1. PLEURAL EFFUSION
THE JUICE, OOZING FROM THE LEAKING
LINGERIE OF LUNGS
DR.RISHIKESAN K.V MD,DNB,
SPECIALIST PHYSICIAN,
VENNIYIL MEDICAL CENTRE,
SHARJAH

2. DEFINITION
•Pleural effusion is an abnormal collection
of fluid in the pleural space resulting from
excess fluid production or decreased absorption
or both.
•It is the most common manifestation of pleural
disease.
•Etiologies range from cardiopulmonary
disorders to symptomatic inflammatory or
malignant diseases.

3. BASICS
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
inter lobar fissures.

4. BASIC ANATOMY
• Parietal Pleura Covers the
inner surface of chest wall
• Blood supply: intercostal
arteries
• Lymphatics drain the pleural
space
• Pain fibers are present from
intercostal nerves
• Mesothelial cells are
immunoreactive
• 5 to 15 mL fluid present in
space
• Normally high fluid flux 1Liter
/day
• Venous drainage : the superior
vena cava
• Visceral Pleura
Envelops entire surface of
both lungs
• The two pleural cavities
are separate
• Composed of
mesothelial cells
• Artery Supply: bronchial
arteries
• Lymphatics drain the
pulmonary parenchyma
• No nerve fibers
• The venous drainage is
pulmonary vein
Both linings subject to disease and disorders

5. PLEURA : VISCERAL AND PARIETAL

6. BASICS ……
The pleural space plays an important role in respiration
by coupling the movement of the chest wall with that of
the lungs in 2 ways.
First, a relative vacuum in the space keeps the
visceral and parietal pleurae in close proximity.
Second, the small volume of pleural fluid, which has
been calculated at 0.13 mL/kg of body weight under
normal circumstances, serves as a lubricant to
facilitate movement of the pleural surfaces against each
other in the course of respirations

7. 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

8. PLEURAL EFFUSION
•Fluid in pleural space > 20 mL
• Two mechanisms
• Excessive formation
• Fluid resorption is disturbed
• Etiology
• 40% cardiac causes
• 60% other
• Pneumonia (48%)
• Malignancy(24%)
• Pulmonary embolism (18%)
• Cirrhosis (6%)

9. 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

10. PATHOPHYSIOLOGY : MECHANISM
# Altered permeability of the pleural
membranes ( inflammation, malignancy, pulmonary
embolus)
# Reduction in intravascular oncotic
pressure
(hypo albuminemia, cirrhosis)
# Increased capillary permeability or vascular
disruption ( trauma, malignancy, inflammation, infection, pulmonary
infarction, drug hypersensitivity, uremia, pancreatitis , infection, )
# Increased capillary hydrostatic pressure in the
systemic and/or pulmonary circulation (congestive heart
failure, superior vena cava syndrome)

11. # Reduction of pressure in the pleural space, preventing full lung
expansion (extensive atelectasis, mesothelioma)
# Decreased lymphatic drainage or complete blockage,
including thoracic duct obstruction or rupture (malignancy,
trauma)
# Increased peritoneal fluid, with migration across the diaphragm
via the lymphatics or structural defect (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 MECHANISMS…….

12. SIGNS AND SYMPTOMS
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

13. DIAGNOSIS – PHYSICAL EXAM
PHY.EX. in pleural
effusion are
variable and
depend on the
volume of the
effusion.
Generally,
there are no
physical findings
for effusions <300
mL. With effusions
>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

14. DIAGNOSISCXR: Often the first step
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 his side.
Decubitus X-ray films can show if the fluid flows freely
within the chest.
Layering of an effusion on lateral decubitus
films defines a freely flowing effusion .
Effusions of more than 175 mL are
usually apparent as blunting of the
costophrenic angle on upright
posteroanterior chest radiographs.

