PLEURAL EFFUSION - DISORDER OF RESPIRATORY SYSTEM (AHN I).pptx

PLEURAL EFFUSION - INTRODUCTION, DEFINITION, INCIDENCE IN WORLD AND INDIA, ETIOLOGY, TYPES (IN DETAIL), PHASES, PATHOPHYSIOLOGY (FLOW CHART), RISK FACTORS, CLINICAL MANIFESTATIONS, DIAGNOSTIC EVALUATIONS, MEDICAL MANAGEMENT WITH RATIONALE (IN TABLE FORM) , SURGICAL MANAGEMENT WITH RATIONALE (IN TABLE FORM), NURSING MANAGEMENT WITH RATIONALE (IN TABLE FORM), COMPLICATIONS, NANDA NURSING DIAGNOSIS

1. Ms. Vaibhavi N Prabhudessai MSc (N) (MSN – Critical Care Nursing Department of Medical Surgical Nursing ADULT HEALTH NURSING I DISORDERS OF RESPIRATORY SYSTEM “PLEURAL EFFUSION”

2. Pleural effusion is a pathological condition characterized by the excess accumulation of fluid within the pleural cavity, the potential space between the visceral pleura covering the lung and the parietal pleura lining the chest wall . Pleural effusion is a common clinical condition characterized by the abnormal accumulation of fluid within the pleural space — the area between the parietal and visceral pleura surrounding the lungs. Under normal physiological conditions, 10–20 mL of pleural fluid is present, serving as a lubricant that minimizes friction during respiration. The pleural space maintains a negative pressure gradient, which facilitates lung expansion during inspiration. Normally, this space contains about 10–20 mL of lubricating fluid that facilitates smooth respiratory movements . Pleural effusion occurs when there is a disruption in the balance between: Formation of pleural fluid (from capillaries and interstitial spaces) Absorption via lymphatic drainage An imbalance between pleural fluid formation and absorption leads to effusion. It is a manifestation of underlying diseases such as heart failure, infection, malignancy, or pulmonary embolism, rather than a disease itself . It is not a disease itself but a clinical manifestation of underlying systemic or local pathology, such as cardiac failure, infection, malignancy, or trauma . The condition significantly impairs pulmonary mechanics, leading to restricted lung expansion, reduced gas exchange, and hypoxemia if untreated. INTRODUCTION

3. Medical Definition – “ The abnormal collection of fluid in the pleural cavity due to excess formation or impaired absorption.” Normal pleural fluid: 0.1–0.2 mL/kg body weight Fluid exceeding 300–500 ml, becomes radiologically detectable . Clinical Definition – “ An abnormal collection of fluid in the pleural space resulting from excess fluid production or decreased fluid absorption.” Normal Pleural fluid volume: 0.1–0.2 mL/kg Normal protein content: <1.5 g/ dL Maintained by balance between: Hydrostatic and oncotic pressures Capillary permeability Lymphatic drainage When this balance is disturbed, fluid accumulates — forming an effusion . DEFINITION

4. Light RW (2010) – “Pleural effusion is the pathological accumulation of fluid between the visceral and parietal pleura, resulting from an imbalance between pleural fluid formation and absorption.” World Health Organization (WHO, 2017) – “Pleural effusion is defined as the excessive accumulation of fluid within the pleural cavity secondary to systemic disorders such as cardiac, hepatic, renal, or local pleural disease leading to impaired lung function.” British Thoracic Society (BTS, 2018) – “Pleural effusion is a clinical condition characterized by the presence of more than 15–20 mL of fluid in the pleural space, causing compression of underlying lung tissue and respiratory compromise.” DEFINITION

5. Worldwide Approximately 1.5 million new cases occur annually in the United States. Most common causes globally: Congestive Heart Failure (CHF) — ~40% cases Pneumonia/ Parapneumonic effusion — ~25% Malignancy — ~15–20% Tuberculosis Seen more frequently in men and older adults due to chronic diseases and smoking-related conditions. Annual incidence: ~1.5 million cases in the United States alone . In India Tuberculosis (TB) is the leading cause, accounting for 60–70% of exudative effusions cases, especially in young adults. Malignant and parapneumonic pleural effusion accounts for around 10–15% of hospital admissions with pleural diseases. Malignant and parapneumonic effusions are increasing due to lifestyle and environmental factors. Incidence higher in men, elderly, and immunocompromised populations. Common in urban poor, HIV-infected, and immunocompromised populations. INCIDENCE

