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Respiratory: Empyema
COL Warren Whitlock, MC, USAIntroduction: Empyema, a pleural effusion of pus caused by progression of infection into the pleural cavity,
is usually a life-threatening complication of pneumonia. It can also arise from inoculation of the pleural cavity
after penetrating chest trauma, esophageal trauma, thoracentesis or chest tube placement.
Subjective: Symptoms
Gray skin, sweating, chills, malaise, fever, chest pain, cough, emaciation, and poor appetite.
Focused History: Have you had pneumonia or a respiratory illness? (Empyema is a complication of
untreated or ineffectively treated pneumonia.) How high is your fever? (Anaerobic empyemas may have
low-grade fever, but high fever is more common.) What makes the symptoms better or worse? (Shallow
breathing and holding or lying on the affected side minimizes chest pain.)
Objective: Signs
Using Basic Tools: Vital signs: Fever > 101.5°F, tachycardia, hypotension
Inspection: Generally toxic appearance. Patient may be somnolent or gravely ill. Mental status changes are
common in impending sepsis. Lying on the affected side for several days may predispose to empyema.
Palpation: Warmth over local area of chest suggests an empyema or other effusion. Enlarged lymph nodes
may indicate infection or cancer.
Percussion: Dullness means a pleural effusion or empyema.
Auscultation: Rales and rhonchi may be heard from surrounding areas of pneumonia. Pleural friction rub
may be heard. Dull respirations with shifting margins of dullness (change in position) indicate fluid effusion;
unchanging pattern of dullness is consistent with empyema
Using Advanced Tools: Lab: Pus in effusion fluid (thoracentesis) is virtually diagnostic of empyema (dam-
age to thoracic duct causing chylothorax is exception); elevated WBC with left shift on differential (bacterial
infection); sputum for Gram stain and culture. CXR: upright, flat and decubitus views (loculated pleural
effusion suggests empyema). Consider PPD skin test for TB in resistant cases.
Assessment:
Differential diagnosis
Other causes of pleural effusion.
Plan:
Treatment
Primary:
- Antibiotics: cefuroxime 750 mg to 1.5 gm IV or IM (if necessary) q8 hours, or ceftriaxone 1-2 gm IV
once/day plus anaerobic coverage such as clindamycin 300-600 mg IV q8 hours. - Chest tube drainage (see Procedure Section) is the most important treatment. Give IV antibiotics before
inserting chest tube. - Supportive: Oxygen, hydration, chest physiotherapy (systematic, forceful percussion of back) (see Nursing
Chapter on CD-ROM).
Primitive: Clear liquids for 24 – 48 hours, humidified environment, ANY antibiotic, prevent lying on one
side.
Patient Education
Activity: Restrict activity
Diet: High calorie with adequate protein to replace body stores