1. Kady Rejret, RN,BSN Alverno College MSN-621
Pleural Effusions
Kady Rejret, RN,BSN
Alverno College MSN-621

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3. OUTCOMES Click on the topic below you would like to view
Describe the pathophysiology of the normal lung
Describe the pathophysiology of a pleural effusion
Describe the main causes of a pleural effusion
Differentiate among the manifestations of fluid collections
Describe the signs and symptoms of a pleural effusion
Explain diagnostic methods
Describe the various treatment options

4. Normal lung pleural effusion
Picture used with permission (Allibone, 2006, p.56)

5. Physiology of the normal lung
The lungs are soft, spongy, cone-shaped organs located in the chest cavity.
They are separated by the mediastinum and the heart.
There are 3 lobes on the right lung and 2 lobes on the left lung.

6. Pleura
-serous fluid that allows for the parietal pleura (outer lining) and visceral pleura (inner lining) to glide over each other without separation (Porth, 2005, p. 639)
-contains about 5-15ml of fluid at one time
-Pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura as a continuous process. (Drummond Hayes, 2001, p. 32)
-about ml of fluid circulates though the pleural space within a 24-hour period (Brubacher & Holmes Gobel, 2003)
-has an alkaline pH of about 7.64 (Drummond Hayes, 2001, p. 33)

7. Layers of the lung Pleural Space
thin, transparent, serous membrane which lines the thoracic cavity
a potential space between the parietal pleura and visceral pleura
Rib Cage
Lung
Picture used with permission Allibone, 2006

8. Layers of the lung Parietal Pleura
Lines the thoracic cavity, including the thoracic cage, mediastinum, and diaphragm
Contains sensory nerve endings that can detect pain
Rib Cage
Lung
Picture used with permission Allibone, 2006

9. Layers of the lung Visceral Pleura
Lines the entire surface of the lung
Contains NO sensory nerve endings that detect pain
Rib Cage
Lung
Picture used with permission Allibone, 2006

10. Review question: Pleuritic chest pain indicates
inflammation or irritation of the
parietal pleura or visceral pleura?
(click on the correct answer)

11. Think again! The visceral pleura contains no
nerve endings for detecting pain.

12. The parietal pleura contains sensory nerve endings that
Correct!
The parietal pleura contains sensory nerve endings that
can detect pain.

13. The pleural space typically contains how much fluid?
Review question:
The pleural space typically contains how much fluid?
5-15ml
50-100ml ml

14. Think again!
about ml of fluid circulates though the pleural space within a 24-hour period

15. Correct! 5-15ml of fluid are present at one time
The pleural space is a potential space between the parietal pleura and visceral pleura, allowing them to glide over each other without separation

16. The normal lung
The lungs are supplied with blood via the pulmonary and bronchial circulations.
Pulmonary circulation: supplied from the pulmonary artery and provides for gas exchange function of the lungs.
Bronchial circulation: distributes blood to the conducting airways and supporting structures of the lung.

17. The normal lung Intrapulmonary pressure
-the pressure within the alveoli as the chest expands on inspiration the intrapulmonary pressure becomes more negative, which causes air to be sucked into the lungs.
(Allibone, 2006, p. 56)
Intrapleural pressure
-Negative pressure is created in the pleural space as the thoracic cage enlarges and the lungs recoil during normal inspiration negative pressure may be lost if fluid collects in the pleural space, making the lung unable to expand fully.
(Allibone, 2006, p. 56)

18. The normal lung
cells within the pleura are primarily mesothelial cells that line the surfaces of the pleural membranes and some white blood cells (WBC).
The visceral pleura absorbs fluid, which then drains into the lymphatic system and returns to the blood
Protein in the circulation and balanced pressures keep excessive amounts of fluid from seeping out of the blood vessels into the pleural space
(Pumonary Channel, 2007)

19. Let’s review Pleural Space Visceral Pleura Parietal Pleura
Click on the words below to send them to their correct position within the diagram.
Rib cage
Lung
Pleural Space
Visceral Pleura
Parietal Pleura
Picture used with permission Allibone, 2006

