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1 Kady Rejret, RN,BSN Alverno College MSN-621 Pleural EffusionsKady Rejret, RN,BSNAlverno College MSN-621
2 Navigating this tutorial Takes you back to the Outcomes pageTakes you to next pageTakes you to previous pageTakes you to previous page viewed
3 OUTCOMES Click on the topic below you would like to view Describe the pathophysiology of the normal lungDescribe the pathophysiology of a pleural effusionDescribe the main causes of a pleural effusionDifferentiate among the manifestations of fluid collectionsDescribe the signs and symptoms of a pleural effusionExplain diagnostic methodsDescribe 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 cavitya potential space between the parietal pleura and visceral pleuraRib CageLungPicture used with permission Allibone, 2006
8 Layers of the lung Parietal Pleura Lines the thoracic cavity, including the thoracic cage, mediastinum, and diaphragmContains sensory nerve endings that can detect painRib CageLungPicture used with permission Allibone, 2006
9 Layers of the lung Visceral Pleura Lines the entire surface of the lungContains NO sensory nerve endings that detect painRib CageLungPicture used with permission Allibone, 2006
10 Review question: Pleuritic chest pain indicates inflammation or irritation of theparietal 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 thatcan detect pain.
13 The pleural space typically contains how much fluid? Review question:The pleural space typically contains how much fluid?5-15ml50-100mlml
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 lungThe 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 lungcells 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 bloodProtein 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 cageLungPleural SpaceVisceral PleuraParietal PleuraPicture used with permission Allibone, 2006
20 Fluid is absorbed by the: Let’s reviewFluid is absorbed by the:Parietal PleuraPleural SpaceVisceral 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 pleuraNegative 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 lungDescribe the pathophysiology of a pleural effusionDescribe the main causes of a pleural effusionDifferentiate among the manifestations of fluid collectionsDescribe the signs and symptoms of a pleural effusionExplain diagnostic methodsDescribe the various treatment options
24 Pleural effusionCreated by an abnormal collection of fluid in the pleural spaceSeen in chest X-ray with presence of about 200ml pleural fluidFluid 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 EffusionFluid 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 EffusionThe 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 alveoliNormally, with each breath the air sacs take in oxygen and release carbon dioxideSometimes 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 EffusionsMalignancy 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 failureInfectionAtelectasisCancerTraumaClick on homeicon whenfinished viewingthese topics
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 spaceThis 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 FailureNegative 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 InfectionPneumonia-inflammation of the lung structures, specifically the alveoli and bronchiolesWBCs accumulate in response to infection and inflammation leading to empyema
35 AtelectasisAtelectasis is an incomplete expansion of the lung which leads to collapse of the alveoliIncreased negative intrapleural pressure can lead to the collection of fluid in the portion of the lung which is not expandingThis can cause an effusion by fluid leaking out of the lung and into the chest cavityAtelectasis typically leads to small pleural effusions not requiring surgical intervention
36 CancerImpaired lymphatic drainage of the pleural space due to obstruction by a tumorTypically 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 bloodstreamA tumor can perforate the thoracic ductShedding 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
39 Transudate Clear, pale yellow, watery substance Influenced by systemic factors that alter the formation or absorption of fluidIncrease in hydrostatic pressureDecrease in plasma oncotic pressureContains few protein cellsCommon 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 >0.6Pleural fluid LDH is more the two-thirds normal upper limit for serumRich in white blood cells and immune cellsAlways has a low pHCommon causes: pneumonia, cancer, and trauma
41 Empyema Pus Yellow, cloudy, and foul odor Most likely due to pneumonia, lung abscess, infected chest woundsHas 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 traumaHigh 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 spaceCan occur as a result of bleeding from the ribs, chest wall, pleura, and the lung
44 Let’s reviewWhich 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 painChest pressureHypoxemiaDecreased breath sounds on the affected sideSome people may exhibit no symptoms!
48 Diagnosis Chest radiograph (x-ray) Chest ultrasound -able to distinguish >200ml of fluidChest ultrasound-locates small amounts or isolated loculated pockets of fluid-able to give precise position of accumulationComputed 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 plasmapHprotein content less than 2% (1-2 g/dL)fewer than 1000 WBCs per cubic millimeterglucose content similar to that of plasmalactate dehydrogenase (LDH) level less than 50% of plasma and sodiumpotassium and calcium concentration similar to that of the interstitial fluid(Abrahamian, 2005, p. 2 of 28)
51 ThoracentesisA needle is inserted into the chest wall to remove the collection of fluid50-100ml of fluid is sent for analysisDetermines the type of fluid (transudate or exudate)Picture used with permission (Allibone, 2006, p. 60)
52 ThoracentesisNot a permanent solution, fluid may reaccumulate after a few daysWill temporarily relieve symptomsPotential complications include bleeding, infection, and pneumothorax
53 tPA (alteplase) Thrombolytic enzyme Converts plasminogen to the enzyme plasmin, which degrades fibrin clotsLyses thrombi and emboliMay be administered into the chest tube catheter to restore patency and improve drainageThe patient is instructed to move positions frequently to distribute the medication throughout the lung
54 Chemical PleurodesisSclerosing agents used: Talc, bleomycin, or doxycylineAdministered through a chest tube to create inflammation and subsequent fusion of the parietal and visceral pleuraFluid is then unable to accumulate in this potential space
55 Chemical PleurodesisThe 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 CatheterSmall, flexible tube inserted into the chest to drain fluid from around the lungsContains a one-way valve that prevents air from entering and fluid from leaking out when cappedAllows for intermittent home drainage using a vacuum bottlePicture 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 lungThe length of time a catheter will remain varies from patient to patient, ranging from a few weeks to several months.
59 Pleurx CatheterBeneficial for patients who are independent and able to perform self drainageMinimizes the time spent in the hospitalPatients are instructed to drain up to 1,000ml of fluid at one timePatients are instructed to call MD if drainage is <50ml on three consecutive sessionsPatients are able to wear usual clothing and continue usual activities
60 Pleurx Catheter Easy to connect vacuum container CapEasy to connect vacuum containerSome patients experience pain upon drainage, slowing the drainage with the clamp or stopping briefly may relieve this painPhotos 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 CatheterClick on the link belowfor more information:Used with permission from Denver Biomedical
64 Let’s reviewWhich treatment option requires NO use of anti-inflammatories?(click on the correct answer)ThoracentesistPAChemical PleurodesisPleurx Catheter
66 Good Job! Chemical Pleurodesis This creates inflammation and subsequent fusion of the parietal and visceral pleuraAnti-inflammatories will counteract this reaction.
67 You have successfully completely this tutorial! Congratulations!Kady Rejret, RN, BSNYou have successfully completely this tutorial!
68 ReferencesAllibone, L. (2006). Assessment and management of patients with pleural effusions. Nursing Standard vol20 no22, 55-64Abrahamian, F. M. (2005). Pleural Effusion. Retrieved March 22, 2007 fromBrubacher, 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), 1-4Denver Biomedical. (2004). Retrieved March 25, 2007 fromDrummond Hayes, D. (2001). Stemming the tide of pleural effusions. Nursing Management 32(12), 29-35Mayo Foundation for Medical Education and Research. (2006). Retrieved April 11, 2007 fromNational Cancer Institute. (2006). Retrieved March 23, 2007 fromNational Lung Health Education Program. (2000). Retrieved April 11, 2007 fromPorth,C.M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed.) Lippincott.Rejret, K. (2007). Personal Photograph.Unattributed clipart: Microsoft Office, 2006.