Art & science respiratory nursing
Management of patients with empyema
Myatt R (2014) Management of patients with empyema.
Nursing Standard. 28, 30, 42-47. Date of submission: October 15 2013; date of acceptance: January 8 2014.
Abstract
Empyema is the term used to describe an accumulation of pus in a
body cavity such as the pleural space as a result of bacterial infection.
The condition is serious because it is difficult for the immune system
to resolve infection in this area. Empyema can be avoided by the use of
appropriate antibiotic therapy and good aseptic technique when dealing
with any situation that breaches the chest wall. Treatment of this
condition may be medical but if the condition does not resolve, surgical
intervention is required. The nursing role involves providing support,
education and long-term management for patients with empyema.
Author
Rebecca Myatt
Nurse case manager, thoracic surgery, Guys Hospital, London.
Correspondence to: Rebecca.Myatt@gstt.nhs.uk
Keywords
Chest drain, clinical nurse specialists, empyema, nurse-led clinic,
outpatient care, patient education, pleural infection
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EMPYEMA, the accumulation of pus in the
pleural space, may have a slow onset as the result
of an untreated pneumonic infection or it may be
the result of a medical intervention. The condition
is usually treated in a specialist environment such
as respiratory medicine or cardiothoracic surgery,
however initial diagnosis may occur in other
clinical areas because empyema tends to develop
undetected in debilitated patients.
Empyema was first identified by the Egyptian
physician Imhotep around 3,000 BC, and
Hippocrates also recognised it 2,500 years later
(Davies et al 2010). Before the 20th century,
treatment involved open drainage of the pleural
cavity, which had a high mortality rate and
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limited success. Management using intercostal
chest drains was widely adopted following an
influenza epidemic in the early 20th century
(Davies et al 2010). This technique, combined
with the introduction of antibiotics, helped to
improve patient outcomes. Most cases of empyema
result from medical intervention, trauma or
pneumonia (Anyanwu et al 2004). The use of
prompt antibiotic therapy and aseptic technique
when dealing with situations that breach the chest
wall can limit the risk of developing the condition.
Occasionally, empyema develops because of
oesophageal trauma or as a result of conditions
causing dysphagia, where food is aspirated leading
to infection.
Treatment of patients with empyema is
frequently complex as a result of multiple
comorbidities and the involvement of many
healthcare professionals, both in hospital and the
community. The specialist nurse has a significant
role in the management of this condition,
especially liaising between interdisciplinary
teams, communicating with the patient and
family, providing education as well as physical and
psychological support, preparing the patient for
discharge and acting as a contact person once the
patient has returned home.
Anatomy and physiology of the lungs
The pleurae are a thin double layered membrane
surrounding the contents of the thoracic cavity.
The parietal pleura covers the inside of the chest
wall, the thoracic side of the diaphragm, the heart
and the area between the lungs, and the visceral
pleura covers the external lung surface (Marieb
2011). The parietal and visceral pleurae are in
close contact and the potential space between them
contains only a thin layer of fluid, approximately
0.1-0.2mL/kg body weight (Rahman et al 2004,
Bourke and Burns 2011), that lubricates the pleural
surfaces and prevents friction during respiration.
Pathophysiology of empyema
Empyema develops in phases (Figure 1). Initially,
the fluid is a free flowing sterile exudate, referred
to commonly as a simple parapneumonic
effusion. During this exudative phase, fluid moves
NURSING STANDARD / RCN PUBLISHING
into the pleural space as a result of increased
pulmonary vascular permeability and the effect
of proinflammatory cytokines on the mesothelial
cells. Prompt treatment with antibiotics is usually
adequate and chest tube drainage is often not
required (Davies et al 2010).
If appropriate antibiotics are not commenced,
the effusion may progress to the fibrinopurulent
phase. Increased amounts of fluid accumulate
in the pleural space and bacteria invade through
the damaged endothelium (Davies et al 2010).
Bacterial invasion accelerates the immune
response, promoting the migration of neutrophils
and depression of fibrinolytic activity as a result
of the activation of the coagulation cascade (Idell
et al 1991, Kroegel and Antony 1997). The fibrin
deposits form pus-filled pockets (septations).
Neutrophil phagocytosis and bacterial death
stimulate the inflammatory process to release
more proteases and bacterial cell wall-derived
fragments (Kroegel and Antony 1997). The
combination of adhesions, loculations and thick
pus make simple drainage ineffective (Lim 2001).