20. Fluid is absorbed by the:
Let’s review
Fluid is absorbed by the:
Parietal Pleura
Pleural Space
Visceral Pleura

21. Think Again - - - Pleural fluid is produced by the parietal pleura
The pleural space is a potential space between the parietal pleura and visceral pleura
Negative pressure is created in the pleural space

22. C o r r e c t ! ! !
Pleural fluid is produced by the parietal pleura and absorbed by the visceral pleura as a continuous process.
The visceral pleura absorbs fluid, which then drains into the lymphatic system and returns to the blood

23. OUTCOMES Click on the topic below you would like to view
Describe the pathophysiology of the normal lung
Describe the pathophysiology of a pleural effusion
Describe the main causes of a pleural effusion
Differentiate among the manifestations of fluid collections
Describe the signs and symptoms of a pleural effusion
Explain diagnostic methods
Describe the various treatment options

24. Pleural effusion
Created by an abnormal collection of fluid in the pleural space
Seen in chest X-ray with presence of about 200ml pleural fluid
Fluid in X-ray seen as a dense, white shadow with a concave upper edge (fluid level)
(Allibone, 2006)
Click on the pleural effusion in the picture!
Used with permission (Allibone, 2006, p. 59)

25. Pleural Effusion
Fluid accumulates in the pleural space by three mechanisms:
-increased drainage of fluid into the space
-increased production of fluid by cells in the space
-decreased drainage of fluid from the space
(pulmonary channel, 2007)

26. Pleural Effusion
The build-up of fluid presses on the lung, making it difficult for the lung to expand fully.
Part or all of the lung may then collapse
(National Cancer Institute, 2007)

27. Pleural Effusion Your lungs contain millions of small, elastic
air sacs called alveoli
Normally, with each breath the air sacs take in oxygen and release carbon dioxide
Sometimes increased pressure in the blood vessels in your lungs forces fluid into the air sacs, filling them with fluid and preventing absorption of oxygen.
(Mayo Foundation for Medical Education and Research, 2006)

28. Pleural Effusions
Malignancy accounts for about 40% of symptomatic pleural effusions, with congestive heart failure and infection being the other leading causes
(National Cancer Institute, 2006)

29. Fluid collection in both lower lobes of the lungs due to CHF
Picture used with permission (Allibone, 2006, p. 59)

30. Main causes of a Pleural Effusion
Congestive Heart Failure (CHF)
Liver failure
Infection
Atelectasis
Cancer
Trauma
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31. Congestive Heart Failure CHF
As the heart fails, pressure in the vein going through the lungs starts to rise.
Due to the heart’s inability to move blood from the pulmonary circulation into the arterial side of systemic circulation, there is a decrease in cardiac output, an increase in left atrial and ventricular end-diastolic pressures, and congestion in the pulmonary circulation.
As the pressure increases, fluid is pushed into the air spaces (alveoli)
This fluid then leaks from the alveoli into the pleural space
This fluid creates a pleural effusion and interrupts normal oxygen movement through the lungs, resulting in shortness of breath

32. CHF CHF is the most common cause of pleural effusion.
Frequently the effusions are bilateral (approximately 75% of the time) but may occur alone on either side with the right side being more common.
Fluid is usually straw colored, with low white blood cell counts (<500 cells/mm3) and a mononuclear cell predominance.
With severe congestive heart failure, fluid may persist in spite of vigorous diuresis.
(National Lung Health Education Program, 2000)
Back

33. Liver Failure
Negative intrapleural pressure may lead to a transudative effusion due to peritoneal fluid from ascites moving across the diaphragm into the chest
(Current Therapy, 2001, p. 208)

34. Infection
Pneumonia
-inflammation of the lung structures, specifically the alveoli and bronchioles
WBCs accumulate in response to infection and inflammation leading to empyema

35. Atelectasis
Atelectasis is an incomplete expansion of the lung which leads to collapse of the alveoli
Increased negative intrapleural pressure can lead to the collection of fluid in the portion of the lung which is not expanding
This can cause an effusion by fluid leaking out of the lung and into the chest cavity
Atelectasis typically leads to small pleural effusions not requiring surgical intervention

