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

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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

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

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.

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 100-200ml 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)

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

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

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

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

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

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

The pleural space typically contains how much fluid? Review question: The pleural space typically contains how much fluid? 5-15ml 50-100ml 100-200ml

Think again! about 100-200ml of fluid circulates though the pleural space within a 24-hour period

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

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.

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)

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)

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

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

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

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

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

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)

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)

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)

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)

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)

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

Main causes of a Pleural Effusion Congestive Heart Failure (CHF) Liver failure Infection Atelectasis Cancer Trauma Click on home icon when finished viewing these topics

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

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

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)

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

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

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)

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

Pleural fluid types Transudate Exudate Empyema Chyle Hemothorax Click on home icon when finished viewing these topics

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

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

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)

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

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

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

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.

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

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!

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

Diagnosis Fluid analysis confirms a pleural effusion Normal pleural fluid has the following characteristics: clear ultrafiltrate of plasma pH 7.60-7.64 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)

Non-surgical Treatment Options Thoracentesis tPA Chemical Pleurodesis Pleurx catheter

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)

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

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

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

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

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

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

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.

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

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

Pleurx Photo by Kady Rejret, 2007

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)

Used with permission from Denver Biomedical Pleurx Catheter Click on the link below for more information: http://www.denverbiomedical.com Used with permission from Denver Biomedical

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

Think again!

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

You have successfully completely this tutorial! Congratulations! Kady Rejret, RN, BSN You have successfully completely this tutorial!

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 http://www.emedicine.com 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 http://www.denverbiomedical.com 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 http://www.mayoclinic.com/health National Cancer Institute. (2006). Retrieved March 23, 2007 from http://www.cancer.gov National Lung Health Education Program. (2000). Retrieved April 11, 2007 from www.nlhep.org Porth,C.M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed.) Lippincott. Rejret, K. (2007). Personal Photograph. Unattributed clipart: Microsoft Office, 2006.