The fibrinopurulent phase is also known as a
complicated parapneumonic effusion.
In the organising phase, fibroblasts proliferate,
creating a solid fibrous peel (Kroegel and Antony
1997). This surrounds the outside of the lung and
prevents re-expansion, impairs lung function
and creates a persistent pleural space (Davies
et al 2010). The fibrous peel is difficult to remove
and often requires surgical thoracotomy and
decortication (Roberts 2003, Anyanwu et al 2004).
The pathogens responsible for pleural infection
vary according to whether it is hospital or
community acquired, or iatrogenic (Davies et al
2010). Streptococcal species are responsible for
up to 65% of community-acquired infections
(Maskell et al 2006, Davies et al 2010), whereas
Staphylococcus aureus accounts for up to 50% of
hospital-acquired cases, with meticillin-resistant
S. aureus accounting for up to two thirds of these
cases (Maskell et al 2006, Davies et al 2010).
The causative organism of pleural infection also
varies between countries. Knowledge of the
microbiological profile and differing bacteriology
is important to guide appropriate antibiotic
therapy (Davies et al 2010).
Diagnosis
Empyema often has an insidious clinical onset,
which makes accurate and timely diagnosis
difficult (Davies et al 2010). For the patient,
it represents a chronic infective state, which
frequently occurs with a malignant disease process
or other long-term condition. A patient may feel
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unwell, but attribute his or her symptoms to other
causes and not seek additional help. Common
symptoms of empyema are shown in Box 1. Nurses
are ideally placed to recognise symptoms, reassure
the patient and alert the relevant medical team.
A pleural effusion may be apparent on a chest
X-ray, but the diagnosis of infection is often made
following aspiration of the fluid and microscopy,
culture and sensitivity examination. Ultrasound
scanning is an important diagnostic tool, because
it detects the exact location of any fluid collection
and accurate aspiration can be performed if
required (Rosenstengel 2012). Rapid diagnosis and
intervention are paramount to reduce morbidity,
mortality and treatment costs (Davies et al 2010).
Frequently, empyema is not detected until the
infection is advanced and the patient is unwell.
Estimated mortality is between 14% and 18%, but
up to 57% of patients diagnosed at an advanced
stage will die as a direct result of the condition
(Ferguson et al 1996, Davies et al 2010). Because
of the high morbidity and the specialised nature of
this infection, it is recommended that a respiratory
physician or thoracic surgeon manage the patient
(Davies et al 2010). Therefore, a patient may
require transfer to a specialist unit for long-term
management. This can increase anxiety for the
patient and family and the rationale for the move
should be explained.
FIGURE 1
Phases of empyema development
Exudative phase simple parapneumonic effusion
Fibrinopurulent phase complicated parapneumonic effusion
Organising phase formation of scar tissue from the fibrin
deposits that surround the lung, preventing full expansion
(Davies et al 2010)
BOX 1
Common symptoms of empyema
Fever (night sweats).
Lethargy.
Dyspnoea.
Anorexia.
Weight loss.
Breathlessness (if large effusion is present).
Chest pain.
Cough.
Purulent sputum.
(British Medical Journal 2013)
march 26 :: vol 28 no 30 :: 2014 43
Art & science respiratory nursing
Pleural infection leading to empyema can
develop following illness or intervention. Up to
57% of patients with pneumonia may develop
a pleural effusion, which usually resolves with
appropriate antimicrobial therapy (Davies
et al 2010); however, if not treated promptly
complications arise. Other risk factors include
iatrogenic pleural infection following pleural,
thoracic or oesophageal surgery, diabetes mellitus,
immunosuppression, gastro-oesophageal reflux,
alcohol misuse and intravenous drug use (Davies
et al 2010, British Medical Journal 2013).
Management
Management of pleural infection depends on
severity. Treatment approaches range from
antibiotic therapy alone to radical surgical
intervention (Rosenstengel 2012). Choice
of antibiotic is guided by underlying
microbiology, local prescribing guidelines
and drug resistance patterns (Rosenstengel
2012). Advice regarding management and
antibiotic therapy is available from the British
Thoracic Society (Davies et al 2010).