36. Cancer
Impaired lymphatic drainage of the pleural space due to obstruction by a tumor
Typically due to the interference with the visceral pleura (which absorbs pleural fluid)
A tumor can obstruct pulmonary veins, preventing fluid from being reabsorbed into the bloodstream
A tumor can perforate the thoracic duct
Shedding of malignant cells into the pleural space, decreasing reabsorption of pleural fluid back into the lymphatic system (Brubacher & Holmes Gobel, 2003, p. 1)

37. Trauma Increased capillary permeability as a result of inflammation
Fluid (most often, blood) may collect in the lung cavity as a result of trauma to the lung

38. Pleural fluid types Transudate Exudate Empyema Chyle Hemothorax
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39. Transudate Clear, pale yellow, watery substance
Influenced by systemic factors that alter the formation or absorption of fluid
Increase in hydrostatic pressure
Decrease in plasma oncotic pressure
Contains few protein cells
Common causes: CHF and liver or kidney disease

40. Exudate Pale yellow and cloudy substance
Influenced by local factors where fluid absorption is altered (inflammation, infection, cancer)
Rich in protein (serum protein greater than 0.5)
Ratio of pleural fluid LDH and serum LDH is >0.6
Pleural fluid LDH is more the two-thirds normal upper limit for serum
Rich in white blood cells and immune cells
Always has a low pH
Common causes: pneumonia, cancer, and trauma

41. Empyema Pus Yellow, cloudy, and foul odor
Most likely due to pneumonia, lung abscess, infected chest wounds
Has a pH > 7.2
(Drummond Hayes, 2001, p. 33)

42. Chyle Milky fluid Consists of lymph and fat
Chyle leaks from the thoracic duct
-due to lymphatic obstruction (tumor) or trauma
High triglyceride levels found in fluid analysis

43. Hemothorax Blood Usually results from chest injury
A blood vessel ruptures into the pleural space or a bulging area into the aorta (aortic aneurysm) leaks blood into the pleural space
Can occur as a result of bleeding from the ribs, chest wall, pleura, and the lung

44. Let’s review
Which is NOT a type of fluid that may cause a pleural effusion?
-empyema
-chylothorax
-pneumothorax
-hemothorax

45. This is a fluid that may cause a Pleural Effusion
Empyema (pus), Chylothorax (chyle), and hemothorax (blood) are all fluids that may result in a pleural effusion.

46. Correct, this is not a fluid!
Pneumothorax is a collection of air in the pleural cavity.

47. Signs and symptoms Dyspnea Cough, usually non-productive
Pleuritic chest pain
Chest pressure
Hypoxemia
Decreased breath sounds on the affected side
Some people may exhibit no symptoms!

48. Diagnosis Chest radiograph (x-ray) Chest ultrasound
-able to distinguish >200ml of fluid
Chest ultrasound
-locates small amounts or isolated loculated pockets of fluid
-able to give precise position of accumulation
Computed Tomography (CT) scan
-Differentiates between fluid collection, lung abcess, or tumor

49. Diagnosis Fluid analysis confirms a pleural effusion
Normal pleural fluid has the following characteristics:
clear ultrafiltrate of plasma pH
protein content less than 2% (1-2 g/dL)
fewer than 1000 WBCs per cubic millimeter
glucose content similar to that of plasma
lactate dehydrogenase (LDH) level less than 50% of plasma and sodium
potassium and calcium concentration similar to that of the interstitial fluid
(Abrahamian, 2005, p. 2 of 28)

50. Non-surgical Treatment Options
Thoracentesis
tPA
Chemical Pleurodesis
Pleurx catheter

51. Thoracentesis
A needle is inserted into the chest wall to remove the collection of fluid
50-100ml of fluid is sent for analysis
Determines the type of fluid (transudate or exudate)
Picture used with permission (Allibone, 2006, p. 60)

52. Thoracentesis
Not a permanent solution, fluid may reaccumulate after a few days
Will temporarily relieve symptoms
Potential complications include bleeding, infection, and pneumothorax

