1. Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 23 Pleural Diseases Figure 23-1. Right-sided pleural effusion. FA, Fluid accumulation; DD, depressed diaphragm; CL, collapsed lung (partially collapsed). Inset, Atelectasis, a common secondary anatomic alteration of the lungs. DD FA CL

2. Copyright © 2006 by Mosby, Inc. Slide 2 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 2 The Pleural Space Overview and definitions  Visceral pleura cover each lung, while the parietal pleura covers the outer structures that bound the lungs.

3. Copyright © 2006 by Mosby, Inc. Slide 3 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 3 The Pleural Space (cont.) Overview and definitions (cont.)  Pleural fluid about 10 to 20 mm thick separates the visceral from parietal pleura.  There is ~8 ml of fluid per hemithorax.  Pleural fluid is very similar to interstitial fluid.  This fluid minimizes the friction caused by the lungs to expanding in the thorax during inspiration.  Pleural pressure is typically negative due to outward thoracic recoil and inward recoil of lung.

4. Copyright © 2006 by Mosby, Inc. Slide 4 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 4 Pleural Effusions  Any abnormal accumulation of fluid in the pleura is considered a pleural effusion.  Fluid enters the pleural space from visceral and parietal pleurae, particularly in face of increased pressure.  Stomata that connect to lymphatic system remove fluid from this space.  Either increased fluid production or blockage of drainage can result in pleural effusions.

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6. Copyright © 2006 by Mosby, Inc. Slide 6 Anatomic Alterations of the Lungs  Lung compression  Atelectasis  Compression of the great veins and decreased cardiac venous return

7. Copyright © 2006 by Mosby, Inc. Slide 7 Etiology Major Causes of a Transudative Pleural Effusion (integrity of pleural space undamaged)  Congestive heart failure (hydrostatic)  Hepatic hydrothorax  Peritoneal dialysis  Nephrotic syndrome (protein loss alters oncotic pressures)  Pulmonary embolus *

8. Copyright © 2006 by Mosby, Inc. Slide 8 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 8 Pleural Effusions (cont.) Transudative effusions  Any effusion that forms while pleural space is undamaged will have [protein] <50% of serum level and LDH <60% of serum level Specific causes of transudative effusions  CHF: high hydrostatic pressure increases pleura fluid production, most common cause of effusions  Nephrotic syndrome: protein loss in urine results in low capillary oncotic pressure and fluid third spacing

9. Copyright © 2006 by Mosby, Inc. Slide 9 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 9 Pleural Effusions (cont.) Specific causes of transudative effusions (cont.)  Hypoalbuminemia: different cause but mimics above  Liver disease: ascites fluid moves through small holes in diaphragm, almost always on right side  Atelectasis: cause pleural pressures to become more negative resulting in small effusions  Lymphatic obstruction: blockage prevents drainage and results in accumulation

10. Copyright © 2006 by Mosby, Inc. Slide 10 Etiology Major Causes of An Exudative Pleural Effusion  Malignant pleural effusions  Malignant mesotheliomas  Pneumonias  Tuberculosis  Fungal disease  Pleural effusion resulting from diseases of the gastrointestinal tract  Pleural effusion resulting from collagen vascular diseases

11. Copyright © 2006 by Mosby, Inc. Slide 11 Etiology Other Pathologic Fluids that Separate the Parietal from the Visceral Pleura  Empyema  Chylothorax  Hemothorax  Hematocrit of pleural fluid must be at least 50% of peripheral blood

12. Copyright © 2006 by Mosby, Inc. Slide 12 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 12 Pleural Effusions (cont.) Exudative effusions  Occur due to inflammation of lung or pleura and will have a higher protein and inflammatory cell content  Thoracentesis may be performed to determine type. Specific causes of exudative effusions  Parapneumonic: secondary to lung inflammation associated with pneumonia  Complicated if clots form and loculate fluid  Persistent fever may signal an empyema, which must be drained for recovery

13. Copyright © 2006 by Mosby, Inc. Slide 13 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 13 Pleural Effusions (cont.) Specific causes of exudative effusions (cont.)  Viral pleurisy: presents with inflammation and pain  Pain may result in atelectasis and hypoxemia.  Tuberculous pleurisy: occurs when caseous granulomas rupture viscera pleura and drain into pleural space  Patients need to be isolated.  Malignancy: most common cause of large unilateral effusions, most require pleurodesis to treat

14. Copyright © 2006 by Mosby, Inc. Slide 14 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 14 Pleural Effusions (cont.) Specific causes of exudative effusions (cont.)  Postoperative: common following abdominal or thoracic surgery  Chylothorax: caused by rupture of thoracic duct, 50% malignant, 20% surgical  Fluid may be white or yellow, sometimes bloody  Hemothorax: trauma or blood vessel hemorrhage into pleura space  Hematocrit > 50% of serum level

15. Copyright © 2006 by Mosby, Inc. Slide 15 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 15 Physiological Importance of Pleural Effusions Mechanics of ventilation  Effusions cause atelectasis due to limited thoracic space resulting in restrictive pattern on PFTs.  Patients commonly dyspneic even with small effusions  Rarely cause fibrothorax with true restrictive impairment Hypoxemia  Most effusions cause increased P(A – a)O 2, which may worsen following thoracentesis.

