management of pleural effusion

1. MR.GOPAL ,..MSC (N),
ASSISTANT PROFESSOR
MEDICAL SURGICAL NURSING
GANGA COLLEGE OF NURSING
COIMBATORE

3. CONTENT OVERVIEW
• Introduction
• Anatomy & physiology
• Definition
• Incidence
• Classification
• Pathophysiology
• Symptoms
• Diagnostic evaluation
• Complications
• Management

4. INTRODUCTION
The body produces pleural fluid in small
amounts to lubricate the surfaces of the pleura, it lines
the chest cavity and surrounds the lungs. The pleural
cavity contains a relatively small amount of fluid,
approximately 10 ml on each side.
A pleural effusion is an abnormal, excessive
collection of this fluid . Excessive amount of such fluid
can impair breathing by limiting the expansion of the
lungs during respiration.

5. ANATOMY & PHYSIOLOGY

6. DEFINITION
Pleural effusion, a collection of fluid in the
pleural space is rarely a primary disease process
but is usually secondary to other diseases. It is
resulting from an imbalance in the normal rate of
pleural fluid production or absorption or both.

7. INCIDENCE
• Approximately 2.5 million pleural
effusions are diagnosed in the world wide
each year

10. CLASSIFICATION & CAUSES
Transudative
effusions
Exudative
effusions

11. TRANSUDATIVE PLEURAL EFFUSIONS
a fluid substance that has passed through a
membrane or has been extruded from a tissue it is of
high fluidity and has a low content of protein cells or
solid materials derived from cells. It caused by fluid
leaking into the pleural space.
This is caused by increased pressure in or low
protein content in the blood vessels . A transudate is
a clear fluid similar to blood serum . It reflect a
systemic disturbance of body.

12. CAUSES
• Atelectasis
• (early)Cirrhosis
• Congestive heart failure
• Hypoalbuminemia
• Nephrotic syndrome
• Peritoneal dialysis

13. EXUDATIVE EFFUSIONS
A fluid rich in protein and cellular elements
that oozes out of blood vessels due to inflammation.
It is caused by blocked blood vessels, inflammation,
lung injury and drug reactions.
An exudate—which often is a cloudy fluid,
containing cells and much protein with signifies
underlying local (pleuropulmonary) disease.

14. CAUSES
• Atelectasis
• Hemothorax Infection (bacteria, viruses, fungi,
tuberculosis, or parasites)
• Pulmonary embolism
• Uremia

15. TYPES OF FLUID
Four types of fluids can accumulate in the pleural
space:
Serous fluid (Hydrothorax) :
A hydrothorax is a condition that results from
serous fluid accumulating in the pleural cavity. This
specific condition can be related to cirrhosis with
ascites in which ascitic fluid leaks into the pleural
cavity.
Pus (Pyothorax or empyema) : is an accumulation
of pus in the pleural cavity.

16. • Blood (haemothorax): is a condition that results
from blood accumulating in the pleural cavity.
• Chyle (chylothorax): Chyle is a milky bodily fluid
consisting of lymph and emulsified fats, or free fatty
acids (FFAs).It is a type of pleural effusion . It
results from lymphatic fluid (chyle) accumulating in
the pleural cavity.
TYPES OF FLUIDS

17. PATHOPHYSIOLOGY
(TRANSUDATIVE)
Etiological factors
Increased pressure in pulmonary capillaries
Increased amount of fluid enter the interstitial space
of the lung

18. Increased interstitial pressure in the sub pleural
interstitial space
Fluid moves from the pulmonary interstitial spaces
across the visceral pleura into the pleural space
Pleural effusion
PATHOPHYSIOLOGY
(TRANSUDATIVE)

19. Invasion of microbes
Initiation of inflammatory response
Vasodilation
Increase capillary permiability
PATHOPHYSIOLOGY
(EXUDATIVE)

20. Leakage of plasma protein
Decreased oncotic pressure
Build up of fluid
PATHOPHYSIOLOGY
(EXUDATIVE)

21. SYMPTOMS
• Chest pain
• Dry cough & fever
• Difficulty breathing when lying down
• Difficulty taking deep breaths
• Persistent hiccups
• Difficulty with physical activity

22. DIAGNOSTIC EVALUATION
• History collection
– A history of pneumonia, chest tumor, cardiac,
renal or liver impairment and cancer related
treatment.
• Physical examination
– Decreased or absent breath sounds, decreased
fremitus and a dull, flat sound when percussed.