15. CHEST X RAY
On supine CXRs, which are commonly used in the
intensive care setting, moderate to large pleural
effusions may appear as a homogenous increase
in density spread over the lower lung fields.
Apparent elevation of the hemidiaphragm,
lateral displacement of the dome of the
diaphragm, or
increased distance between the apparent left
hemidiaphragm and the gastric air bubble
suggests subpulmonic effusions

16. LEARNING POINTS
Most often, pleural effusions are discovered on
imaging tests. Common tests used to identify
pleural effusions include: CHEST X RAY

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

18. CT BILATERAL PLEURAL EFFUSIONS

19. LEARNING POINTS
Chest CT scanning with contrast should be performed in all
patients with an undiagnosed pleural effusion, to detect
Thickened pleura or
signs of invasion of underlying or adjacent
structures.
The two diagnostic imperatives in this situation are
pulmonary embolism and tuberculous pleurisy
In both cases, the pleural effusion is a harbinger of potential
future morbidity.
CT angiography should be ordered if pulmonary embolism is
strongly suggested.

20. DIAGNOSIS - ULTRASOUND
Ultrasound can help guide
drainage; identify whether pleural
effusions are free flowing.
USS can aid in the differentiation
of transudates from exudates:
those with septated and
homogenously echogenic
patterns are always exudates,
whereas hypoechoeic effusions
may be either

21. •Should thoracentesis be
performed?
•If thoracentesis is done
•Is the fluid a transudate
or exudate?
•If the fluid is an exudate
•What is the etiology?
Pleural Effusion Confirmed

22. DIAGNOSTIC ALGORITHM
WHEN PLEURAL EFFUSION IS
DETECTED TWO QUESTIONS NEED
TO BE ANSWERED
IS IT A TRANSUDATE ( DUE TO
SYSTEMIC DISEASES) OR AN
EXUDATE ( DUE TO DISEASE OF
PLEURA ITSELF)?
IF THE EFFUSION IS EXUDATE WHAT
IS THE DISEASE RESPONSIBLE FOR IT?
EXAMINING THE PLEURAL FLUID
MAY GIVE AN ANSWER TO THESE
QUESTIONS
NEARLY EVERY PATIENT WITH
PLEURAL EFFUSION SHOULD HAVE A
DIAGNOSTIC THORACENTESIS

23. 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.

24. LEARNING BITES : THORACENTESIS
•Most patients should be tapped
• Newly recognized effusion
• Two exceptions
• Small Effusions ( < 1 cm on decubitus, US )
• Congestive Heart Failure
• Thoracentesis required only if bilateral
effusions not equal ie ASYMMETRICAL EFFUSION
• Fever
• Pleuritic chest pain
• Impending respiratory failure

25. ANALYSIS GROSS APPEARANCE
GROSS
• BLOODY
• WHITE MILKY
• BLACK
• YELLOW GREEN
• DARK GREEN
• ANCHOVY SAUCE PASTE
• PUS (FETID ODOUR)
• CLEAR
• AMBER COLOR (SMELL OF URINE)
DIAGNOSIS
• MALIGNANCY,ASBESTOSIS,PUL.INFARCT
-ION,POST CARD.SURGERY SYNDROME
• CHYLOTHORAX,PSEUDOCHYLOTHORAX
• ASPERGILLUS NIGER
• RA PLEURISY: TEST GLUCOSE
• BILOTHORAX
• AMOEBIC LIVER ABSCESS
• EMPYEMA
• CENTRAL LINE
• URINOTHORAX :CHECK UREA AND
CREATINE OF THE PLEURAL FLUID

26. PLEURAL FLUID ANALYSIS
• Divide the fluid and routinely undertake the following:
• Send one sterile pot and a fluoride tube (for glucose
measurement) to biochemistry for protein, lactate
dehydrogenase, and glucose
• Send an EDTA vial for a differential white cell count either to
cytology or haematology, depending on the local hospital policy
• Send a sterile pot of fluid to microbiology if you suspect pleural
infection
• If malignancy is a possibility, send a sterile sample for cytology
• You should measure the pH of pleural fluid whenever you suspect
pleural infection

27. CELLS AND DIFFERENTIAL COUNTS
• Volume 0.2 mL/kg
• Cells/ mm3 1000 – 5000
• Mesothelial cells 60%
• Monocytes 30%
•Lymphocytes 5%
• PMN’s 5%
• Protein 1-2 g/d L
• LDH <50% plasma level
• Glucose  plasma level
• pH ≥ plasma level
Cell Count:
PMN predominates in
parapneumonic effusions.
Pleural fluid lymphocytosis,
with values >85% , suggests
TB, CABG, lymphoma,
sarcoidosis, chronic RA
pleurisy, yellow nail
syndrome, and
chylothorax.

