EMPYEMA
An
empyema is an accumulation of thick, purulent fluid within the pleural space,
often with fibrin development and a loculated (walled-off) area where infection
is located. Most empyemas occur as complications of bacterial pneumonia or lung
abscess. Other causes include penetrating chest trauma, hematogenous infection
of the pleural space, nonbacterial infections, or iatrogenic causes (after
thoracic surgery or thoracentesis).
At
first the pleural fluid is thin, with a low leukocyte count, but it frequently
progresses to a fibropurulent stage and, finally, to a stage where it encloses
the lung within a thick exudative mem-brane (loculated empyema)
With
an empyema, the patient is acutely ill and has signs and symptoms similar to
those of an acute respiratory infection or pneumonia (fever, night sweats,
pleural pain, cough, dyspnea, anorexia, weight loss). If the patient is
immunocompromised, the symptoms may be more vague. If the patient has received
antimi-crobial therapy, the clinical manifestations may be less obvious.
Chest
auscultation demonstrates decreased or absent breath sounds over the affected
area, and there is dullness on chest percussion as well as decreased fremitus.
The diagnosis is established by a chest x-ray or chest CT scan. Usually a
diagnostic thoracentesis is per-formed, often under ultrasound guidance.
The
objectives of treatment are to drain the pleural cavity and to achieve full
expansion of the lung. The fluid is drained and ap-propriate antibiotics, in
large doses, are prescribed based on the causative organism. Sterilization of
the empyema cavity requires 4 to 6 weeks of antibiotics. Drainage of the
pleural fluid depends on the stage of the disease and is accomplished by one of
the fol-lowing methods:
·
Needle aspiration (thoracentesis)
with a thin percutaneous catheter, if the volume is small and the fluid not too
puru-lent or thick
·
Tube thoracostomy with fibrinolytic
agents instilled through the chest tube in patients with loculated or
complicated pleural effusions
·
Open chest drainage via thoracotomy,
including potential rib resection, to remove the thickened pleura, pus, and
de-bris and to remove the underlying diseased pulmonary tissue
With
long-standing inflammation, an exudate can form over the lung, trapping it and
interfering with its normal expansion. This exudate must be removed surgically
(decortication). The drainage tube is left in place until the pus-filled space
is obliter-ated completely. The complete obliteration of the pleural space is
monitored by serial chest x-rays, and the patient should be in-formed that
treatment may be long term. Patients are frequently discharged from the
hospital with a chest tube in place, with in-structions to monitor fluid
drainage at home.
Resolution
of empyema is a prolonged process. The nurse helps the patient cope with the
condition and instructs the patient in lung-expanding breathing exercises to
restore normal respiratory function. The nurse also provides care specific to
the method of drainage of the pleural fluid (eg, needle aspiration, closed
chest drainage, or rib resection and drainage). When a patient is dis-charged
to home with a drainage tube or system in place, the nurse instructs the
patient and family on care of the drainage sys-tem and drain site, measurement
and observation of drainage, signs and symptoms of infection, and how and when
to contact the health care provider.
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