Unit V Empyema PRESENTED BY REVIEWED BY Ms

Unit V Empyema PRESENTED BY: REVIEWED BY: Ms. Pavithra K Mr. Jobin Lecturer, MSN dept Asst. Professor, MSN dept

LEARNING OBJECTIVES At the end of the class students will be able to • define Empyema • enlist the causes of Empyema • Explain the patho-physiology of Empyema • Enlist the clinical features of Empyema • enumerate the management of Empyema

Introduction • Plueral empyema is a collection of pus in the pleural cavity caused by microorganisms. • It happens in the context of a pneumonia, injury or chest injury. Its one of various kind of pleural effusion.

Pleural Empyema / Pyothorax / Purulent Pleuritis / Empyema Thoracis § Accumulation of Pus in the Pleural cavity.

Causes Tubercular • Mycobacterium tuberculosis Non tubercular • Pneumonia, penetrating trauma Infectious cause • Staphylococci, gram negative organisms, fungai, enterococci

Predisposing factors • Pneumonia is the most common factor • Obstruction q bronchiogenic carcinoma q Forgien body • Suppurative lung disease q Bronchiectasis q Lung absecess • surgical trauma

Pathology-Stages 1. : Exudative phase/ inflammmatory phase • Immediate response with outpouring of fluids • During this phase the fluid is relatively thin and the lung is expandable

Stages 2. Transitional (Fibrinopurulent) stage: ( day 7 to 21 day) § Thick, Opaque fluid with positive culture (pus) and Deposition of thin fibrin layer over the pleura § Higher white cell count. § Lung movements become increasingly restricted.

Stages cont, 3. Stage of vascularization • Fibroblast grow into the exudate • With increasing fibrosis the process becomes chronic and the lung is fixed more firmly • If untreated the empyema may drain spontaneously through the chest wall or into the lungs

Symptoms & signs § § § § • Fever Cough & Expectoration. Pleuretic chest pain. Dyspnoea Easy fatiguability. Loss of weight. Night sweating. Tenderness in the chest wall Finger clubbing.

Complications § § § Rupture into the lung; Broncho. Pleural fistula. Spread to the lung tissue; septic shock. Fibrothorax Pericarditis

Diagnosis § § § History and physical findings CXR USG CT Thoracentesis

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.

Antimicrobial Therapy § § Choice of antibiotic – microbiological C/S testing. Anaerobes- may be treated with Benzylpenicillin. If resistant – metronidazole. Better response – Clindamycin + Penicillin

Primary treatment options • Antibiotics • Recurrent thoracocentesis • Lytic therapy: instillation of 2. 5 lakh units of streptokinase in 100 ml of saline for 10 days increases the drainage • Insertion of chest drain

Thoracocenthesis § Big caliber needle. § Repeated aspiration is carried out.

Chest Tube § Closed tube thoracostomy. § Localization § Chest imaging using ultrasonography and/or computed tomography § Size: 20 - 28 F § Passed under USG guidance, helps in breaking fibrinous septa and pus rapidly gets removed

Bronchoscopy § Recommended following the successful conclusion of closed drainage. § endobronchial causes of obstruction, such as tumour or foreign body.

Rib Resection Drainage § Performed under LA/GA § when the pus is thick and loculated. § Resection of the lowest rib above and below which pus can be aspirated. § Open all the intact cyst that leads to conversion into free pus. § Then place wide bore tube surrounded by gauze in the unsutured wound. § Daily dressing. § Irrigate the cavity with antibiotics until the infection is controlled § Antibiotics should continue for 6 weeks.

Rib Resection Drainage

Decortication/ thoracoplasty § Elective surgical procedure § Involves collapse of the thoracic chest wall into the cavity and filling remainder of the cavity with thoracic muscle such as lattismus dorsi or with omentum

Decortication

Nursing Management Assessment -Assess the respiratory rate, rhythm -Auscultate lung sounds -Identify the type of chest pain -Assess for shortness of breath -Observe skin color , characteristics of secreations

Nursing Diagnosis Impaired gas exchange related to decreased ventilation and mucous plugs Ineffective airway clearance related to excessive secretion and ineffective coughing Anxiety related to acute breathing difficulties and fear of suffocation

EVALUATION • • • What is Empyema ? Enlist the causes of Empyema Explain the Patho-physiology of Empyema ? List down the clinical features of Empyema Enumerate the Management of Empyema ?

REFERENCE • Smeltzer – Brunner & Suddharth Textbook of Medical Surgical Nursing, Wolters kluwer publishers, 12 th edition 2009. • Black – Medical Surgical Nursing, Elsevier publishers, 8 th edition 2009. • Nettina – Lippincott manual of Nursing Practice, Wolters kluwer publishers, 7 th edition 2014. • Lewis – Medical Surgical Nursing, Elsevier publishers, 10 th edition, 2017