It is impossible to clinically differentiate between
the presence of a complicated parapneumonic
effusion requiring chest tube drainage and a simple
effusion that may resolve with antibiotic therapy
using a chest X-ray alone (Davies et al 2010). It
is, therefore, recommended that all patients with
a pleural effusion have diagnostic pleural fluid
sampling, preferably under ultrasound guidance
(Davies et al 2010). Fluid is analysed for pH,
protein, glucose and lactate dehydrogenase to
confirm whether it is a transudate or exudate,
which can aid with diagnosis, microbiology to guide
antibiotic prescribing, and cytology to detect the
presence of malignant cells and acid fast bacilli if
mycobacterial infection is suspected (Davies et al
2010, Rosenstengel 2012).
Patients with a purulent or cloudy effusion, or
with pleural fluid with a pH greater than 7.2
should receive prompt pleural space chest tube
drainage, to allow the infected fluid to be removed
(Davies et al 2010). This reduces sepsis as well as
reducing the risk of formation of septations. This
is known as a loculated pleural effusion. Previous
medical management of a loculated effusion has
included the use of intrapleural fibrinolytic drugs
such as streptokinase or urokinase to break down
the septations. However, a large double-blind
randomised controlled trial found this treatment
was of little benefit (Maskell et al 2005).
Therefore, it is only recommended following
discussion with a thoracic surgeon for patients
with symptoms such as dyspnoea and for whom
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surgery is not imminent, for example in those
who are not fit for surgery because of other
comorbidities (Davies et al 2010).
Concurrent antibiotic therapy is initiated based
on local antibiotic policy and resistance patterns.
Amino-penicillins such as amoxicillin and
ampicillin, penicillins combined with
beta-lactamase inhibitors (co-amoxiclav,
piperacillin with tazobactam) and cephalosporins
such as cephalexin and cephradine have good
penetration of the pleural space compared to
aminoglycosides (gentamicin, streptomycin,
neomycin) (Davies et al 2010). Duration of
antibiotic therapy is based on a combination of
clinical response, radiological improvement,
bacteriology and inflammatory marker
improvements, for example C-reactive protein,
and is usually for at least three weeks (Davies et al
2010, Rosenstengel 2012).
Surgical intervention is considered on
an individual basis and is based on clinical
improvement and residual sepsis in association
with persistent pleural collection (Davies et al
2010). Video-assisted thoracoscopic surgery
involving surgical debridement or decortication is
increasingly performed, often with good results,
although open thoracic drainage or thoracotomy
and decortication are alternative techniques
(Zahid et al 2011). Video-assisted surgery does
not necessarily require a general anaesthetic,
decortication can be performed in patients who
are awake using an epidural or para-vertebral
nerve block, and this is important in patients
with multiple comorbidities (Zahid et al 2011).
However, thoracic surgery can be high risk for
a patient debilitated by a chronic disease, and
therefore a full risk and benefit analysis, and
discussion with the patient and family are required
before any procedure. All inpatients need to be
assessed for risk of hospital-acquired complications
and treated according to local policy for issues such
as thrombosis prophylaxis and pressure area care.
In addition, patients with empyema require
dietetic support and food supplements to ensure
adequate nutrition.
Length of inpatient stay following surgical
intervention will vary according to individual
recovery rates. Some patients require prolonged
hospitalisation and rehabilitation following this
procedure and resolution of infection. For others,
when they have overcome the initial surgical episode,
they may be discharged with a long-term chest drain,
oral antibiotic therapy and regular outpatient follow
up. Decisions regarding management are taken in
conjunction with the patient, carers and medical
staff as well as relevant members of the wider
multidisciplinary team (Box 2).
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Role of the clinical nurse specialist
The clinical nurse specialist has a significant role
in the management of patients with empyema both
in the ward environment and following discharge
because these individuals may receive continued
outpatient care for several months, depending
on their progress. Over time, a good rapport
can be established, which is vital to support the
individual in coping with this chronic condition.
Since this type of infection is not common, the
terminology may be unfamiliar to the patient and
his or her family, and explanation may be required.
Education with regard to management, treatment
options and long-term prognosis is also necessary.
The clinical nurse specialist is ideally placed to
offer physical and psychological support and assist
long-term care and follow up for these individuals.
In some cases, the clinical nurse specialist may
meet the patient before surgery or fluid aspiration,
FIGURE 2
Pre-operative chest X-ray showing left empyema
FIGURE 3
Post-operative chest X-ray showing left empyema
and chest drain in situ
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providing an opportunity for discussion regarding
expectations, management and potential length of
time for full resolution of the condition. The nurse
can also begin assessment of whether management
at home would be feasible and the level of support
available in the community.
