorax.
• Normally, negative (sub-atmospheric) pressure exists
between the visceral pleura and parietal pleura known as
the pleural space.

31. Etiology
• Primary (idiopathic or simple pneumothorax)
• Caused by ruptured sub pleural apical blebs( small
subpleural thin-walled air-containing spaces)
• Secondary (pneumothorax as a complication of underlying
lung disease)
• COPD (smoking) → rupture of bullae (fluid-filled blister
or sac)in emphysema.

33. Figure:
BULLAE

34. cont....
• Infection
• Pulmonary tuberculosis
• Cystic fibrosis
• Marfan syndrome
• Malignancy

35. cont....
• Catamenial pneumothorax (thoracic endometriosis):
extremely rare
• Blunt trauma (e.g., motor vehicle accident in which the
thorax hits the steering wheel or rib fracture occurs)
• Penetrating injury (e.g. gunshot, stab wound(knife injury)

36. cont....
• Latrogenic pneumothorax: mechanical ventilation with
high PEEP (barotrauma), thoracocentesis, central venous
catheter placement, bronchoscopy, lung biopsy

37. cont....
Risk factors
• Family history
• Male sex
• Young age
• Asthenic body habitus (slim, tall stature)

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• Smoking (90% of cases): up to 20-fold increase in risk (risk
increases with the cumulative number of cigarettes
smoked)

39. Types
1.Spontaneous pneumothorax or simple pneumothorax
• A simple pneumothorax most commonly occurs as air
enters the pleural space from lungs surface.It is most
commonly occur due to rupture of bleb or bronchopleural
fistula.
• It occurs as a result of an underlying lung pathology such
as COPD, Asthma, Tuberculosis, Cystic Fibrosis or
Whooping Cough.

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2.Traumatic pneumothorax
• Open pneumothorax :occurs with penetrating chest trauma
that allows air from the environment to enter the pleural
space.
• Closed pneumothorax:occurs with blunt trauma( ribs
facture)that allows air from the lung to enter the pleural space

42. cont...
• Iatrogenic pneumothorax involves laceration of visceral
pleura during a procedure such as thoracentesis or central-
line insertion
• A traumatic pneumothorax occurs when air escapes from a
laceration in the lung itself and enters the pleural space or
enters the pleural space through a wound in the chest wall.

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• It may result from blunt trauma (eg, rib fractures),
penetrating chest or abdominal trauma (eg, stab wounds
or gunshot wounds), or diaphragmatic tears.

44. cont...
• It may occur during invasive thoracic procedures ( thora-
centesis, transbronchial lung biopsy, insertion of a
subclavian line) in which the pleura is inadvertently
punctured, or with barotrauma from mechanical
ventilation.

45. cont..
Tension pneumothorax
• A tension pneumothorax occurs when air is drawn into the
pleural space from a lacerated lung or through a small
opening or wound in the chest wall.
• In effect, a one-way valve or ball valve mechanism occurs
where air enters the pleural space but cannot escape.

47. cont.....
• With each breath, tension (positive pressure) is increased
within the affected pleural space.
• This causes the lung to collapse and the heart, the great
vessels, and the trachea to shift toward the unaffected side
of the chest (mediastinal shift).

48. cont....
• Both respiration and circulatory function are compromised
because of the increased intra thoracic pressure, which
decreases venous return to the heart, causing decreased
cardiac output and impairment of peripheral circulation.

49. Sign and symptoms
• Tachypnoea( increased rate of breathing)
• Tachycardia
• Severe dyspnea in tension pneumothorax
• Decreased respiratory excursion(chest movement) in
tension and traumatic pneumothorax
• Absent breath sounds on affected side in traumatic and
tension pneumothorax

50. Cont...
Spontaneous
• Abrupt onset
• Pleuritic chest pain
• Shortness of breath

51. Cont.....
• Unequal lung excursion(do not expand )
• Decreased breath sounds and hyperresonant percussion
tone on affected side

52. Cont..
• Traumatic
• Air movement through an open wound.
• Tension
• Hypotension, shock
• Distended neck veins
• Tracheal deviation towards unaffected side

53. Pathophysiology
• Normally, in pleura pressure is negative (negative pleural
pressure) (to maintain lung inflation)
• Any breaches in the pleural space result in the loss of
negative pleural pressure.
• Reduce expansion of lungs.

54. cont......
• Reduce exchange of gases.
• Causing partial or total collapse of lung.

55. Diagnostic investigation
• History and physical examination.
• Ultrasound
• Arterial blood gas analysis
• Chest x-ray and CT scan confirms presence of air in pleural
space.