53. tPA (alteplase) Thrombolytic enzyme
Converts plasminogen to the enzyme plasmin, which degrades fibrin clots
Lyses thrombi and emboli
May be administered into the chest tube catheter to restore patency and improve drainage
The patient is instructed to move positions frequently to distribute the medication throughout the lung

54. Chemical Pleurodesis
Sclerosing agents used: Talc, bleomycin, or doxycyline
Administered through a chest tube to create inflammation and subsequent fusion of the parietal and visceral pleura
Fluid is then unable to accumulate in this potential space

55. Chemical Pleurodesis
The goal of chemical pleurodesis is to cause an irritation between the two layers covering the lung.
The sclerosant irritates the pleurae which results in inflammation and causes the pleurae to stick together.
The procedure can be done at the bedside or in the operating room.
Do not administer with any anti-inflammatory agents

56. Pleurx Catheter
Small, flexible tube inserted into the chest to drain fluid from around the lungs
Contains a one-way valve that prevents air from entering and fluid from leaking out when capped
Allows for intermittent home drainage using a vacuum bottle
Picture used with permission from Denver Biomedical

57. Pleurx Catheter In chest wall where fluid is accumulating
Picture used with permission from Denver Biomedical

58. Pleurx Catheters Catheters are typically drained every one to two days
Keeping the lung fairly free of fluid, will most likely permanently stop the fluid from building up, so that the catheter can be removed.
The catheter may remain until fluid quits draining from the lung
The length of time a catheter will remain varies from patient to patient, ranging from a few weeks to several months.

59. Pleurx Catheter
Beneficial for patients who are independent and able to perform self drainage
Minimizes the time spent in the hospital
Patients are instructed to drain up to 1,000ml of fluid at one time
Patients are instructed to call MD if drainage is <50ml on three consecutive sessions
Patients are able to wear usual clothing and continue usual activities

60. Pleurx Catheter Easy to connect vacuum container
Cap
Easy to connect vacuum container
Some patients experience pain upon drainage, slowing the drainage with the clamp or stopping briefly may relieve this pain
Photos by Kady Rejret, 2007

61. Pleurx
Photo by Kady Rejret, 2007

62. Pleurx Catheter Benefits
• Reduces hospital length of stay
• Reduces costs
• Improves quality of life
• 46% pleurodesis in 29 days (median)
• Provides effective palliation of symptoms of pleural effusions
• Often implanted on an outpatient basis
• May be used with most trapped lung patients
• Minimizes pain
• Placed under local anesthetic
(Denver Biomedical, 2004)

63. Used with permission from Denver Biomedical
Pleurx Catheter
Click on the link below
for more information:
Used with permission from Denver Biomedical

64. Let’s review
Which treatment option requires NO use of anti-inflammatories?
(click on the correct answer)
Thoracentesis
tPA
Chemical Pleurodesis
Pleurx Catheter

65. Think again!

66. Good Job! Chemical Pleurodesis
This creates inflammation and subsequent fusion of the parietal and visceral pleura
Anti-inflammatories will counteract this reaction.

67. You have successfully completely this tutorial!
Congratulations!
Kady Rejret, RN, BSN
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68. References
Allibone, L. (2006). Assessment and management of patients with pleural effusions. Nursing Standard vol20 no22, 55-64
Abrahamian, F. M. (2005). Pleural Effusion. Retrieved March 22, 2007 from
Brubacher, S. & Holmes Gobel, B. (2003). Use of the pleurx pleural catheter for the management of malignant pleural effusions. Clinical Journal of Oncology Nursing 7 (1), 1-4
Denver Biomedical. (2004). Retrieved March 25, 2007 from
Drummond Hayes, D. (2001). Stemming the tide of pleural effusions. Nursing Management 32(12), 29-35
Mayo Foundation for Medical Education and Research. (2006). Retrieved April 11, 2007 from
National Cancer Institute. (2006). Retrieved March 23, 2007 from
National Lung Health Education Program. (2000). Retrieved April 11, 2007 from
Porth,C.M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed.) Lippincott.
Rejret, K. (2007). Personal Photograph.
Unattributed clipart: Microsoft Office, 2006.