INTRODUCTION

:
Pleural effusion, the collection of fluid in the pleural space is not a disease but it is a sign of various other serious disorder. The client with lung disorders are a challenge to nurse providing care. Normally the pleural space contains 5 to 15 ml of fluid which act as a lubricant that allows the pleural surface to move without friction. It may be a complication of heart failure, tb, pneumonia, pulmonary and viral infections etc.

MEANING:
Any abnormal amount of pleural fluid in the pleural space is called pleural effusion. It is the collection in excess of physiological amounts, i.e. More than 30 – 50 ml.

NORMAL PHYSIOLOGY OF PLEURAL FUID
Each lung is covered by a thin membrane called the visceral pleura, which adheres closely to the alveoli of the lungs. The ribs and connective tissues of the chest wall are covered on the inner surface by a similar membrane called the parietal pleura. It covers not only the ribs but also mediastinum and the diaphragm. There is a space between the visceral and parietal pleura that averages 10- 20 mm in width and is filled with pleural fluid. This pleural fluid enters the pleural space across both the visceral and parietal pleurae, particularly when the interstitial pressure within either the lung or chest wall is increased. The main route for pleural fluid removal is small holes within the parietal pleura called stomata. The parietal stomata connects with intercoastal lymphatic vessels under the ribs that drain posteriorly into the medistinum. In the mediastinum, the pleural fluid drains into the thoracic duct, a large lymphatic channel within the chest, which empties into the left subclavian vein. Abnormalities of increased fluid production or blockade of drainage can cause pleural fluid to accumulate. The lymphatic exit rate may be decreased by obstruction of the parietal pleural stomas, inhibition of lymphatic contractility, infiltration of draining parasternal lympnodes and rising systemic venous pressure into which the lymph drains.

CAUSES OF PLEURAL EFFUSION:
Pleural effusion can be classified or pathlogicprocess are explained basis on the causative factors of each. Depends upon the cause it is divided into the following: Transudative pleural effusion Exudative pleural effusion

In nephritic syndrome. which causes exudation that contains large number of rbcs. Another rare cause is the obstruction of venacava. an absolute pleural fluid LDH level less than 2/3rd normal for serum suggests the presence of a transudate. which is bilateral in 88% of cases. It results in the formation of pulmonary throboemboli. In patients with nephrosis.TRANSUDATIVE PLEURAL EFFUSION Any pleral effusion that forms when the integrity of the pleural space is undamaged is called transudative pleural effusion. usually incase of thrombosis. In the absence of serum values . A pleural fluid total concentration less than 50 % of the serum level and LDH value less than 60 % of the serum value indicate the presence of a transudative pleural effusion. there is leakage of protein and results in decreased oncotic pressure within the blood to hold appropriate amount of fluid within the blood vessels. pericardial effusion and generalized peripheral edema. pleural effusion. The primary cause for pleural effusion is the abnormality in (increase)hydrostatic pressure and (decrease) oncotic pressure. Approximately half of the patients with congestive heart failure will develop transudative effusion. a) CONGESTIVE HEART FAILURE: This is the most important cause of transudativepleural effusion. Following are the certain diseases that results in pleural effusion. These patients becomes edematous and fluid leakes into the lung interstitium and pleural space. protein s which keeps blood from clotting is deficient from leaking into the urine. . Elevated pulmonary venous pressure Increased interstitial fluid in lungs Increased lung water decompress into pleural space Limited capability to remove fluid through the intercoastal vein (increased systemic venous pressure) The capacity of pleural lymphatic drainages has exceeded Pleural effusion b) RENAL DISEASES Nephrotic syndrome and renal failure are the important causes in which hypoproteinemia and fluid overload results in gross asitis. Elevation of pressure in the left atrium and pulmonary veins is the hallmark of congestive heart failure.

