Empyema is an accumulation of thick, purulent fluid within the pleural space. At first, the pleural fluid is thin, with a low leukocyte count, but it frequently progresses to a fibropurulent stage and then to a stage where it encloses the lung within a thick exudative membrane (loculated empyema).

• The patient is acutely ill with signs and symptoms similar to those of an acute respiratory infection or pneumonia (e.g., fever, night sweats, pleural pain, cough, dyspnea, anorexia, weight loss).
• Symptoms may be vague if the patient is immunocompromised.
• Symptoms may be less obvious if the patient has received antimicrobial therapy.

• Chest auscultation demonstrates decreased or absent breath sounds over the affected area, dullness on chest percussion, or decreased fremitus.
• Conduct chest computed tomography (CT) and thoracentesis (under ultrasound guidance).

The objectives of treatment are to drain the pleural cavity and to achieve complete expansion of the lung. The fluid is drained, and appropriate antibiotics (usually IV) for 4 to 6 weeks, in large doses, are prescribed on the basis of the causative organism. Drainage of the pleural fluid depends on the stage of the disease and is accomplished by one of the following methods:

• Needle aspiration (thoracentesis) if volume is small and fluid is not too thick
• Tube thoracostomy with fibrinolytic agents instilled through chest tube when indicated
• Open-chest drainage via thoracotomy to remove thickened pleura, pus, and debris and to remove the underlying diseased pulmonary tissue
• Decortication (surgical removal) of exudate if inflammation has been long-standing
• Drainage tube possibly remaining for weeks to months
• Monitoring of drainage and serial chest x-rays

• Provide care specific to method of pleural fluid drainage.
• Help patient cope with condition; instruct in lung-expanding breathing exercises to restore normal respiratory function.
• Instruct patient and family about care of drainage system and drain site; measure and observe drainage.
• Educate patient and family in signs and symptoms of infection and how and when to contact the health care provider.

For more information, see Chapter 23 in Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth's textbook of medical-surgical nursing (14th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.