Pleural Effusions

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Pleural Effusions

• Kady Rejret RNBSN
• Alverno College MSN-621

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OUTCOMESClick on the topic below you would like
to view

• Describe the pathophysiology of the normal lung
• Describe the pathophysiology of a pleural
  effusion
  
• Describe the main causes of a pleural effusion
• Differentiate among the manifestations of fluid
  collections
  
• Describe the signs and symptoms of a pleural
  effusion
  
• Explain diagnostic methods
• Describe the various treatment options

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Normal lung pleural effusion
Picture used with permission (Allibone 2006
p.56)
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Physiology of the normal lung

• The lungs are soft spongy cone-shaped organs
  located in the chest cavity.
  
• They are separated by the mediastinum and the
  heart.
  
• There are 3 lobes on the right lung and 2 lobes
  on the left lung.

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Pleura

• -serous fluid that allows for the parietal pleura
  (outer lining) and visceral pleura (inner lining)
  to glide over each other without separation
  (Porth 2005 p. 639)
• -contains about 5-15ml of fluid at one time
• -Pleural fluid is produced by the parietal pleura
  and absorbed by the visceral pleura as a
  continuous process. (Drummond Hayes 2001 p.
  32)
• -about 100-200ml of fluid circulates though the
  pleural space within a 24-hour period (Brubacher
  Holmes Gobel 2003)
  
• -has an alkaline pH of about 7.64 (Drummond
  Hayes 2001 p. 33)

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Layers of the lung

• Pleural Space

• thin transparent serous membrane which lines
  the thoracic cavity
  
• a potential space between the parietal pleura
  and visceral pleura
  

Rib Cage
Lung
Picture used with permission Allibone 2006
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Layers of the lung

• Parietal Pleura
• Lines the thoracic cavity including the thoracic
  cage mediastinum and diaphragm
  
• Contains sensory nerve endings that can detect
  pain

Rib Cage
Lung
Picture used with permission Allibone 2006
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Layers of the lung

• Visceral Pleura
• Lines the entire surface of the lung
• Contains NO sensory nerve endings that detect pain

Rib Cage
Lung
Picture used with permission Allibone 2006
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Review question

• Pleuritic chest pain indicates
• inflammation or irritation of the
• parietal pleura or visceral pleura
• (click on the correct answer)

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Think again!

• The visceral pleura contains no
• nerve endings for detecting pain.

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Correct!

• The parietal pleura contains sensory nerve
  endings that
  
• can detect pain.

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Review question

• The pleural space typically contains how much
  fluid
  
• 5-15ml
• 50-100ml
• 100-200ml

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Think again!

• about 100-200ml of fluid circulates though the
  pleural space within a 24-hour period
  

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Correct!

• 5-15ml of fluid are present at one time
• The pleural space is a potential space between
  the parietal pleura and visceral pleura allowing
  them to glide over each other without separation

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The normal lung

• The lungs are supplied with blood via the
  pulmonary and bronchial circulations.
  
• Pulmonary circulation supplied from the
  pulmonary artery and provides for gas exchange
  function of the lungs.
  
• Bronchial circulation distributes blood to the
  conducting airways and supporting structures of
  the lung.

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The normal lung

• Intrapulmonary pressure
• -the pressure within the alveoli
  -as the chest expands on
  inspiration the intrapulmonary pressure becomes
  more negative which causes air to be sucked into
  the lungs.
• (Allibone 2006 p. 56)

• Intrapleural pressure
• -Negative pressure is created in the pleural
  space as the thoracic cage enlarges and the lungs
  recoil during normal inspiration
  -negative pressure may be lost if fluid
  collects in the pleural space making the lung
  unable to expand fully.
• (Allibone 2006 p. 56)

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The normal lung

• cells within the pleura are primarily mesothelial
  cells that line the surfaces of the pleural
  membranes and some white blood cells (WBC).
  
• The visceral pleura absorbs fluid which then
  drains into the lymphatic system and returns to
  the blood
  
• Protein in the circulation and balanced pressures
  keep excessive amounts of fluid from seeping out
  of the blood vessels into the pleural space
  
• (Pumonary Channel 2007)

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Lets review
Click on the words below to send them to their
correct position within the diagram.
Rib cage
Lung
Pleural Space
Visceral Pleura
Parietal Pleura
Picture used with permission Allibone 2006
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Lets review

• Fluid is absorbed by the
• Parietal Pleura
• Pleural Space
• Visceral Pleura

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Think Again - - -

• Pleural fluid is produced by the parietal pleura
• The pleural space is a potential space between
  the parietal pleura and visceral pleura
  
• Negative pressure is created in the pleural space

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C o r r e c t ! ! !