56. On a chest X-ray, pneumothorax
can appear as a dark, triangular area
surrounded by white lung tissue.
The affected lung will appear
smaller than normal, and the heart
may appear displaced to the side
opposite the pneumothorax

57. Management
• The goal in treating a pneumothorax is to relieve the
pressure on your lung, allowing it to re-expand.
• Antibiotics are usually prescribed to combat infection from
contamination.
• Oxygen therapy.The patient with possible tension
pneumothorax should immediately be given a high
concentration of supplemental oxygen to treat the
hypoxemia(low level of oxygen in blood).

58. cont...
• Spontaneous Pneumothorax
• Treatment is generally nonoperative if pneumothorax is not
too extensive.
• Observe and allow for spontaneous resolution for less than
50% pneumothorax in otherwise healthy person.

59. cont....
• Needle aspiration or chest tube drainage may be
necessary to achieve re-expansion of collapsed lung if
greater than 50% pneumothorax.
• Surgical intervention: Pleurodesis- or thoracotomy with
resection of apical blebs is advised for patients with
recurrent

60. cont...
• Tension Pneumothorax
• Immediate decompression (reduce pressure)to prevent
cardiovascular collapse by thoracentesis or chest tube
insertion to let air escape
• Chest tube drainage with underwater-seal suction to allow
for full lung expansion and healing

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• Open Pneumothorax
• Close the chest wound immediately to restore adequate
ventilation and respiration. A Patient is instructed to
inhale and exhale gently against a closed glottis (Valsalva
maneuver) as a pressure dressing (petroleum gauze
secured with elastic adhesive) is applied. This maneuver
helps to expand collapsed lung.

62. cont...
• Chest tube is inserted and water-seal drainage set up to
permit evacuation of fluid/air and produce re-expansion of
the lung.

63. cont...
• Surgical intervention may be necessary to repair trauma.
• Maintain patency of chest tubes.
• Assist patient to splint chest while turning or coughing
and administer pain medications is needed.

64. Nursing Management
• Assess for crackling beneath the skin, indicating
subcutaneous emphysema( air in tissues).
• Decreased or absent breath sounds over the collapsed lung.
• Percussion may demonstrate hyper resonance on the
affected side.

65. cont....
• Pain -quality ,location,severity,duration,onset,and factor
relieving and aggravation.
• Assess for hemodynamic status ,ECG for dysrhythmias.

66. Nursing Diagnoses
• Ineffective Breathing Pattern related to air in the pleural
space
• Impaired Gas Exchange related to atelectasis and collapse
of lung
• Pain related to air pressure change in pleural cavity
• Knowledge deficit related to disease and its management

67. Nursing Interventions
Achieving Effective Breathing Pattern
• Maintain patent airway; suction as needed(ET and oral suction )
• Position patient upright if condition permits to allow greater chest
expansion.
• Maintain patency of chest tubes.

68. cont.....
• Assist patient to splint chest while turning or coughing and
administer pain medications as needed.
• Provide ventilator support if necessary.
• Monitor vital sign hourly for assessing condition of patient
including respiratory rate.

69. cont....
• Check timely the ventilator for its working condition.
• Prove chest physiotherapy such as percussion ;vibration.

70. cont.....
• Resolving Impaired Gas Exchange
• Encourage patient in the use of incentive spirometer.
• Monitor oximetry and ABG levels to determine
oxygenation.
• Provide oxygen as needed.

71. cont....
• Pain management.
• Adherence to the prescribed pharmacological regimen.

72. complication.
• Respiratory failure
• Cardiac arrest
• Pneumomediastinum (air is present in the mediastinum)
• Pneumoperitoneum (air is in the peritoneal cavity)
• pulmonary edema
• Bronchopleural fistula

73. Assignment
• write down three nursing diagnosis and its intervention
of pneumothorax?

74. REFERENCES
• Hinkle J L. and Cheever K H. Brunner &Suddarth's
Textbook of Medical-Surgical nursing. 13th ed.
Philadelphia: Wolters Kluwer Health, Lippincott Williams
& Wilkins; 2014
• Smeltzer S C, Bare B G, Hinkle J L, Cheever K H.Brunner
and Siddharth’s, Textbook of Medical Surgical Nursing vol
1.12th edition. Wolters Kluwer (India) Publication Pvt
limited, New Delhi; 2012.

75. cont...
• Black J M, Hawks J H. “Medical Surgical Nursing” vol 1
.8th edition. Reed Elsevier India, Repro India Limited;
2019.