Pleural Effusion

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Pleural Effusion

• Key Concepts in Pathophysiology
• The parietal pleura is a membrane lining the
  chest cavity.
• The visceral pleura surrounds the lungs.
• In between the parietal and visceral pleurae
  lies a fluid-filled space.
• The fluid within the pleural space holds the two
  pleurae together, creating a negative pressure
  to help the lungs expand, and it serves to
  lubricate the two layers to ease friction
  during inhalation and exhalation.
• Pleural Effusion is an excessive amount of
  fluid located between the visceral and parietal
  layers.
• Pleural effusion is a secondary disorder.
• Causes can be systemic or local.
• The increase in fluid in the pleural space can
  displace lung tissue, resulting in compression
  atelectasis.

The Physics of Pleural Effusion Transudative
Fluid is caused by an increase in hydrostatic
pressure within the pleural capillaries or a
decrease in colloid osmotic pressure in the
circulatory system. Exudative Fluid is caused by
an increase in capillary permeability resulting
from inflammatory process related in infections
and malignancies.

• Systemic Causes of Pleural Effusion
• Hydrothorax - Non-inflammatory collection of
  fluid related to heart failure, renal failure,
  liver failure.
• Empyema - Pus in pleural space resulting from
  infections, malignancies, connective tissue
  disorders.
• Local Causes of Pleural Effusion
• Hemothorax - Blood in pleural space resulting
  from chest wall injuries, complications of
  surgery, etc.
• Chylothorax - Excess lymphatic fluid caused by
  malignancy, inflammation from infections (TB,
  pneumonia for example).

Fluid within the pleural space prevents friction
when the plueral surfaces of the lung move. There
is normally 5-15 ml of fluid within the pleural
space, and more than 25 ml is termed an effusion.
Symptoms may not appear until there is an
accumulation of 300 ml or more of fluid.

• Signs and Symptoms
• Pleural effusion should be suspected in any
  patient with dyspnea.
• Other symptoms may include
• Pleuritic or nonpleuritic chest pain
• Nonproductive cough
• Asymmetric chest expansion
• Dullness to percussion
• Decreased or absent breath sounds
• Reduced vocal and tactile fremitus
• Presence of a pleural rub
• Size Matters
• The patient with a small-moderate pleural
  effusion (lt300ml) may have minimal dyspnea.
• A patient with a large pleural effusion
  (gt1,000ml) likely suffers from respiratory
  distress, and the effusion may cause tracheal
  deviation.
• Rate Matters

Nursing Implications - Diagnosis, Assessment
Treatment Diagnosis Assessment
Treatment
Pleural fluid is obtained by thorancentesis
(aspiration of fluid from the pleural space) to
differentiate exudates from transudates. Cultural
sensitivity cytological examination of fluid is
performed to help determine appropriate course of
treatment. Thoracoscopy allows direct
visualization and sampling of the pleura.
Diagnostic in gt90 of patients with pleural
malignancy and negative cytology. Ultrasonography
detects pleural effusions with greater accuracy
than chest radiography. CT Scans are useful for
differentiating pleural disease from lung abscess
and for diagnosing pleural malignancy.
Treatment is aimed at relief of respiratory
compromise and associated pain. Goal of treatment
is to resolve underlying disease process causing
the problem prevention of complications
(atelectasis, pneumonthorax) Nursing Management
includes Assessment - pain, v/s, respiratory
rate and status, lung sounds (ausculation
percussion) Medication Administration -
antipyretics, antibiotics Monitor - s/s for
change in status (tachycardia, hypotension,
increasing SOB)
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Nursing Considerations

• Interventions
• Manage patients anxiety
• Manage pain
• Provide support during thoracentesis
• Monitor for s/s of complications after procedure
  (e.g., reexpansion pulmonary edema, effusion)
• Monitor chest tube drainage system record
  drainage
• Position on unaffected side to relieve pressure

• Pain Management R/T Procedures
• Tell him what to expect
• Educate him on pain management options
• Assess his understanding of the pain management
  regimen
• Find out what has worked for him in the past
• Dont assume - sedation isnt analgesia. Pain
  medications are still needed
• Establish signals that he can use during
  procedure to indicate needs for more pain meds

• Management of Patient With Chest Tubing
• Monitor v/s q2hr - RR, pattern, depth, SpO2
  highest priority
• Assess for symmetry of breath sounds bilaterally
• Assess insertion site for subcutaneous emphysema
• Encourage deep breathing coughing to promote
  drainage and lung expansion
• Keep tubing free of kinks
• Avoid clamping of tubes for extended period of
  time (prevents escape of air/fluid increases
  risk of pneumothorax or cardiac tamponade
• Check to ensure connections are secure to chest
  wall
• Keep collection apparatus below patients chest
  level
• Ensure water seal fluctuates with respiratory
  effort (tidaling). If not, check for tube kinks
• Record drainage amount characteristics per
  protocol - mark chamber levels with date/time
• Include drainage in fluid I/O records
• Report gt70 ml/hr of bright red blood or
  free-flowing drainage
• Assist with ambulation as tolerate

Handout References - Coughlin, A.M. Parchinsky,
C. (2006). Go with the flow of chest tube
therapy. Nursing, 36(3), 36-42. - Darcy, Y.
(2004). Managing procedural pain. Nursing,
34(12), 76. - Dev, S.P. Nascimiento B.
(2007). Chest-tube insertion. New England Journal
of Medicine, 357(15), 17. - Hogan, M.A. Hill,
K. (2004). Pathophysiology Reviews and
Rationales. Upper Saddle River, New Jersey
Prentice Hall. - Pendharkar, S.R. (2007).
Guidance on how to identify the cause - a
diagnostic approach to pleural effusion. Journal
of Respiratory Diseases, 28(12), 565. -
Porcel, J.M. Light, R.W. (2006). Diagnostic
approach to pleural effusion in adults. American
Family Physician, 73(7), 1211-1220.- Smeltzer,
S. Bare, B. (2003). Bunner Suddarths
Textbook of Medical-Surgical Nursing (10th ed.).
Philadelphia, PA Lippinott Williams
Wilkins. Abstract obtiained from Nursing
Understanding Pleural Effusion,, 2004, 34(8),
64. Prepared by Patty Lynch, Neal Fromm and
Alyson Conway, PLU SON for N441 - February 19,
2008