Pleural effusion

PLEURAL EFFUSION,DEFINITION,TYPES,AETIOLOGY ,CLINICAL MANIFESTATIONS,DIAGNOSTIC MESSURES,MANAGEMENT

1. Pleural effusion CREATED BY UNAIS MD HARISON THAIKKAT ALMAS COLLEGE OF NURSING KOTTAKKAL, ML]ALAPPURAM

2. itroduction A  pleural effusion  is excess fluid that accumulates in the  pleural cavity , the fluid-filled space that surrounds the  lungs . This excess can impair  breathing  by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are  hydrothorax  (serous fluid),  hemothorax  (blood),  urinothorax  (urine),  chylothorax  ( chyle ), or  pyothorax  (pus). A  pneumothorax  is the accumulation of  air  in the pleural space, and is commonly called a "collapsed lung."

3. pleura

4. defnition Pleural effusion: inflammation of the pleura, accompanied by collection of fluid in the pleural space. Normal Pleural fluid: 0.3 ml/kg BW Protein: 1.5 g/ dL pH: alkaline (7.60) Cells: 1700 cells/ml (75% macrophages, 23% lymphocytes & 2% mesothelial cells)

5. types By the origin of the fluid: Serous fluid  ( hydrothorax ) Blood  ( haemothorax ) Chyle  ( chylothorax ) Pus  ( pyothorax  or  empyema ) Urine  ( urinothorax )

6. By pathophysiology : Transudative pleural effusion Exudative pleural effusion

7. 1) Transudative pleural effusion The most common causes of  transudative  pleural effusions in the United States are  heart failure  and  cirrhosis   Nephrotic syndrome , leading to the loss of large amounts of  albumin  in urine and resultant  low albumin  levels in the blood and reduced colloid osmotic pressure, is another less common cause of pleural effusion

8. .  Pulmonary emboli  were once thought to cause transudative effusions, but have been recently shown to be exudative . [

9. Conditions associated with transudative pleural effusions include: [2] Congestive heart failure Liver  cirrhosis Severe hypoalbuminemia Nephrotic syndrome Acute atelectasis Myxedema Peritoneal dialysis Meigs ' syndrome Obstructive uropathy End-stage kidney disease

10. 2) Exudative pleural effusion Exudative pleural effusion occur I the case of iflammatory reactios The mechanism for the exudative pleural effusion is probably related to increased permeability of the  capillaries  in the lung, which results from the release of  cytokines  or inflammatory mediators (e.g.  vascular endothelial growth factor ) from the  platelet -rich  blood clots . The excessive interstitial lung fluid traverses the  visceral pleura  and accumulates in the  pleural space .

11. Conditions associated with exudative pleural effusions: [ 2] After heart surgery (from incomplete evacuation of blood resulting in  retained blood syndrome ) Parapneumonic effusion  due to  pneumonia Malignancy (either lung cancer or metastases to the pleura from elsewhere) Infection ( empyema due to bacterial pneumonia) Trauma Pulmonary infarction Pulmonary embolism Autoimmune disorders Pancreatitis Ruptured esophagus ( Boerhaave's syndrome ) Rheumatoid  pleurisy Drug-induced  lupus

12. When a pleural effusion has been determined to be  exudative , additional evaluation is needed to determine its cause, and  amylase ,  glucose ,  pH  and cell counts should be measured. Red blood cell counts are elevated in cases of bloody effusions (for example after heart surgery or hemothorax from incomplete evacuation of blood). Amylase levels are elevated in cases of  esophageal rupture ,  pancreatic pleural effusion , or  cancer . Glucose is decreased with cancer, bacterial infections, or  rheumatoid pleuritis . pH is low in  empyema  (<7.2) and may be low in cancer. If cancer is suspected, the pleural fluid is sent for  cytology . If cytology is negative, and cancer is still suspected, either a  thoracoscopy , or needle biopsy [3]  of the pleura may be performed. Gram staining  and culture should also be done. If  tuberculosis  is possible, examination for  Mycobacterium tuberculosis  (either a  Ziehl–Neelsen  or  Kinyoun stain , and mycobacterial cultures) should be done. A  polymerase chain reaction  for tuberculous DNA may be done, or  adenosine deaminase  or  interferon gamma  levels may also be checked.