16. Copyright © 2006 by Mosby, Inc. Slide 16 Overview of the Cardiopulmonary Clinical Manifestations Associated with PLEURAL EFFUSION The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with pleural effusion (see Figure 23-1).

17. Copyright © 2006 by Mosby, Inc. Slide 17 Figure 9-7. Atelectasis clinical scenario.

18. Copyright © 2006 by Mosby, Inc. Slide 18 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside Vital signs  Increased respiratory rate  Stimulation of peripheral chemoreceptors  Other possible mechanisms Decreased lung compliance Decreased lung compliance Activation of the deflation receptors Activation of the deflation receptors Activation of the irritant receptors Activation of the irritant receptors Stimulation of the J receptors Stimulation of the J receptors Pain/anxiety Pain/anxiety  Increased heart rate, cardiac output, blood pressure

19. Copyright © 2006 by Mosby, Inc. Slide 19 Clinical Data Obtained at the Patient’s Bedside Clinical Data Obtained at the Patient’s Bedside  Chest pain/decreased chest expansion  Cyanosis  Cough (dry, nonproductive)  Chest assessment findings  Tracheal shift  Decreased tactile and vocal fremitus  Dull percussion note  Diminished breath sounds  Displaced heart sounds

20. Copyright © 2006 by Mosby, Inc. Slide 20 Clinical Data Obtained from Laboratory Tests and Special Procedures

21. Copyright © 2006 by Mosby, Inc. Slide 21 Pulmonary Function Study: Lung Volume and Capacity Findings V T RV FRC TLC N or     VC IC ERV RV/TLC%    N V T RV FRC TLC N or     VC IC ERV RV/TLC%    N

22. Copyright © 2006 by Mosby, Inc. Slide 22 Arterial Blood Gases Small Pleural Effusion  Acute alveolar hyperventilation with hypoxemia pH PaCO 2 HCO 3 - PaO 2    (Slightly)  pH PaCO 2 HCO 3 - PaO 2    (Slightly) 

23. Copyright © 2006 by Mosby, Inc. Slide 23 Time and Progression of Disease 100 50 30 80 0 0 Pa CO 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa O 2 Disease Onset Pa O 2 or Pa CO 2 Figure 4-2. Pa O 2 and Pa CO 2 trends during acute alveolar hyperventilation.

24. Copyright © 2006 by Mosby, Inc. Slide 24 Arterial Blood Gases Large Pleural Effusion  Acute ventilatory failure with hypoxemia pH PaCO 2 HCO 3 - PaO 2   (Slightly)  pH PaCO 2 HCO 3 - PaO 2   (Slightly) 

25. Copyright © 2006 by Mosby, Inc. Slide 25 Time and Progression of Disease 100 50 30 80 0 Pa O 2 10 20 40 Alveolar Hyperventilation 60 70 90 Point at which PaO 2 declines enough to stimulate peripheral oxygen receptors Pa CO 2 Acute Ventilatory Failure Disease Onset Point at which disease becomes severe and patient begins to become fatigued Pa 0 2 or Pa C0 2 Figure 4-7. PaO 2 and PaCO 2 trends during acute ventilatory failure.

26. Copyright © 2006 by Mosby, Inc. Slide 26 Oxygenation Indices Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal  (severe) O 2 ER Sv O 2   Q S /Q T D O 2 V O 2 C(a-v) O 2   Normal  (severe) O 2 ER Sv O 2  

27. Copyright © 2006 by Mosby, Inc. Slide 27 Hemodynamic Indices (Severe Pleural Effusion) CVP RAPPAPCWP  COSVSVICI  RVSWILVSWIPVRSVR 

28. Copyright © 2006 by Mosby, Inc. Slide 28 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 28 Diagnostic Tests for Pleural Effusions Chest radiography  Most common method of detecting effusions  Upright PA and lateral decubitus are useful.  1-cm meniscus lung to rib allows for thoracentesis

29. Copyright © 2006 by Mosby, Inc. Slide 29 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 29 Diagnostic Tests for Pleural Effusions (cont.) Ultrasonography and computed tomography  Ultrasound is very sensitive to pleural effusions.  May use to localize and direct for thoracentesis  Contrast-enhanced CT is most sensitive study for effusions.