28. PLEURAL FLUID EOSINOPHILIA
Pleural fluid eosinophilia (PFE), with values greater than 10% of
nucleated cells, is seen in approximately 10% of effusions.
No correlation with peripheral blood eosinophilia.
PFE is most often caused by air or blood in the pleural
space.
PFE may be the result of pulmonary embolism with
infarction or benign asbestos pleural effusion.
PFE may be associated with CSS, nonmalignant diseases,
including parasitic disease , fungal infection and a
variety of medications.

29. LEARNING BITES
The presence of PFE makes tuberculous
pleurisy as well as empyema unlikely.
Mesothelial cells > 5% of total nucleated
cells makes a diagnosis of TB less likely.
Markedly increased numbers of
mesothelial cells, suggests PE as the
cause of effusion.

30. You see a 68 year old man in clinic who has a three
week history of increasing breathlessness. His chest x ray
shows a large left pleural effusion. You perform a
diagnostic pleural aspiration. The pleural fluid analysis
shows:
Protein 50 g/l
Lactate dehydrogenase (LDH) 457 (blood LDH 124)
Glucose 3.8 (blood glucose 4.8)
pH 7.32.
Which of the following statements is correct?
The fluid is an exudate
A pleural fluid protein of 50 g/l is
consistent with an exudative effusion.

31. Classically, if the patient's serum protein is
normal, a pleural fluid protein less than 30 g/l
usually indicates a transudate and a pleural
fluid protein greater than 30 g/l
usually indicates an exudate. Light's
criteria allow a more accurate differentiation
and should be the practical standard. In
practice, the criteria are often used if the
pleural fluid protein is between 25 and 35 g/l.

33. LIGHT’S CRITERIA
DIFFERENTIATES TRANSUDATES FROM EXUDATES
IF ATLEAST ONE OF THE FOLLOWING IS MET, THEN
EXUDATE
TRANSUDATIVE PLEURAL EFFUSION MEETS NONE
PLEURAL FLUID PROTEIN/SERUM PROTEIN >.5
PLEURAL FLUID LDH/ SERUM LDH >.6
PLEURAL FLUID LDH > 2/3 THE UPPER LIMITS OF
SERUM LDH

34. SERUM PLEURAL FLUID PROTEIN GRADIENT

35. TRANSUDATIVE EXUDATIVE EFFUSION
• Congestive Heart Failure.
The most common cause
of pleural effusion is LVF
• Nephrotic syndrome
• Cirrhosis
• Meig’s Syndrome
• Hydronephrosis
• Peritoneal Dialysis
• Para pneumonic (The most
common exudative pleural effusion)
• Malignancy
• Pulmonary Embolism (either
transudate or exudate)
• Tuberculosis
• Traumatic
• Collagen Vascular
Disease(SLE,RA…)
• Drug Induced, Uraemia,
Dressler’s Syndrome…….

36. DIAGNOSIS
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
Exudative pleural effusions - caused by alterations in local
factors that influence the formation and absorption of
pleural fluid

37. LDHPROTEIN
• MOST TRANSUDATES HAVE A
TOTAL PROTEIN OF <3
GM/DL
• TB PLEURAL EFFUSION
GRATER THAN 4GM/DL
• IF THE PROTEIN
CONCENTRATION IS > 7-8
GM/DL, CONSIDER THE
DIAGNOSIS OF
WALDENSTROMS
MACROGLUBULINAEMIA OR
MULTIPLE MYELOMA
LDH
• ONE OF THE KEY CRITERIA FOR
LIGHT’S CRITERIA
• LDH MORE THAN 1000,
COMMONLY SEEN IN Empyema,
Rheumatoid pleurisy and
Malignancy
Pneumocystis jirovecci
PLEURAL EFFUSION
PLEURAL FLUID LDH/ SERUM LDH :
>1
PLEURAL FLUID PROTEIN/SERUM
PROTEIN : < .5