• Pleural fluid is produced by the parietal pleura
  and absorbed by the visceral pleura as a
  continuous process.
  
• The visceral pleura absorbs fluid which then
  drains into the lymphatic system and returns to
  the blood

23
OUTCOMESClick on the topic below you would like
to view

• Describe the pathophysiology of the normal lung
• Describe the pathophysiology of a pleural
  effusion
  
• Describe the main causes of a pleural effusion
• Differentiate among the manifestations of fluid
  collections
  
• Describe the signs and symptoms of a pleural
  effusion
  
• Explain diagnostic methods
• Describe the various treatment options

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Pleural effusion

• Created by an abnormal collection of fluid in the
  pleural space
  
• Seen in chest X-ray with presence of about 200ml
  pleural fluid
  
• Fluid in X-ray seen as a dense white shadow with
  a concave upper edge (fluid level)
  
• (Allibone 2006)

Click on the pleural effusion in the picture!
Used with permission (Allibone 2006 p. 59)
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Pleural Effusion

• Fluid accumulates in the pleural space by three
  mechanisms
  
• -increased drainage of fluid into the space
• -increased production of fluid by cells in the
  space
  
• -decreased drainage of fluid from the space
• (pulmonary channel 2007)

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Pleural Effusion

• The build-up of fluid presses on the lung making
  it difficult for the lung to expand fully.
  
• Part or all of the lung may then collapse
• (National Cancer Institute 2007)

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Pleural Effusion

• Your lungs contain millions of small elastic
• air sacs called alveoli
• Normally with each breath the air sacs take in
  oxygen and release carbon dioxide
  
• Sometimes increased pressure in the blood vessels
  in your lungs forces fluid into the air sacs
  filling them with fluid and preventing absorption
  of oxygen.
• (Mayo Foundation for Medical Education and
  Research 2006)

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Pleural Effusions

• Malignancy accounts for about 40 of symptomatic
  pleural effusions with congestive heart failure
  and infection being the other leading causes
  
• (National Cancer Institute 2006)

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Fluid collection in both lower lobes of the lungs
due to CHF
Picture used with permission (Allibone 2006 p.
59)
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Main causes of a Pleural Effusion

• Congestive Heart Failure (CHF)
• Liver failure
• Infection
• Atelectasis
• Cancer
• Trauma

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Congestive Heart FailureCHF

• As the heart fails pressure in the vein going
  through the lungs starts to rise.
  
• Due to the hearts inability to move blood from
  the pulmonary circulation into the arterial side
  of systemic circulation there is a decrease in
  cardiac output an increase in left atrial and
  ventricular end-diastolic pressures and
  congestion in the pulmonary circulation.
• As the pressure increases fluid is pushed into
  the air spaces (alveoli)
  
• This fluid then leaks from the alveoli into the
  pleural space
  
• This fluid creates a pleural effusion and
  interrupts normal oxygen movement through the
  lungs resulting in shortness of breath
  

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CHF

• CHF is the most common cause of pleural effusion.
  
  
• Frequently the effusions are bilateral
  (approximately 75 of the time) but may occur
  alone on either side with the right side being
  more common.
• Fluid is usually straw colored with low white
  blood cell counts (mononuclear cell predominance.
  
• With severe congestive heart failure fluid may
  persist in spite of vigorous diuresis.
  
• (National Lung Health Education Program 2000)

Back
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Liver Failure

• Negative intrapleural pressure may lead to a
  transudative effusion due to peritoneal fluid
  from ascites moving across the diaphragm into the
  chest
• (Current Therapy 2001 p. 208)

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Infection

• Pneumonia
• -inflammation of the lung structures
  specifically the alveoli and bronchioles
  
• WBCs accumulate in response to infection and
  inflammation leading to empyema
  

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Atelectasis

• Atelectasis is an incomplete expansion of the
  lung which leads to collapse of the alveoli
  
• Increased negative intrapleural pressure can lead
  to the collection of fluid in the portion of the
  lung which is not expanding
  
• This can cause an effusion by fluid leaking out
  of the lung and into the chest cavity
  
• Atelectasis typically leads to small pleural
  effusions not requiring surgical intervention

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Cancer

• Impaired lymphatic drainage of the pleural space
  due to obstruction by a tumor
  