30. Copyright © 2006 by Mosby, Inc. Slide 30 Radiologic Findings Chest radiograph  Blunting of the costophrenic angle  Fluid level on the affected side  Depressed diaphragm  Mediastinal shift (possibly) to unaffected side  Atelectasis  Meniscus sign

31. Copyright © 2006 by Mosby, Inc. Slide 31 Figure 23-2. Right-sided pleural effusion (small black arrow) complicated by a pneumothorax (large white arrow).

32. Copyright © 2006 by Mosby, Inc. Slide 32 Figure 23-3. Chest radiograph of a patient with a pulmonary abscess in the right lung, extrapleural bleeding (arrows), and pleural effusion. (From Rau JL, Jr., Pearce DJ: Understanding chest radiographs, Denver, 1984, Multi-Media Publishing.)

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34. Copyright © 2006 by Mosby, Inc. Slide 34 AVR

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37. Copyright © 2006 by Mosby, Inc. Slide 37 MRSA

38. Copyright © 2006 by Mosby, Inc. Slide 38 General Management of Pleural Effusion  The management of each patient with pleural effusion must be individualized  Should a thoracentesis be performed?  Can the underlying cause be treated?  Should a chest tube be inserted?  Examination of pleural fluid may be needed to assess: Transudate Transudate Exudate Exudate

39. Copyright © 2006 by Mosby, Inc. Slide 39 Mosby items and derived items © 2009 by Mosby, Inc., an affiliate of Elsevier Inc. 39 Thoracentesis  Percutaneous needle aspiration of effusion sample for laboratory analysis  Drainage for lung reexpansion involves placement of a chest tube  Risks include  Artery laceration  Infection  Pneumothorax  Chest tube insertion video Chest tube insertion video Chest tube insertion video

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41. Copyright © 2006 by Mosby, Inc. Slide 41 General Management of Pleural Effusion Respiratory care treatment protocols  Oxygen therapy protocol  Hyperinflation therapy protocol  Mechanical ventilation protocol

42. Copyright © 2006 by Mosby, Inc. Slide 42 General Management of Pleural Effusion Pleurodesis  Chemical or medication injected into the chest cavity  Talc  Tetracycline  Bleomycin sulfate  Produces inflammatory reaction between lungs and inner chest cavity  Causes lung to stick to chest cavity

43. Copyright © 2006 by Mosby, Inc. Slide 43 Review  How much pleural fluid is in the average person’s hemithorax?  8 ml  The protein concentration of pleural fluid is similar to what other fluid in the body?  Interstitial fluid (1.3 – 1.4 g/dl 2 )  Where does the parietal pleura join the visceral pleura?  Hilum

44. Copyright © 2006 by Mosby, Inc. Slide 44  In the upright person, where is the pleural pressure most negative?  Apex of the lung  What is the main route of removal for pleural fluid?  Stomata within parietal pleura to  Intercostal lymphatic vessels to  Lymph nodes in the mediastinum to  Thoracic duct to  Subclavian vein

45. Copyright © 2006 by Mosby, Inc. Slide 45  What are the general causes of increased pleural fluid?  Increased production  Blockade of drainage  When do transudative pleural effusions form?  Hydrostatic and oncotic pressures are abnormal  What is the most common cause of clinical pleural effusions?  CHF

46. Copyright © 2006 by Mosby, Inc. Slide 46  What is the most common condition that causes lymphatic obstruction?  Metastasized CA to the mediastinum  What causes exudative pleural effusions?  Inflammation in lung or pleura  What is a complicated parapneumonic pleural effusion?  High protein content causes fibrin strand formation that loculates pleural effusion

47. Copyright © 2006 by Mosby, Inc. Slide 47  What is the typical presentation of a person with pleurodynia?  Shallow respiration  Deep breathing limited by pain  Refractory hypoxemia  What is the most common cause of large unilateral pleural effusions among persons older than 60?  Malignancies (lung / breast / pleural surface)

48. Copyright © 2006 by Mosby, Inc. Slide 48  Where are effusions most likely to occur following cardiac surgery?  Left side  What is chyle?  Milky fluid produced from digestion in small intestine  How does a chylothorax occur?  Disruption of thoracic duct by malignancy, surgery or trauma  What confirms the diagnosis of chylothorax?  Pleural fluid triglyceride concentration > 110 mg/dl

49. Copyright © 2006 by Mosby, Inc. Slide 49  How much fluid has accumulated in the pleural space when blunting of the costophrenic angle is noted on CXR?  > 1000 ml  Why can oxygenation worsen after thoracentesis?  Changes in ventilation-perfusion matching are not instantaneous  What are the three major risks of thoracentesis?  Intercostal artery laceration  Infection  pneumothorax

50. Copyright © 2006 by Mosby, Inc. Slide 50  What is the maximum amount of fluid to be removed by thoracentesis?  1000 ml  Why is this?  Prevent re-expansion pulmonary edema