38. PLEURAL FLUID GLUCOSE
• A LOW PLEURAL FLUID GLUCOSE CONCENTRATION <30-50
MG/DL OR PLEURAL FLUID/SERUM GLUCOSE <.5 NARROWS
THE DIFFERENTIAL
CAUSES:
• Malignant effusion,
• Tuberculous pleuritis,
• Esophageal rupture, or
• Lupus pleuritis.
A very low pleural glucose concentration (i.e.< 30 mg/d L)
further restricts diagnostic possibilities, to rheumatoid
pleurisy or empyema

39. PLEURAL FLUID PH
• Pleural fluid pH is highly correlated with pleural fluid glucose levels
• A pleural fluid pH of less than 7.30 with a normal arterial blood pH level
is caused by the same diagnoses as listed above for low pleural fluid
glucose.
• In parapneumonic effusions a pleural fluid pH of less than
7.1-7.2 indicates the need for urgent drainage of the effusion,
while a pleural fluid pH of more than 7.3 suggests that the
effusion may be managed with systemic antibiotics alone.
• In malignant effusions, a pleural fluid pH of less than 7.3
has been associated in some reports with more extensive
pleural involvement, higher yield on cytology, decreased
success of pleurodesis, and shorter survival times < 30
days

40. PLEURAL FLUID AMYLASE
•PLEURAL FLUID AMYLASE MORE THAN ULN FOR
SERUM AMYLASE
•PLEURAL FLUID AMYLASE/SERUM AMYLASE > 1
DIFFERENTIALS
• CHRONIC PANCREATIC PLEURAL EFFUSION
• ESOPHAGEAL RUPTURE
• ACUTE PANCREATITIS
• MALIGNANCY

41. ADENOSINE DEAMINASE
• High levels of ADA are
commonly seen in tuberculous
effusions, but false positives
(especially with empyema,
rheumatoid effusions, and
lymphomas) do occur.
• Routine measurement of ADA is
not encouraged in non-
endemic areas such as the UK.
In endemic areas,
however, a low
pleural fluid ADA
effectively excludes
pleural tuberculosis.
SINCE LESS THAN 40% OF TB PLEURAL EFFUSION
HAVE POSITIVE PLEURAL FLUID CULTURE
ALTERNATIVE MEANS SUCH AS THE LEVEL OF
ADA, GAMMA INTERFERON OR PCR ARE USED
TO ESTABLISH THE DIAGNOSIS

42. OTHER USEFUL TESTS
•Brain Natriuretric Peptide Normal <1000 p g/mL ; >1000 in
CHF
•Triglycerides > 110 mg/d L
• Chylothorax
•Microbiology (bacterial and mycobacterial culture)
If clinically indicated, send samples for Gram staining and
culture. Inoculation of blood culture bottles may improve
yield.
•Cytology
Request cytology if you suspect malignancy - it provides the
diagnosis in 60% of all malignant effusions.
The diagnostic yield increases with a second sample, but not
with further samples

43. IS IT WORTH DOING ?
Tumour markers
• There is no routine clinical role for these at present.
Rheumatoid factor, antinuclear antibody, complement
• Pleural fluid values mirror serum levels and are of little
additional benefit.
Bronchoscopy
• The majority of pleural effusions seen in clinical practice
are not associated with a lung parenchymal abnormality
as the cause. Bronchoscopy is therefore only advised
if the patient has symptoms such as haemoptysis or
CT features suggesting endobronchial involvement.