6. Category Mechanism Etiology (Causes) Transudative Effusion (due to systemic factors altering hydrostatic/oncotic pressure) Due to altered hydrostatic or oncotic pressure without pleural inflammation - Congestive heart failure (↑ hydrostatic pressure) - Cirrhosis with ascites (hepatic hydrothorax) - Nephrotic syndrome (↓ oncotic pressure) - Hypoalbuminemia - Myxedema Exudative Effusion (due to local pleural pathology - inflammation) Due to increased capillary permeability or impaired lymphatic drainage secondary to local inflammation - Tuberculosis - Pneumonia (parapneumonic effusion) - Malignancy (lung, breast, ovarian, lymphoma) - Pulmonary embolism - Pancreatitis - Autoimmune diseases (Rheumatoid arthritis or SLE) Empyema Pus in pleural space due to bacterial infection - Staphylococcus aureus , Streptococcus pneumonia - Pyogenic infection causing pus in pleural space Hemothorax Blood accumulation in pleural cavity - Chest trauma, malignancy, ruptured aneurysm / blood vessels Chylothorax Lymphatic (chyle) leakage due to thoracic duct injury - Trauma, lymphoma, post- esophagectomy , thoracic duct injury ETIOLOGY

7. Transudative Effusion Caused by systemic factors (e.g., increased hydrostatic pressure, decreased oncotic pressure), rather than local pleural disease . Fluid: clear, straw- colored , watery, and low protein (<3 g/ dL ). Light’s Criteria: Does not meet exudative cut-offs. Example: CHF, cirrhosis, nephrotic syndrome. Exudative Effusion Due to local inflammation, infection, or malignancy. Caused by local pleural pathology leading to increased capillary permeability. Fluid : turbid/cloudy/purulent, high protein (>3 g/ dL ), increased LDH. Example: TB, pneumonia, malignant cancer. TYPES

8. Hemothorax Accumulation of blood in the pleural space. Pleural fluid hematocrit >50% of peripheral blood. Requires immediate drainage to prevent fibrosis. Chylothorax Accumulation of lymph ( chyle ) due to thoracic duct obstruction or injury. Milky-white pleural fluid rich in triglycerides (>110 mg/ dL ). Results from thoracic duct rupture or lymphoma . Empyema Collection of thick, purulent, pus-filled in the pleural space from bacterial infection. Indicates advanced infection; requires chest tube drainage and antibiotics. TYPES

9. Phase Duration Process 1. Initiation (Acute Inflammatory Phase) First 24–48 hours This is the earliest stage triggered by an underlying systemic or local insult such as infection, trauma, or heart failure. Inflammatory mediators (histamine, cytokines, interleukins) cause vasodilation and increased capillary permeability, allowing plasma proteins and cells to seep into the pleural space. The fluid at this point is clear or slightly yellow and sterile. Pleural irritation produces mild pleuritic pain and breathlessness. Early intervention here can halt progression. 2. Exudative Phase Day 2–4 With ongoing inflammation, protein-rich exudate accumulates due to sustained permeability changes in the pleural vessels. The fluid becomes turbid, rich in leukocytes and fibrinogen. The balance between production and absorption of pleural fluid is disrupted. At this stage, pleural friction rub and mild respiratory distress are often evident. The condition remains potentially reversible with medical therapy or drainage. PHASES

10. Phase Duration Process 3. Fibrinopurulent ( Loculated ) Phase Day 5–10 As the inflammatory process intensifies, fibrin is deposited extensively over pleural surfaces, creating septations and loculations that trap the fluid in multiple pockets. Bacterial invasion may occur, leading to empyema (pus in the pleural cavity). The fluid becomes thick, opaque, and purulent, with a high concentration of neutrophils and debris. This phase often results in partial lung collapse and demands active drainage to prevent chronic fibrosis. 4. Organizational (Fibrotic) Phase After 10–14 days Persistent inflammation activates fibroblast proliferation and collagen deposition on both pleural layers. This leads to the formation of a fibrous peel or cortex around the lung, preventing its re-expansion — a condition termed “trapped lung”. The pleura becomes thickened, rigid, and adherent, reducing pulmonary compliance. Medical management alone is inadequate; surgical decortication or pleurectomy may be required. 5. Chronic (Healed or Sequelae) Phase After several weeks to months In chronic or unresolved cases, the pleural cavity may develop permanent fibrous adhesions or calcifications, leading to fibrothorax . The affected lung remains partially collapsed, and the patient may experience chronic dyspnea , restrictive lung disease, or recurrent effusions. In some cases, low-grade infection persists. This phase represents the end stage of unresolving pleural disease and often leaves residual functional impairment. PHASES