pleural effusion is more common after the surgery. Bone marrow transplantation is also associated with pleural effusion which is transudative in nature. The pleural space is under negative pressure during inspiration and because ascitc fluid is under positive pressure. any small hole in the diaphragm can resultin movement of ascetic fluid in the pleural space to form hepatic hydrothorax. In case of ascitis. Peritoneal dialysate can migrate into the pleural cavity in patients undergoing ambulatory peritoneal dialysis. f) FONTAN PROCEDURE With the fontan procedure. d) ATELECTASIS When segments of lung collapse. EXUDATIVE PLEURAL EFFUSION An Exudative pleural effusion is by inflammation in the lung or pleura. e) LYMPHATIC OBSTRUCTION Lymphatic obstruction within the medistinum causes poor pleural fluid regressfrom the pleural space. an anastomosis is created between the superior venacava. Low protein level in the blood allows fluid to leak into the interstitial tissue and pleural space.c) HEPATIC DISEASE: Transudative effusion due to hepatic dysfunction complicates hepatic cirrhosis in about 6% of the cases.although the pleural space is otherwise normal. the end stage liver disease causes transudative fluid to accumulate in the abdomen. This type of pleural effusion has more amount of protein and inflammatory cells present than transudative. Pleural effusion is rarely formed until the serum albumin level is less than 1. Hypoalbumenemia results as a complication of aids or chronic liver disease.Hypoalbuminaemia and asitis are the important pathogenic mechanism. Important . these effusions regress. With relief of bronchial obstruction and postoperative pain.8 mg/dl. intrapleural pressure becomes more negative and can produce small effusions. The most common case is cancer that metastasizes to the mediastinum. A central venous line which is inappropriately placed in the pleural space can infuse large amount of transudative effusion into the pleural space. It is seen only in recipient of allogenic transplants and in children. with preference for the right side. the right atrium or the inferior venacava and pulmonary artery to bypass the right ventricle ususlly in tricuspid atersia . g) RARE CAUSES Urinothorax occurs after rupture of ureter causing a urine leak into the retroperitoneal space which refluxes into the chest.

pleural effusion is reports to occur with infectious hepatitis. TB (1. small pleural effusions and pain. Diffuse malignant pleural mesothelioma is defined as autocanthous pleural malignancy arising from the residual mesothelial population and its stroma. influenza virus and patients with HIV virus.(in the presence of specific cell mediated immunity tubercle bacilli provoke an intense hyper sensitivity reaction and outporing of fluid) d) MALIGNANT Neoplastic involvement of pleura may results from direct invasion (bronchial carcinoma). c) TUBERCULOUS PLEURISY Tuberculous pleural effusion occurs when caseous granuloma in the lung ruptures through the visceral pleural surface causing an exudative inflammatory effusion. b) VIRAL PLEURISY Viral lung infections can cause pleural inflammation. Experiments shows that such effusions results from body’s immune reaction to tuberculin proteins.Upper abdominal operations causes inflammation of the diaphragm and effusion.55%) a) PARAPNEUMONIC Parapneumonic pleural effusion is as a result of inflammation of the lung parenchyma. e) POSTOPERATIVE A variety of operations involving the chest or upper abdomen produce pleural fluid. lymphatic assess(malignant lymphoma. hematogenousspread(various primaries). It is almost exclusively associated with asbestos exposure. Pleural effusion forms in pneumonia because of inflammation in the lungs increases interstitial lung water and pleural fluid production. It develops when the pleural fluid has high protein content to clot. Viral infection is responsible for much higher percentage of pleural effusion without parenchymal infiltration. carcinoma of the breast). Disruption of the .causes are: (1) infectious conditions (50 %) (2) malignant disease (25 %) (3) thromboembolic disease (19%) (4) GI disease (4%) (5) autoimmune. The net result is collection of pleural fliud into different loculi within the pleural cavity. dengue hemmorhagic fever. Effusion with no detectable pleural invasion of pleura is called paramalignant. Effusion following cardiac surgery usually arepredominant on the left side and tend to be bloody. The clotting cause the fibrin strand to span the visceral and parietal pleurae. f) CHYLOTHORAX The thoracic duct is a lymphatic channel that runs from the abdomen through the mediastinum to enter the abdomen through the mediastinum to enter the left subclavian vein.