44. PARAPNEUMONIC EFFUSION
• ANY PLEURAL EFFUSION ASSOCIATED WITH BACTERIAL
PNEUMONIA, LUNG ABSCESS , OR BRONCHIECTASIS
• GRAM STAIN AND BACTERIAL CULTURE WILL IDENTIFY
INFECTED PLEURAL FLUIDS
• EFFECTIVE ANTIBIOTIC THERAPY IS THE KEY ISSUE FOR
CONTROLLING INFECTION
WHEN PLEURAL FLUID ANALYSIS MEETS ANY OF THE FOLLOWING
CRITERIA ICTD SHOULD BE DONE IMMEDIATELY
1.EMPYEMA
2.PLEURAL FLUID CULTURE IS POSITIVE
3.PLEURAL FLUID GLUCOSE IS LESS THAN 40 MG%
4.PLEURAL FLUID P H <7.0

45. TUBERCULOUS PLEURAL EFFUSION
• MOST PATIENTS PRESENT WITH PLEURITC CHEST PAIN
• TUBERCULOSIS TOXIC SYNDROME : DRY COUGH,LOW
GRADE FEVER, NIGHT SWEAT AND LOSS OF WEIGHT.
• POSITIVE TUBERCULIN- PPD- TEST, SIGNIFICANTLY HIGH ADA LEVEL IN
PLEURAL FLUID (ADA ACTIVITY OF > 43 U/ML)
• EXUDATIVE EFFUSION WITH MARKEDLY ELEVATED PROTEIN LEVEL >50
GM/L.
• IFN GAMMA CONCENTRATION >140 p g/ml SUPPORT THE DIAGNOSIS
• DIFFERENTIAL WHITE CELL COUNT SHOWS > 80% LYMPHOCYTES.
• PLEURAL BIOPSY HAS GOT THE GRATEST UTILITY IN ESTABLISHING THE
DIAGNOSIS.
• DEMONSTRATION OF CASEATING GRANULOMA AS WELL AS ACID FAST
BACILLI AS THE CONFIRMATORY PROOF

46. WHY DO WE TREAT TB EFFUSION?
Tuberculous pleuritis is typically self-
limited. If not treated the effusion will resolve but
pulmonary or extra pulmonary tuberculosis
subsequently develops in >65% of patients within
five years.
Empiric ATT is the option, pending culture results
when sufficient clinical suspicion is present, such
as an unexplained exudative or lymphocytic
effusion in a patient with a positive PPD finding

47. MANAGEMENT OF TUBERCULOUS PLEURAL
EFFUSION
• ATT : ADEQUATE THERAPY IS NINE MONTHS TREATMENT
WITH RIFAMPICIN AND INH DAILY
• PERFORMANCE OF THERAPEUTIC THORACENTESIS IS
HIGHLY RECOMMENDED
• HIGHLY SYMPTOMATIC PATIENTS SHOLUD BE PUT ON
PEDNISOLONE 40MG.DAILY AND THEN GRADUALLY
TAPERED OVER SEVERAL WEEKS
• THE ADMINISTRATION OF CORTICOSTEROIDS WILL RAPIDLY
RELEIVE THE SYMPTOMS OF FEVER,CHEST PAIN AND
MALAISE.
• IT DOESN’T DISSEMINATE THE DISEASE

48. DRESSLER’S SYNDROME
• POST CARDIAC INJURY SYNDROMES .
•POST CABG EFFUSIONS ARE COMMON.
• EXAGGERATED IMMUNE RESPONSE TO CARDIACANTIGENS
•PLEURITIC CHEST PAIN ,FEVER,HIGH ESR,
LEUCOCYTOSIS, ANTI MYOCARDIAL ANTIBODIES.
• PMN LEUCOCYTOSIS <30 DAYS;LATER LYMPHOCYTOSIS
•NSAIDS AND STEROIDS AS TREATMENT
• 1-12 MONTHS AFTER SURGERY, AVERAGE 3 WEEKS

49. MALIGNANT PLEURAL EFFUSION
MALIGNANT PLEURAL EFFUSIONS SIGNIFY
INCURABLE DISEASE .
THE SECOND MOST COMMON TYPE OF
EXUDATIVE EFFUSION.
THE 3 TUMORS THAT CAUSE approx. 75%
OF MALIGNANT EFFUSIONS ARE LUNG,
BREAST & LYMPHOMA
MEAN SURVIVAL < 1 YEAR.
RECURRENT MASSIVE EFFUSIONS MAY
NEED REPEATED THORACENTESIS,
PLEURODESIS OR PLACEMENT OF
INDWELLING TUNNELED CATHETERS WHICH
PROVIDES GOOD PALLIATION