11. PHASES Phase Progress Pathological Event Reversibility 1 Initiation Very Early Increased capillary permeability, inflammatory fluid leakage Fully reversible 2 Exudative Early Leukocytes and Protein-rich inflammatory exudate accumulation in pleural space Reversible 3 Fibrinopurulent Intermediate Fibrin deposition, pus formation, bacterial invasion, empyema, loculation Partially reversible 4 Organizational Late Fibroblast proliferation, fibrous thickening, pleural thickening Often irreversible 5 Chronic Very Late Fibrosis, adhesion, lung entrapment, trapped lung, restrictive sequelae Permanent damage

12. Underlying disease process (CHF, TB, malignancy, pneumonia) ↓ Altered starling forces ↓ ↑ Capillary hydrostatic pressure / ↓ Oncotic pressure (Transudative) OR Inflammation → ↑ Pleural capillary permeability (Exudative) ↓ Lymphatic drainage obstruction ↓ Excess pleural fluid formation / impaired absorption ↓ Imbalance between fluid formation and absorption ↓ Accumulation of fluid in pleural cavity / space ↓ PATHOPHYSIOLOGY

13. ↓ Lung compression and atelectasis (Atelectasis - the partial or complete collapse of a lung or a section of a lung (lobe), occurring when the tiny air sacs (alveoli) deflate or fill with fluid) ↓ ↓ Lung expansion ↓ ↓ Functional residual capacity → ↓ Gas exchange ↓ Hypoxemia, Dyspnea , Tachypnea ↓ Chest pain and discomfort → Respiratory distress PATHOPHYSIOLOGY

14. Chronic heart failure, cirrhosis or renal disease Tuberculosis infection Chronic infections Pneumonia Malignancy (lung/breast cancer, lymphoma) Chronic renal or hepatic disease Chest trauma or surgery Autoimmune disorders (Systemic Lupus Erythematous, Rheumatoid Arthritis) Pulmonary embolism Long-term smokers or alcoholics Immunocompromised status (HIV, diabetes) Prolonged immobility Poor nutrition RISK FACTORS

15. System Clinical Manifestations Respiratory Progressive dyspnea, orthopnea ((in transudative effusion), non-productive cough, pleuritic chest pain, decreased chest expansion Inspection Reduced chest expansion, asymmetrical chest, lag on affected side Palpation Decreased tactile fremitus Percussion Dullness over effusion area Auscultation Diminished or absent breath sounds, possible pleural rub above fluid level General (Systemic) Fever, malaise (infection), weight loss, night sweats (malignancy or TB), tachypnea , cyanosis (severe cases / advanced stages) RISK FACTORS

16. Test Findings/Significance Chest X-ray Blunting of costophrenic angle, meniscus sign, mediastinal shift in large effusion Ultrasound (USG Thorax) Detects minimal fluid effusion, guides thoracentesis safely CT (chest) Scan Identifies pleural thickening, nodules, loculations, and underlying pathology Pleural Fluid Analysis (Thoracentesis) - Diagnostic Aspiration and analysis of pleural fluid. Light’s Criteria Used to differentiate / determine transudate vs exudate. Exudate if: 1. Pleural fluid protein/serum protein > 1.5 g/dL 2. Pleural LDH/serum LDH > 0.6 3. Pleural LDH > 2/3 upper limit of serum LDH Pleural Fluid Analysis - Appearance: clear, turbid, bloody - Protein, LDH, sugar, pH, cell count Microbiology Tests Gram stain, AFB, culture sensitivity (infection) Cytology Detects malignant cells Biopsy (Pleural) For tuberculosis/malignancy (carcinoma) diagnosis confirmation DAIGNOSTIC EVALUATIONS

