2. Introduction-1
The pleura consists of 2 layers
– Parietal pleura
– Visceral pleura
The space between the 2 layers is called the
pleural space
Normally the pleural space contains
− 5 to 15 mL of clear liquid
− With low protein content
− Small number of mononuclear cells
4. Introduction-3
Parietal pleura cover the
inner surface of the
thoracic cavity, including
the diaphragm, and ribs
Visceral pleura envelope
all surfaces of the lungs.
5. Introduction-4
Fluid in the pleural space acts as a lubricant
–Allowing the pleural surfaces to move without friction
6. Introduction-5
Pleural effusion – presence of excessive amount of fluid in the
pleural space
Rarely as a primary disease
–Usually secondary to other diseases
»May be a complication of pneumonia, lung cancer, TB,
pulmonary embolism, and CHF
7. Clinical manifestations-1
Usually are those caused by the underlying
disease
The size of the effusion determine the severity of
symptoms
A large pleural effusion causes shortness of
breath (SOB)
Small effusion, dyspnea may be absent or only
minimal
8. Clinical manifestations-2
Other S/S include
− Decreased or absent breath sounds
− Decreased fremitus
− Dull, flat sound on percussion
− Fever
–Chills
–Pleuritic chest pain
–Coughing
10. Medical management-1
Specific treatment is directed at the underlying cause (eg, heart
failure, pneumonia, lung cancer)
Thoracentesis is performed to
–Obtain a specimen for analysis
–Relieve dyspnea and respiratory compromise
11. Nursing management-1
Pain management
–Administer analgesics
–Patient to assume positions that are the least painful.
Chest tube drainage – used to collect fluid
If a chest tube drainage and water-seal system is used
–Monitoring the system’s function
–Recording the amount of drainage
–Recording color
16. Introduction-1
Accumulation of thick, purulent fluid within
the pleural space
Most empyemas occur as complications of
–Bacterial pneumonia
–Lung abscess
–Tuberculosis
17. Introduction-2
Other causes include
–penetrating chest trauma (stab or gunshot wound)
–complication from lung surgery
–inoculation of the pleural cavity after thoracentesis or chest
tube placement
19. Pathophysiology-1
There are three stages of empyema:
–Exudative stage
–Fibrinopurulent stage
–organizing stage
Exudative
–Fluid is thin, with a low leukocyte count
–Then pleural fluid increases with or without
the presence of pus
21. Classes of empyema-1
Simple empyema
Seen early in the course of the illness
Pus is present, but it is free flowing
Rx is easy
− The pleural cavity can easily be drained
Complex empyema
The longer empyema is left untreated, the
greater the chance that one will develop
complex empyema
22. Classes of empyema-2
The inflammation is more severe
Body forms lots of scar tissue in the pleural space
− causes the cavity to become divided into
multiple, smaller cavities(loculation)
»infected areas become difficult to drain
»complete drainage of pus is essential for
treatment
23. Medical management-1
Aspiration of purulent fluid (thoracentesis)
–to identify the microorganisms (culture and
sensitivity)
–to relief Shortness of Breath
–Thoracotomy (surgical opening of the
thorax) is performed
–chest tube is inserted, then connected to an
underwater-seal drainage bottle
24. Medical management-2
I/V antibiotics, such as flagyl (metronidazole), and penicillins
can be prescribed
Antipyretics (acetaminophen) can be prescribed for fever
25. Nursing management-1
Breathing and coughing exercises should be encourage
deep-breathing
Administer oxygen per nasal cannula at 2 to 6 L / min
if hypoxic
If thoracentesis is performed, the patient is observed for
respiratory distress
Monitor and record the vital signs
Monitor intakes and outputs
26. Nursing management-2
Assist the patient with self-care activities
If the client is to undergo surgery, all the appropriate pre-
operative preparations should be done before the surgery
28. Introduction-1
A lung abscess is a localized necrotic lesion of
the lung parenchyma containing purulent
material
As the abscess increases, the tissue more
becomes necrotic
–affected area collapses and creates a cavity
with purulent material (pus)
30. Etiology-1
Lung abscess may be caused by
–aspiration of oral anaerobes into the lung
–as a complication of
»bacterial pneumonia
»TB
»pulmonary embolism
»chest trauma
31. Etiology-2
May occur due to functional obstruction of the
bronchi by a tumor or foreign body
Patients at risk of aspiration
–Pts with impaired cough reflexes
–Swallowing difficulties
–Altered state of consciousness from anesthesia
–central nervous system disorders (seizure,
stroke)
32. Etiology-3
Most abscesses found in the lung affected by aspiration
The site of the abscess is determined by the patient’s position
33. Pathophysiology-1
Necrotic lesion may be initiated by
– aspiration of infected material
– bronchial obstruction
» result in ischaemia then cell death (necrosis).
− chest trauma
34. Pathophysiology-2
With excess necrosis and cellular exudate
– results in cavitation and liquefaction
» pus and cellular debris fill the area
Initially, the cavity may or may not extend directly into a
bronchus
The necrotic process may extend up to the lumen of a
bronchus or the pleural space
– communicate with the respiratory tract, the pleural cavity,
or both.
35. Pathophysiology-3
If the bronchus is involved, the purulent contents are
expectorated in the form of sputum.
If the pleura is involved, an empyema results.
A communication or connection between the bronchus and
pleura is known as a bronchopleural fistula.
37. Clinical manifestations
Chills and fever
Chest pain
Pleuritis
Productive cough
Sputum may be purulent, foul-smelling or blood streaked
Finger clubbing
Dyspnea
Chest dullness on percussion
Decreased or absent breaths sounds
Crackles on auscultation
38. Diagnostic evaluation
History
Physical examination
− auscultation of the chest – dull or absent breath sounds in
the area of the abscess
Diagnostic test
− CT scan usually locate the abscess
− blood and sputum culture – identification of the micro-
organism
Thoracentesis – aspirated fluid for culture and sensitivity tests
39. Prevention of lung abscess
The following will reduce the risk of lung abscess:
− appropriate antibiotic therapy before teeth extraction
− appropriate antimicrobial therapy for patients with
pneumonia
− adequate dental and oral hygiene
40. Medical management-1
Postural drainage
– help the patient mobilize and expectorate secretions
Chest catheter placement for abscess drainage
Lobectomy
− when there is massive hemoptysis
− no response to medical management
IV antibiotics may be prescribed
– penicillin, clindamycin (cleocin), metronidazole e.c.t
41. Nursing management
Teach the patient to perform deep breathing and coughing
exercises to help expand the lungs
Monitor and record vital signs
Assist patient with postural drainage
Administer the prescribed medications
Keep the patient in semi-fowler’s position
Encourage the patient to eat a diet high in protein and calories
Offer the patient emotional support