• Typically due to the interference with the
  visceral pleura (which absorbs pleural fluid)
  
• A tumor can obstruct pulmonary veins preventing
  fluid from being reabsorbed into the bloodstream
  
• A tumor can perforate the thoracic duct
• Shedding of malignant cells into the pleural
  space decreasing reabsorption of pleural fluid
  back into the lymphatic system (Brubacher
  Holmes Gobel 2003 p. 1)

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Trauma

• Increased capillary permeability as a result of
  inflammation
  
• Fluid (most often blood) may collect in the lung
  cavity as a result of trauma to the lung

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Pleural fluid types

• Transudate
• Exudate
• Empyema
• Chyle
• Hemothorax

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Transudate

• Clear pale yellow watery substance
• Influenced by systemic factors that alter the
  formation or absorption of fluid
  
• Increase in hydrostatic pressure
• Decrease in plasma oncotic pressure
• Contains few protein cells
• Common causes CHF and liver or kidney disease

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Exudate

• Pale yellow and cloudy substance
• Influenced by local factors where fluid
  absorption is altered (inflammation infection
  cancer)
  
• Rich in protein (serum protein greater than 0.5)
• Ratio of pleural fluid LDH and serum LDH is 0.6
• Pleural fluid LDH is more the two-thirds normal
  upper limit for serum
  
• Rich in white blood cells and immune cells
• Always has a low pH
• Common causes pneumonia cancer and trauma

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Empyema

• Pus
• Yellow cloudy and foul odor
• Most likely due to pneumonia lung abscess
  infected chest wounds
  
• Has a pH 7.2
• (Drummond Hayes 2001 p. 33)

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Chyle

• Milky fluid
• Consists of lymph and fat
• Chyle leaks from the thoracic duct
• -due to lymphatic obstruction (tumor) or
  trauma
  
• High triglyceride levels found in fluid analysis

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Hemothorax

• Blood
• Usually results from chest injury
• A blood vessel ruptures into the pleural space or
  a bulging area into the aorta (aortic aneurysm)
  leaks blood into the pleural space
  
• Can occur as a result of bleeding from the ribs
  chest wall pleura and the lung

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Lets review

• Which is NOT a type of fluid that may cause a
  pleural effusion
  
• -empyema
• -chylothorax
• -pneumothorax
• -hemothorax

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This is a fluid that may cause a Pleural Effusion

• Empyema (pus) Chylothorax (chyle) and
  hemothorax (blood) are all fluids that may result
  in a pleural effusion.

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Correct this is not a fluid!

• Pneumothorax is a collection of air in the
  pleural cavity.

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Signs and symptoms

• Dyspnea
• Cough usually non-productive
• Pleuritic chest pain
• Chest pressure
• Hypoxemia
• Decreased breath sounds on the affected side
• Some people may exhibit no symptoms!

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Diagnosis

• Chest radiograph (x-ray)
• -able to distinguish 200ml of fluid
• Chest ultrasound
• -locates small amounts or isolated loculated
  pockets of fluid
  
• -able to give precise position of accumulation
• Computed Tomography (CT) scan
• -Differentiates between fluid collection lung
  abcess or tumor

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Diagnosis

• Fluid analysis confirms a pleural effusion
• Normal pleural fluid has the following
  characteristics
  
• clear ultrafiltrate of plasma
• pH 7.60-7.64
• protein content less than 2 (1-2 g/dL)
• fewer than 1000 WBCs per cubic millimeter
• glucose content similar to that of plasma
• lactate dehydrogenase (LDH) level less than 50
  of plasma and sodium
  
• potassium and calcium concentration similar to
  that of the interstitial fluid
  
• (Abrahamian 2005 p. 2 of 28)

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Non-surgical Treatment Options

• Thoracentesis
• tPA
• Chemical Pleurodesis
• Pleurx catheter

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Thoracentesis

• A needle is inserted into the chest wall to
  remove the collection of fluid
  
• 50-100ml of fluid is sent for analysis
• Determines the type of fluid (transudate or
  exudate)
  

Picture used with permission (Allibone 2006 p.
60)
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Thoracentesis

• Not a permanent solution fluid may reaccumulate
  after a few days
  
• Will temporarily relieve symptoms
• Potential complications include bleeding
  infection and pneumothorax

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tPA (alteplase)

• Thrombolytic enzyme
• Converts plasminogen to the enzyme plasmin which
  degrades fibrin clots
  
• Lyses thrombi and emboli
• May be administered into the chest tube catheter
  to restore patency and improve drainage
  
• The patient is instructed to move positions
  frequently to distribute the medication
  throughout the lung
  

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Chemical Pleurodesis

• Sclerosing agents used Talc bleomycin or
  doxycyline
  
• Administered through a chest tube to create
  inflammation and subsequent fusion of the
  parietal and visceral pleura
  
• Fluid is then unable to accumulate in this
  potential space

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Chemical Pleurodesis

• The goal of chemical pleurodesis is to cause an
  irritation between the two layers covering the
  lung.
  
