PLEURAL EFFUSION

PGCPN ‘11 - Group 2

WHAT IS PLEURAL EFFUSION?

• Unusual fluid in the lungs

• Build up of excess fluid between the layers of the pleura outside the lungs.

INCIDENCE

It is very common in the Philippines, with approximately 100,000 cases diagnosed each year.

CATEGORIES OF PLEURAL EFFUSION

UNCOMPLICATED COMPLICATEDFluid:

Free of Serious Inflammation or infection

Significant Inflammation or infection

Rarely causes permanent Lung problems

Causes Impaired Breathing.

TRANSUDATIVE EXUDATIVE

Fluid Similar Has excess Protein, blood, and/or evidence of

inflammation and infection.

Drainage Rarely requires drainage unless

very large.

Maybe required depending on its

size and the severity of

inflammation.

Caused by CHF Pneumonia and Lung Cancer

CATEGORIES OF PLEURAL EFFUSION

PATHOPHYSIOLOGY

The pleural space is bordered by the parietal and visceral pleurae.

PARIETAL PLEURA - covers the inner surface of the thoracic cavity, including the mediastinum, diaphragm, and ribs.

VISCERAL PLEURA - envelops all lung surfaces, including the interlobar fissures.

PATHOPHYSIOLOGY

The normal pleural space contains approximately 1 mL of fluid, representing the balance between (1) hydrostatic and oncotic forces in the visceral and parietal pleural vessels and (2) extensive lymphatic drainage.

DISRUPTION OF BALANCE

Pleural Effusion

The etiologic spectrum of pleural effusion is extensive.Most pleural effusions are caused by congestive heart

failure, pneumonia, malignancy, or pulmonary embolism.

an indicator of an underlying

disease process

May be pulmonary

or non-pulmonary

May be acute or chronic

The following mechanisms play a role in the formation of pleural effusion:

Altered permeability of the pleural membranes (eg, inflammation, malignancy, pulmonary embolus)

Reduction in intravascular oncotic pressure (eg, hypoalbuminemia, cirrhosis)

Increased capillary permeability or vascular disruption (eg, trauma, malignancy, inflammation, infection, pulmonary infarction, drug hypersensitivity, uremia, pancreatitis)

Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation (eg, congestive heart failure, superior vena cava syndrome)

Reduction of pressure in the pleural space, preventing full lung expansion (eg, extensive atelectasis, mesothelioma)

Decreased lymphatic drainage or complete blockage, including thoracic duct obstruction or rupture (eg, malignancy, trauma)

Increased peritoneal fluid, with migration across the diaphragm via the lymphatics or structural defect (eg, cirrhosis, peritoneal dialysis)

Movement of fluid from pulmonary edema across the visceral pleura

Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing further fluid accumulation

The following mechanisms play a role in the formation of pleural effusion:

PATHOPHYSIOLOGY – SIGNS / SYMPTOMS

The net result of effusion formation is a flattening or inversion of the diaphragm, mechanical dissociation of the visceral and parietal pleura, and a restrictive ventilatory defect.

Common symptoms associated with pleural effusion may include:

chest pain, difficulty breathing, painful breathing (pleurisy), and cough (either a dry cough or a productive cough).

Deep breathing typically increases the pain. Symptoms of fever, chills, and loss of appetite often accompany pleural effusions caused by infectious agents

DIAGNOSIS – Physical Exam

Physical findings in pleural effusion are variable and depend on the volume of the effusion. Generally, there are no physical findings for effusions smaller than 300 mL. With effusions larger than 300 mL, findings may include the following:

Dullness to percussion, decreased tactile fremitus, and

asymmetrical chest expansion, with diminished or delayed

expansion on the side of the effusion – MOST RELIABLE

FINDINGS

Mediastinal shift away from the effusion - effusions of greater

than 1000 mL

Diminished or inaudible

breath sounds

Egophony - ("e" to "a" changes) at the most superior aspect of the

pleural effusion

Pleural friction rub

Most often, pleural effusions are discovered on imaging tests. Common tests used to identify pleural effusions include:

DIAGNOSIS –CHEST X-RAY

often the first step in identifying a pleural effusion.

Pleural effusions appear on chest X-rays as white space at the base of the lung.

If a pleural effusion is likely, additional X-ray films may be taken while a person lies on her side.

Decubitus X-ray films can show if the fluid flows freely within the chest.