50. HEART FAILURE WITH ASYMMETRICAL EFFUSION
A 78 year old woman
presents with a 3 week h/o
increasing breathlessness,
orthopnoea, and peripheral
oedema. She had an AWMI
2 months ago.
Her CXR shows venous
congestion and bilateral
pleural effusions, with the
right sided effusion larger
than the left. What would
you do?
•Start therapy for heart
failure and observe
• This woman gives a typical
history of heart failure, which
you should treat before you
perform further investigations.
Asymmetrical pleural
effusions are recognised in
heart failure. You should only
attempt a pleural aspiration if
the patient fails to respond to
treatment for the heart failure.

51. IDIOPATHIC EXUDATIVE EFFUSIONS
• DESPITE REPEATED DIAGNOSTIC THORACENTESES
APPROX. 20% OF EXUDATIVE EFFUSIONS REMAIN
UNDIAGNOSED.
• MAY BE BENIGN ASBESTOSIS ( EXPOSURE TO ASBESTOSE
10-20 YEARS BACK)
• DRUG INDUCED ( NITROFURANTOIN, AMIODARONE,PHENYTOIN,METHOTREXATE )
• DRUG INDUCED LUPUS OR
• HEPATIC HYDROTHORAX WITH MINIMAL OR
UNDETECTABLE ASCITES.
In practice, many patients with undiagnosed effusions
turn out to have malignancy.

52. NO FURTHER EVALUATION IF….
•PATIENT CLINICALLY STABLE
•NO WEIGHT LOSS
•ADA AS WELL AS PPD NORMAL
•NO FEVER
•THE EFFUSION OCCUPIES LESS THAN 50% OF
THE HEMITHORAX
ONE SHOULDN’T BE TOO AGGRESSIVE IF THE
PATIENT IMPROVING CLINICALLY

53. MANAGEMENT OF PLEURAL EFFUSION
Medical Management:
Antibiotics
Analgesics
 Diuretics
Cardiotonic Drugs
Thoracentesis
CTT
Pleurodesis

54. Thoracentesis
aspiration of fluid or air
from the pleural cavity.
instillation of
medication into the
pleural space
MEDICAL/SURGICAL MANAGEMENT, DRUGS,
AND TREATMENT

55. If mesothelioma is likely, you should
tattoo the site of aspiration with Indian ink.
This will enable prophylactic radiotherapy
to be given if the diagnosis is confirmed.
Repeated aspiration attempts are not
recommended, but if more than one
pleural puncture is made, you need to
mark both sites.

56. You are told to remove "a good litre or so" of pleural fluid
from a stoical 82 year old man who has presented to clinic
with a large pleural effusion. During the procedure, after
you have removed 900 ml, he develops chest discomfort
but says he can bear it. What would you do?
Stop the procedure
You should stop the procedure if a patient develops chest
discomfort or a cough, or if resistance to the aspiration is
felt. These may indicate the development of re-expansion
pulmonary oedema. Aspiration of 900 ml should achieve
symptomatic relief, and so it would be appropriate to stop.

57. RE EXPANSION PULMONARY EDEMA
It is serious and can be fatal.
The exact pathophysiology is not fully understood.
Alteration of endothelial permeability and disruption of the
alveolar-capillary membrane, are probably involved.
Re-expansion pulmonary oedema may either resolve
spontaneously or result in hypoxic respiratory failure with
catastrophic circulatory collapse.
Draining a large amount of fluid (usually more than 1.5 l)
too rapidly, especially if the lung has been
collapsed for several weeks, may lead to
re-expansion pulmonary oedema.