Following medical or surgical intervention, there
is an initial inpatient period where the patients chest
drain is connected to a traditional underwater sealed
drainage bottle. When the patient has recovered
from the acute episode, a period of rehabilitation is
required to allow him or her to regain confidence
and independence. Resolution of the infection
and lung re-expansion is closely observed through
haematological and radiological monitoring.
Many patients require a chest drain for a long
period of time, often several months. To improve
mobility, these patients can be fitted with valved
ambulatory bags (Figure 4). These allow the chest
drain to remain in situ, but with a portable bag to
collect any drainage. They are also much lighter,
more discreet, and enable increased mobility and
independence than the drainage bottles. Because
treatment is frequently lengthy, the ambulatory
BOX 2
Case study: an 82-year-old with long-term empyema
John (a pseudonym) was referred with a history of dyspnoea, pyrexia,
lethargy, weight loss and night sweats following a pneumonic infection,
and was diagnosed with left empyema (Figure 2). His condition did not
improve following initial antibiotic therapy and chest tube drainage, and
he was becoming progressively more unwell. He was assessed in the
critical care unit by the surgical team and although high risk because of
his age and infective state, it was determined that he may benefit from
surgery to clear the infected pleural space. The risks and benefits of the
surgery were explained to John and his family, and after considerable
discussion they agreed to proceed.
Following successful decortication and drainage, John faced a lengthy
recovery with a long-term drain. He was initially managed on the ward,
however his family was keen that he should return home and felt he
would recover more quickly in familiar surroundings. After three weeks,
he was discharged with daily visits from the community nursing team,
community dietetic support and weekly outpatient follow up. Over the next
few months, the chest drain was gradually withdrawn (shortened) as his
lung expanded and the residual infection resolved. Weekly appointments
became fortnightly and then monthly.
The clinical nurse specialist supported John and his family by providing
education before discharge, liaison with community teams, practical
assistance with drain management and reassurance regarding the
progress of the condition. Johns family was aware that they could
contact one of the nurse specialists at any time should they have
questions between appointments.
After ten months, significant radiological improvement combined with
Johns vastly improved clinical condition indicated that the drain could
be removed. John was discharged with instructions to contact the team
if there were any signs of recurrence. Figure 3 shows one of the final
X-ray images before removal of the drain and the position of a safety pin
through the drain and against the skin to ensure the drain was secure.
march 26 :: vol 28 no 30 :: 2014 45
Art & science respiratory nursing
bag also enables the patient to be discharged home
with a drain in place.
Nursing care of the ambulatory chest drain bag
initially involves patient support and education.
On a practical level, information is required
regarding positioning, emptying and changing
the bag. This frequently requires multiple
demonstrations in hospital before the patient
and family feel confident to complete the task.
Troubleshooting common problems such as
spillages, disconnection of the bag or cessation of
drainage are also discussed in detail and advice is
given on what to do if the drain falls out.
If chest tube drainage proves ineffective and
long-term drainage is required for residual sepsis,
the patient may require surgical rib resection
(Davies et al 2010), creating an opening in the chest
wall known as a pleural window or pleurostomy
(Anyanwu et al 2004). This removes the need for an
intercostal drain, and any fluid can be drained into
a stoma bag. For many individuals, this is a better
option because the chest drain can be uncomfortable
and the drainage device visible. Use of a stoma bag
is considered by patients to be more discreet and
causes fewer lifestyle restrictions. The clinical nurse
specialist can assist the transition from one device to
another by providing practical demonstrations and
answering questions regarding management.
Empyema has an offensive odour that is often
distressing to patients and their families. A local audit
carried out on the thoracic surgical unit at Guys and
FIGURE 4
Ambulatory chest drain bag
(Reprinted with permission from Smiths Medical, ASD, Inc.
Refer to the Smiths Medical Portex Ambulatory Bag
Operators Manual Instructions for use this contains
specific information including contraindications, warnings,
precautions and potential complications for the safe and
proper use of the product).
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St Thomas NHS Foundation Trust (unpublished
data) found that patients fear others becoming aware
of the odour and this can lead them to restrict their
movements, and become isolated and depressed.