DIAGNOSIS – CT SCAN

Compared to chest X-rays, CT scans produce more detailed information about pleural effusions and other lung abnormalities.

DIAGNOSIS - ULTRASOUND

Ultrasound can help guide drainage and identify whether pleural effusions are free-flowing.

DIAGNOSIS - THORACENTESIS

should be done in almost all patients who have pleural fluid that is ≥ 10 mm in thickness on CT, ultrasonography, or lateral decubitus x-ray and that is new or of uncertain etiology.

In general, the only patients who do not require thoracentesis are those who have heart failure with symmetric pleural effusions and no chest pain or fever; in these patients, diuresis can be tried, and thoracentesis avoided unless effusions persist for ≥ 3 days.

1. Chemical composition including protein, lactate dehydrogenase (LDH), albumin, amylase, pH, and glucose

2. Gram stain and culture to identify possible bacterial infections

3. Cell count and differential

4. Cytopathology to identify cancer cells, but may also identify some infective organisms

5. Other tests as suggested by the clinical situation – lipids, fungal culture, viral culture, specific immunoglobulins

DIAGNOSIS – LIGHT’S CRITERIA

Transudate - produced through pressure filtration without capillary injury

Exudate - "inflammatory fluid" leaking between cells.

Transudative pleural effusions - caused by systemic factors that alter the pleural equilibrium, or Starling forces. The components of the Starling forces–hydrostatic pressure, permeability, oncotic pressure (effective pressure due to the composition of the pleural fluid and blood)–are altered in many diseases, e.g., left ventricular failure, renal failure, hepatic failure, and cirrhosis.

Exudative pleural effusions - caused by alterations in local factors that influence the formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary embolism, and viral infection).

Medical Management:

Antibiotics

Analgesics

Diuretics

Cardiotonic Drugs

Thoracentesis

CTT

Pleurodesis

MEDICAL/SURGICAL MANAGEMENT, DRUGS, AND

TREATMENT

Thoracentesis

aspiration of fluid or air from the pleural cavity.

instillation of medication into the pleural space

MEDICAL/SURGICAL MANAGEMENT, DRUGS, AND

TREATMENT

NURSING MANAGEMENT –Thoracentesis

Verify a signed informed consent Assist client to an appropriate

position Instruct client not to move during

the procedure including no coughing or deep breathing.

Provide comfort Maintain asepsis Monitor vital signs during the

procedure – also monitor pulse oximetry if client is connected to it.

Apply a dressing over a puncture and position the client on the unaffected side. Instruct the client to stay in this position for at least 1 hour.

During the first several hours after thoracentesis frequently assess and document vital signs, oxygen saturation, respiratory status including respiratory excursion, lung sounds, cough and hemoptysis and puncture site for bleeding or crepitus.

Obtain a chest x-ray

NURSING MANAGEMENT –Thoracentesis

Chest Tube Thoracostomy

done to drain fluid, blood and air from the space around the lungs. whether the accumulation is the result of rapid traumatic filling or insidious malignant seepage, placement of a chest tube allows for continuous, large volume drainage until the underlying pathology can be more formally addressed.

MEDICAL/SURGICAL MANAGEMENT, DRUGS, AND

TREATMENT

Ensure a signed consent for chest tube insertion

Position as indicated for the procedure

Assist with chest tube insertion as needed

Assist respiratory status at least every 4 hours.

Maintain a closed system.

Ensure tubing with no kinks or not compressed

Check the water seal frequently.

Palpate the area around the chest tube site for subcutaneous emphysema or crepitus.

Encourage client for coughing and deep breathing

Assist with frequent position changes and sitting and ambulation as allowed

NURSING MANAGEMENT –Closed Tube Thoracostomy

Pleurodesis

also known as Pleural Sclerosis. Involves instilling an irritant into the pleural space to cause inflammatory changes that result in bridging fibrosis between the visceral and parietal pleural surfaces.

MEDICAL/SURGICAL MANAGEMENT, DRUGS, AND

TREATMENT

Ensure informed consent Record baseline vital signs Consider the use of pre medication Position patient comfortably An existing effusion should be completely drained

before the procedure Ensure a recent chest x-ray Observe for excessive pain and breathlessness Patient ambulation is possibly helpful to ensure

good spread of the slurry

NURSING MANAGEMENT –Pleurodesis

THANK YOU!