58. 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

59. @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

60. On the ward round, you see a 55 year old man with COPD was
admitted with an AECB three days ago. He continues to have
fevers and raised inflammatory markers following treatment. His
CXR shows a small to moderate pleural effusion. You request an
USG pleural aspiration. The aspirate yields frank pus, which is sent
for microscopy and culture. How would you manage him?
Continue with antibiotics and arrange for a
guided chest drain insertion
He requires drainage of the pleural fluid with ongoing
antimicrobial treatment. The addition of anaerobic cover
is appropriate, if not already started. As he has an
underlying lung disease and a small collection, this should
be done under imaging guidance.

61. 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.
CHEST TUBE THORACOSTOMY

62. TRIANGLE OF
SAFETY
• The British Thoracic Society
guidelines define a triangle
of safety for needle
insertion, bordered by:
• The anterior border of
latissimus dorsi
• The lateral border of
pectoralis major muscle
and
• The line superior to the
horizontal level of the
nipple with the apex based
within the axilla.

63. POSITION A suggested position is
SEMI-DECUBITUS ON THE BED AT 45
degrees WITH THE ARM BEHIND THE HEAD
SO AS TO EXPOSE THE AXILLARY AREA.
The drain should ideally be
inserted in the SAFE TRIANGLE
which is delineated by the lateral
border of the pectoralis major ,
the anterior border of the
latissimus dorsi and a line
horizontal with the nipple.
Most clinicians insert the tube via
an incision at this space in the
ANTERIOR AXILLARY or 4th or 5th
intercostal MIDAXILLARY LINE

64. 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 ,sitting and ambulation as
allowed
NURSING MANAGEMENT – CLOSED TUBE THORACOSTOMY

65. LEARNING BITES
Your consultant asks you to
perform a therapeutic pleural
aspiration on a woman who is
taking warfarin for atrial
fibrillation.
She has presented with a large
right pleural effusion on her
chest x ray and is increasingly
distressed as a result of her
breathlessness. Her INR is 2.0.

66. GUIDELINES
•Aspirate 1 litre of fluid for symptomatic relief and
diagnostic purposes
• This common clinical scenario often raises difficult management
questions. There are no published data to suggest an increased risk of
bleeding following a pleural aspiration or insertion of a chest drain in
patients with an underlying coagulopathy or thrombocytopenia In clinical
practice, therapeutic and diagnostic pleural aspiration
are generally performed when the INR is less than or
equal to 2.
• For elective insertion of a chest drain, the British Thoracic Society
guidelines recommend that time is given for the anticoagulation effects to
resolve.
• Guidelines suggest that percutaneous lung or pleural
biopsies are not performed with an INR greater than 1.4.

67. Pleurodesis is performed to
prevent recurrence of
pneumothorax or recurrent
pleural effusion 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.
PLEURODESIS

68. 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

69. Q AND A
•Cytological analysis of two
separate samples of pleural
fluid from a man with an
undiagnosed exudative pleural effusion, who
presented with worsening dyspnoea in the
absence of other symptoms, reveals no
malignant cells.
•Initial Gram and Ziehl-Nielsen stains are
negative. What would you do next ?

70. ………….THORACOSCOPY
•Medical thoracoscopy would be an
appropriate next step.
•This would allow pleural biopsies to be
taken under direct vision and therapeutic
drainage of pleural fluid.
•If appearances suggested pleural
malignancy, pleurodesis with talc
poudrage could be done.

71. TAKE HOME MESSAGE
ASYMPTOMATIC OR MILDLY SYMPTOMATIC EFFUSIONS
MAY JUST BE LEFT AND OBSERVED.
A LARGE PLEURAL EFFUSION THAT MAKES YOU BREATHLESS
CAN BE DRAINED.
UNLESS THE UNDERLYING CAUSE CAN BE TREATED, AN
EFFUSION IS LIKELY TO RETURN.
REPEATED DRAINING, PERMANENT ICTD,
PLEUROPERITONEAL SHUNT, AND PLEURECTOMY ARE
DIFFERENT OPTIONS FOR RECURRENT EFFUSIONS.
PLEURODESIS IS MOST OFTEN USED IN THE TREATMENT OF
REPEATED EFFUSIONS CAUSED BY CANCER.

72. THANK
YOU……
ANY
QUESTIONS
??????????