23. • Imaging test
– Chest x-ray,
– CT-scan thorax
– Ultrasonography thorax:
Even small amounts of
pleural effusion can be
detected accurately by
ultrasonography
DIAGNOSTIC EVALUATION

24. • Laboratory test:
– Thoracentesis
– Pleural biopsy
– Complete blood count
– Pleural fluid cytology
• WBC count & Malignant cells
• Predominant cell type (neutrophil, Lymphocytes ,
Eosinophils, red blood cells)
• Lymphocytosis- If >50% leucocytosis then suspect TB
DIAGNOSTIC EVALUATION

25. COMPLICATION
• Lung scarring,
• Pneumothorax (collapse of the lung) as a
complication of thoracentesis,
• Empyema (a collection of pus within the pleural
space),
• Sepsis (blood infection) sometimes leading to
death.

26. MANAGEMENT
Following community acquired pneumonia:
• Cefuroxime,
• Penicillin,
• Flucloxacillin ,
• Amoxicillin
• Flucloxaxillin
• Clindamycin

27. Hospital acquired pneumonia:
– Broadespectrum antibiotics that cover aerobic
gram negative rods
Tuberculosis- category I treatment:
– Prednisolone orally 4-6weeks promotes rapid
absorption of the pleural Fluid and prevents
fibrosis.
Congestive cardiac failure:
– Treat with diuretics and other anti-failure
medications.

28. • Metastatic pleural effusions
–Chest tube drainage
–Chemotherapy
–Radiation therapy

29. SURGICAL MANAGEMENT
Video-assisted thoracoscopic surgery (VATS)
A minimally-invasive approach that is completed
through 1 to 3 small (approximately ½ -inch) incisions
in the chest. This procedure is effective in managing
pleural effusions that are difficult to drain or recur due
to malignancy. Sterile talc or an antibiotic may be
inserted at the time of surgery to prevent the fluid
build-up.

30. • Thoracotomy ( “open” thoracic surgery)
A thoracotomy is performed through a 6- to 8-
inch incision in the chest and is recommended for
pleural effusions when infection is present. A
thoracotomy is performed to remove all of the fibrous
tissue and aids in evacuating the infection from the
pleural space. Patients will require chest tubes for 2
days to 2 weeks after surgery to continue draining
fluid.
SURGICAL MANAGEMENT

31. • Pleurodesis : Is injects an irritating substance
(such as talc or doxycycline) through a chest tube
into the pleural space. The substance inflames the
pleura and chest wall, which then bind tightly to
each other as they heal.
• Pleural decortication. Surgeons can operate
inside the pleural space, removing potentially
dangerous inflammation and unhealthy tissue.
SURGICAL MANAGEMENT

32. NURSING MANAGEMENT
• Ineffective breathing pattern related to
decreased lung expansion(accumulation of liquid),
as evidenced by dyspnea, changes in depth of
breathing, accessory muscle use
• Acute Pain related to accumulation of fluid in the
pleural space and rubbing of thoracostomy tube to
the lungs

33. • Impaired gas exchange related to ineffective
breathing pattern as evidenced by hypoxia
• Risk for infection related to the presence of fluid
in the pleural space and the incision site.
• Risk for nutrition impairment, less than body
requirement related to inability to ingest adequate
nutrients

34. • Lewis & dirksen, (2015) textbook of medical –
surgical nursing, 2nd South asian edition,
elsevier publication.
• Brunner & suddarth’s, (2014) textbook of
medical – surgical nursing, 13th edition, wolters
kluwer publications.
REFERENCE

35. REFERENCE
• Blok BK. Thoracentesis. In: Roberts JR, Custalow
CB, Thomsen TW, eds. Roberts and Hedges' Clinical
Procedures in Emergency Medicine and Acute Care.
7th ed. Philadelphia, PA: Elsevier; 2019:chap 9.
• Broaddus VC, Light RW. Pleural effusion. In:
Broaddus VC, Mason RJ, Ernst JD, et al, eds. Murray
and Nadel's Textbook of Respiratory Medicine. 6th ed.
Philadelphia, PA: Elsevier Saunders; 2016:chap 79.