Some patients associated the odour with poor
hygiene and became preoccupied with trying to
wash it away or disguise it. In these situations,
the specialist nurse can reassure the patient and
provide practical and psychological support. The
patient should be encouraged to shower with a
drain or stoma bag in situ, as long as the device is
not submerged. Patients should carry out personal
hygiene, and change the bag and dressing regularly
to reduce the risk of unpleasant odours. Encouraging
patients to dress in familiar, comfortable clothes and
make regular trips out of the house can help them
to establish a routine with which they become more
confident over time. Patients often become adept
at disguising the bag, either under clothes or in a
particular handbag or shopping bag.
Initially, both the patient and family can feel
anxious about leaving the hospital environment
with a chest drain or stoma in place. This is
overcome by changing to an ambulatory chest
drain bag before discharge and allowing the
patient to familiarise him or herself with the
device. Increased mobility and independence are
incentives to self-management of these devices.
Psychological and practical support is offered by
regular explanations, demonstrations of care and
reassurance regarding self-management.
Long-term management of the chest drain
To meet the psychological and physical needs of
patients with empyema, a specific outpatient clinic
run by clinical nurse specialists was established
within the thoracic outpatients service at Guys
and St Thomas NHS Foundation Trust. The clinic
is held twice per week alongside consultant-led
outpatient clinics. Hospital visits are combined
with telephone contact at home and regular
communication with the consultant surgeon. In
addition, visits by community nursing teams ensure
careful management of these patients. Audit results
(unpublished data) showed that over a two-year
period, 26% of the patients with empyema who
attended the clinic were managed with a long-term
drain or stoma bag.
The patients are cared for over a prolonged
period, allowing good rapport to develop with the
team. Observing or speaking to the individual on
a weekly basis gives nurses the opportunity to see
how patients become confident and empowered
when managing their condition. This provides
evidence of how nursing input, patience and
education can affect an individual during treatment
and recovery. The following recommendations
NURSING STANDARD / RCN PUBLISHING
should to be taken into account when considering
a clinical nurse specialist-led outpatient clinic for
managing patients with empyema:
Explanations may need to be repeated with
regard to the function of and requirement for
the chest drain before the patient and family feel
confident enough to return home with the drain
in situ. Reassurance is required before the patient
is confident to undertake normal activities such
as sleeping and showering.
Patients should be encouraged to mobilise, and
the collection device should be kept below the
level of the chest drain entry site. This promotes
fluid drainage and prevents back-flow into the
pleural cavity. The patient should be warned not
to sit or lie on the tube or bag because this can
obstruct drainage or cause the contents to leak.
The chest drain entry site should be covered with
a small non-adherent dressing and secured with
hypo-allergenic tape. Large quantities of tape
are not required if the suture holding the chest
drain in place (anchor suture) is secure. The
removal of large dressings can be uncomfortable
for patients, especially hirsute men, and large
dressings can restrict chest expansion.
Dressings should be changed daily if possible,
observing for signs of infection, oozing and
surgical emphysema, which is rare. The anchor
suture should also be assessed because it can
erode through the skin, causing the drain to alter
position or fall out.
The collection device should be changed
according to the amount and type of drainage.
A large volume of fluid is heavy for the patient
to carry and can pull on the anchor suture.
The patient should be given a supply of drainage
equipment to allow for changes between
outpatient visits. Family members often become
adept at changing bags and dressings.
Community nursing teams require specific
instructions for the management of the drain
and contact telephone numbers for the ward,
nurse specialist and medical team in the event
that problems arise at the patients home.
The patient should contact his or her medical
team if signs of infection, increased dyspnoea or
surgical emphysema are observed, or if the drain
falls out or becomes blocked.
The selection of clothing can be difficult for
patients, especially for females. Loose tops can
help disguise the drain and the ambulatory bag,
and supportive sports vests or camisoles can be
worn instead of a brassiere. The patient should
be encouraged to experiment with outfits on the
ward before discharge home to determine what
is comfortable and provides confidence.
The drain should not be removed without the
knowledge of the medical or surgical consultant
who recommended insertion.
Conclusion
Empyema is a distressing and uncomfortable
condition, and patients may require long-term use
of an intercostal chest drain, which can be managed
effectively in the community. With the help and
support of the clinical nurse specialist, medical
team and community nurses, many patients with
empyema are able to manage their ambulatory drain
or stoma confidently NS

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