• The sclerosant irritates the pleurae which
  results in inflammation and causes the pleurae to
  stick together.
  
• The procedure can be done at the bedside or in
  the operating room.
  
• Do not administer with any anti-inflammatory
  agents

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Pleurx Catheter

• Small flexible tube inserted into the chest to
  drain fluid from around the lungs
  
• Contains a one-way valve that prevents air from
  entering and fluid from leaking out when capped
  
• Allows for intermittent home drainage using a
  vacuum bottle

Picture used with permission from Denver
Biomedical
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Pleurx Catheter
In chest wall where fluid is accumulating
Picture used with permission from Denver
Biomedical
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Pleurx Catheters

• Catheters are typically drained every one to two
  days
  
• Keeping the lung fairly free of fluid will most
  likely permanently stop the fluid from building
  up so that the catheter can be removed.
  
• The catheter may remain until fluid quits
  draining from the lung
  
• The length of time a catheter will remain varies
  from patient to patient ranging from a few weeks
  to several months.

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Pleurx Catheter

• Beneficial for patients who are independent and
  able to perform self drainage
  
• Minimizes the time spent in the hospital
• Patients are instructed to drain up to 1000ml of
  fluid at one time
  
• Patients are instructed to call MD if drainage is
  
• Patients are able to wear usual clothing and
  continue usual activities

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Pleurx Catheter
Cap

• Easy to connect vacuum container
• Some patients experience pain upon drainage
  slowing the drainage with the clamp or stopping
  briefly may relieve this pain
  

Photos by Kady Rejret 2007
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Pleurx
Photo by Kady Rejret 2007
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Pleurx Catheter Benefits

• Reduces hospital length of stay
• Reduces costs
• Improves quality of life
• 46 pleurodesis in 29 days (median)
• Provides effective palliation of symptoms of
  pleural effusions
  
• Often implanted on an outpatient basis
• May be used with most trapped lung patients
• Minimizes pain
• Placed under local anesthetic
• (Denver Biomedical 2004)

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Pleurx Catheter

• Click on the link below
• for more information
• http//www.denverbiomedical.com
• Used with permission from Denver Biomedical

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Lets review
Which treatment option requires NO use of
anti-inflammatories (click on the correct answer
)

• Thoracentesis
• tPA
• Chemical Pleurodesis
• Pleurx Catheter

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Think again!


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Good Job!

• Chemical Pleurodesis
• This creates inflammation and subsequent fusion
  of the parietal and visceral pleura
  
• Anti-inflammatories will counteract this
  reaction.
  

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Congratulations!
Kady Rejret RN BSN

• You have successfully completely this tutorial!

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References

• Allibone L. (2006). Assessment and management
  of patients with pleural effusions. Nursing
  Standard vol20 no22 55-64
  
• Abrahamian F. M. (2005). Pleural Effusion.
  Retrieved March 22 2007 from http//www.emedicine
  .com
  
• Brubacher S. Holmes Gobel B. (2003). Use of
  the pleurx pleural catheter for the management of
  malignant pleural effusions. Clinical Journal of
  Oncology Nursing 7 (1) 1-4
• Denver Biomedical. (2004). Retrieved March 25
  2007 from http//www.denverbiomedical.com
  
• Drummond Hayes D. (2001). Stemming the tide of
  pleural effusions. Nursing Management 32(12)
  29-35
  
• Mayo Foundation for Medical Education and
  Research. (2006). Retrieved April 11 2007 from
  http//www.mayoclinic.com/health
  
• National Cancer Institute. (2006). Retrieved
  March 23 2007 from http//www.cancer.gov
  
• National Lung Health Education Program. (2000).
  Retrieved April 11 2007 from www.nlhep.org
  
• PorthC.M. (2005). Pathophysiology Concepts of
  Altered Health States (7th ed.) Lippincott.
  
• Rejret K. (2007). Personal Photograph.
• Unattributed clipart Microsoft Office 2006.