17. MEDICAL MANAGEMENT Intervention Purpose/Rationale Oxygen therapy Corrects hypoxemia caused by reduced gas exchange and improves oxygen saturation Broad-spectrum antibiotics - Treat underlying infection (e.g., pneumonia, TB) - Eradicates infection causing parapneumonic effusion or empyema Diuretics (e.g., Furosemide, Spironolactone) Reduces systemic and pulmonary congestion and fluid overload (in CHF- related effusions) Corticosteroids Reduces pleural inflammation in autoimmune or inflammatory malignant effusions causes Antitubercular therapy Treats TB effusion / tubercular effusion Analgesics and Antipyretics (NSAIDs) Relieves pleuritic chest pain and fever Therapeutic Thoracentesis Diagnostic and therapeutic removal of accumulated fluid to relieve dyspnea Nutritional support (protein-rich diet) - Prevents malnutrition and promotes / supports healing - Enhances immune function

18. SURGICAL MANAGEMENT Procedure Purpose/Rationale Chest tube drainage (Intercostal Drain) - Continuous evacuation of pleural fluid or pus (empyema) or large effusion - Prevents reaccumulation Pleurodesis (Chemical - talc, doxycycline) Fusion / Obliterates of pleural layers / space using agents (e.g., talc) to prevent recurrence in malignancy / malignant effusions Pleurectomy Surgical removal of thickened pleura in chronic or recurrent cases or trapped lung Decortication Removes fibrous peel / tissue restricting lung expansion and allows lung re-expansion Video-Assisted Thoracoscopic Surgery (VATS) Minimally invasive, used for drainage and biopsy procedure or decortication Pleuroperitoneal shunt Used in refractory recurrent effusions when conventional methods fail

19. NURSING MANAGEMENT Nursing Intervention Rationale Assess respiratory status frequently (rate, rhythm, depth, SpO ₂ - oxygen saturation) To detect respiratory distress and evaluate effectiveness of therapy Position in high Fowler’s or orthopneic position - Promotes lung expansion and eases breathing - Improves tissue oxygenation Administer oxygen therapy as prescribed - Corrects hypoxia and maintains adequate oxygenation - Improves tissue oxygenation Encourage deep breathing and coughing exercises Prevents atelectasis and promotes lung re-expansion Encourage incentive spirometry Maintains ventilation Monitor chest drainage (if tube present – check chest tube patency and drainage characteristics) Detects blockage or pneumothorax or air leak early

20. NURSING MANAGEMENT Nursing Intervention Rationale Administer medications as ordered (diuretics, antibiotics, analgesics) - Manages underlying cause and relieves symptoms - Ensures effective treatment of cause Assist during thoracentesis Ensures aseptic precautions and patient comfort Provide comfort measures Reduces anxiety and pain Provide psychological support and education Reduces anxiety and promotes adherence to treatment Promote adequate nutrition and hydration Supports immune function and recovery Educate patient and family (disease process, preventive measures) Promotes understanding and adherence to treatment

21. COMPLICATIONS Empyema (infected pleural fluid) Fibrothorax / Trapped lung Pneumothorax (post- thoracentesis ) Sepsis Respiratory failure Re-expansion pulmonary edema Pleural thickening and adhesions Malignant transformation (in chronic cases)

22. NANDA DIAGNOSIS Actual Diagnoses Impaired gas exchange related to decreased lung expansion secondary to pleural fluid accumulation . Ineffective breathing pattern related to mechanical compression of lungs / pleural compression . Acute pain related to pleural inflammation and coughing . Activity intolerance related to imbalance between oxygen supply and demand / dyspnea and fatigue . Anxiety related to dyspnea and hospitalization / breathlessness and unfamiliar hospital environment.

23. NANDA DIAGNOSIS Potential Diagnoses Risk for infection related to chest drainage system or invasive procedures . Risk for impaired skin integrity related to immobilization / prolonged bed rest or poor nutrition . Risk for fluid volume deficit related to diuretic therapy or repeated drainage . Risk for ineffective airway clearance related to decreased lung expansion / decreased cough effort . Risk for reaccumulation of pleural fluid related to underlying disease condition.