13. ethiology 1)Osmotic hydraulicpressure Congestive heart failure Sup vena caval obstruction Constrictive pericarditis Cirrhosis with ascitis Hypo albumenemia Salt retaining syndrome Hydrnephrosis Nephrotic syndrome

14. 2)infections Para pneumonic effusion(bacterial) Bacterial empayema TB Fungi Parasites Viruses&myco plasma

15. 3)Neo plasms Primary & meta static tumors Lymphoma & lukemia Benign&malignant tumors in pleura Intra abdominal tumors 4)vascular diseases Pulmonary embolism Wegner granulomatous

16. 3)Neo plasms Primary & meta static tumors Lymphoma & lukemia Benign&malignant tumors in pleura Intra abdominal tumors 4)vascular diseases Pulmonary embolism Wegner granulomatous

17. 5)intra abdominal diseases Pancreatitis & pancreatic pseudo cyst Sub diaphragmatic abcess Malignancy with ascitis Meigs syndrome Hepatic cirrosis with ascitis 6)trauma Hemothorax Esophageal rupture Intra abdominal surgery chylothorax

18. 7)miscellaneous Drug induced Uremic pleuritis Myxedema Yellow nail syndrome Familial meditaerranian fever

19. pathophysiology

20. Clinical maifestation * key symptom -------> shortness of breath Fluid filling the pleural space makes it hard for the lungs to fully expand, causing the patient to take many breaths so as to get enough oxygen. * If parietal pleura is irritated -------> mild pain or a sharp stabbing pleuritic type of pain . ** Some patients will have a dry cough .

21. Fever Night sweating Wt loss

22. Occasionally ------> no symptoms at all. * This is more likely when the effusion results from: recent abdominal surgery, cancer, or tuberculosis. * Tapping on the chest will show stony dullness, and decrease breath sound

23. History collection Physical examination Diagnostic evaluation

24. Diagnostic evaluation x ray The fluid itself can be seen at the bottom of the lung or lungs, hiding the normal lung structure. If heart failure is present, the x-ray shadow of the heart will be enlarged

25. Ultrasound may disclose a small effusion that caused no abnormal findings during chest examination. C.T. scan is very helpful if the lungs themselves are diseased

26. CT scan of chest showing loculated pleural effusion in left side. Some thickening of pleura is also noted .

27. Thoracoscopy

28. Pleural Biopsy Most helpful in evaluating for TB Limited utility for CA (40-50% positive) Repeat cytology x 3 Sarcoid , fungal: might be helpful

29. Pleural fluid examination

30. management Treatment based on the cause Transudative effusions are managed by treating the underlying medical disorder The management of exudative effusions depends on the underlying etiology of the effusion

31. Pharmacological maagemet Pharmacologic management of pleural effusion depends on the condition’s etiology . For example, medical management includes nitrates and diuretics for congestive heart failure and pulmonary edema , antibiotics for parapneumonic effusion and empyema , and anticoagulation for pulmonary embolism Antibiotics, Ampicillin and sulbactam ( Unasyn ) Imipenem and cilastatin ( Primaxin ) Clindamycin ( Cleocin )

32. 2) Vasodilators Nitroglycerin ( Nitrostat , Nitro-Bid, Nitro- Dur , Nitrolingual ) 3)diuretics Furosemide ( Lasix ) 4)Anti coagulant Heparin

33. Surgical management 1)Therapeutic Thoracentesis Therapeutic thoracentesis is used to remove larger amounts of pleural fluid to alleviate dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusion 2) Tube Thoracostomy Although small, freely flowing parapneumonic effusions can be drained by therapeutic thoracentesis , complicated parapneumonic effusions or empyemas require drainage by tube thoracostomy .

34. Traditionally, large-bore chest tubes (20-36F) have been used to drain the thick pleural fluid and to break up loculations in empyemas . 3) Pleurodesis 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, effectively obliterating the potential pleural space

35.   Pleurodesis is most often used for recurrent malignant effusions, such as in patients with lung cancer or metastatic breast or ovarian cancer 4) Indwelling Tunneled Pleural Catheters TPC can be inserted as an outpatient procedure and can be intermittently drained at home, minimizing the amount of time spent in the hospital for patients with short prognoses

36. thoracentesis

37. Nursig management •Implement medical regimen: Prepare and position patient for thoracentesis and offer support throughout the procedure. •Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed intervals. • Administer nursing care related to the underlying cause of the pleural • Assist patient in pain relief. Assist patient to assume positions that are least painful. Administer pain medication as prescribed and needed to continue frequent turning and ambulation. •If the patient is to be managed as an outpatient with a pleural catheter for drainage, educate the patient and family about management and care of the catheter and drainage system. effusion

38. nursing diagnosis

39. Ineffective breathinnng pattern rellated to accumulation of fluid in pleural space Impaired gas exchannging related toalveolarcapillarymembbrane changes and respiratory fatigue Activity intolerance related to mismatch in oxygen supplay and demand Acute pain related to lnflammation of pleura

40. complications The potential complications associated with pleural effusion are: lung scarring, pneumothorax  (collapse of the lung) as a complication of thoracentesis , empyema (a collection of pus within the pleural space), and sepsis  (blood infection) sometimes leading to death