CLINICAL FEATURES  Pleural fluid more than 30 – 50 ml  Progressive dyspnoea with decreased chest wall movement on the affected side. attetenuated or abolished breath sounds and fremitus . Other causes are related to AIDS and organ transplantation especially lung transplantation.(classical sign of cresent or typical pleural effusion)  Decreased vocal resonance and fremitus  Pleural friction rub. suppurative complication due to infection. k) MISCELLANEOUS CONDITIONS Uremic pleurisy. j) DRUG INDUCED PLEURAL EFFUSION Pleural effusion is associated with certain drug such as Dantrolenesodium(lomg acting skeletal muscle relaxant).which may rupture into the pleural space and can cause a chylothorax. Although it is seen most commonly seen after a penetrating or blunt chest trauma. The most common causes are trauma. a rare complication of chronic renal failure that describes an exudative inflammatory blood stained effusion may insidiously progress to fibrosis. Interleukin 2. The pleural fluid appears bilious and treatment consists of re-establishment of biliary drainage. rheumatoid arthritis etc.  Dullness to percussion . h) CONNECTIVE TISSUE DISORDERS Pleural effusions are seen in connective tissue disorders like systemic lupus erythomatous.  Dyspnoea of varying degrees. Methysergide. Amiodarone. a number of medical conditions can also lead to these disorders. Procarbazine. Ergot alkaloids.  Mediastinal shift . surgery and malignancy.thoracic duct anywhere along the course of duct ca cause leakage of chyle into the mediastinum. The fistula may be secondary to trauma. g) HEMOTHORAX It is the presence of blood in the pleural space. i) BILIOUS PLEURAL EFFUSION It is due to a fistula from the biliary tree to the pleral space.  In large effusion there may be tracheal deviation away from the effusion  Bulging of intercoastal space  Unilaterraly lagging breath excursions.

biochemical.it may be hemmorhagic (tumor). ULTRASOUND Pleural fluid and loculli can be used to locate the presence of pleural effusion. which interfers with the detection of pulmonary infilterates. Glucose and pH level helps to identify the etiology. Orthopnea  Dry non productive cough  Snowball crunching sign on auscultation DIAGNOSTIC PROCEDURES CHEST RADIOGRAPHY It is better to obtain a chest radiograph with the patient in upright position to show a pleural meniscus at the pleural fluid meniscus at the costophrenic angles. suppurative. In supine position the radiograph shows a generalized haze. The amount of protein. viscosity and smell leads to the primary categorization into serous. Measurement of pleural amylase helps in the identification of pancreatic disease. cholesterol etc. the chest CT gives information about the underlying lung parenchyma and the primary process causing the effusion. ANALYSIS OF PLEURAL FLUID In thoracentesis the pleural fluid is collected percutaneously. In lateral position the presence of 1 cm meniscus from the lung to the rib margin suggest that the effusion is large. sanginous or chylous effusion. LDH.3) are charecteristics of empyema.2 gm/dl suggest the presence of transudate. COMPUTED TOMOGRAPHY It helps to delineate the pleural membrane and differentiate peripheral lung consolidation from pleural fluid formation. diaphragm motility etc. PET identifies malignant effusion with a sensitivity of 91 % and specificity of 100 %. ph<7. which is an indication of chest wall tumor. In addition to show the size and location of pleural effusion. tuberculosis and rheumatic effusion. helps to identify the site for thoracentesis. cytological and microbiological assessment. It describes the charectersistics of effusion (exudative/transudative). . Low level(glucose <0. MRI & PET MRI can be used to identify the thin layer of extrapleural fat. are used for analysis. A sample of more than 20 ml is needed for basic macroscopic.5. Serum albumin level of more than 1. The general appearance including color.

1. pleural-peritoneal shunt. According to Light's criteria (Light. TUBERCULOSIS PLEURISY . 1972). Frusemide and combination of thiazide and spirinolactone are usually used diuretics. rich in cholesterol (recurrent effusion as in TB). it indicates empyema. fluid overload and protein deficiency.chylorous (in lymphatic obstruction or trauma to thoracic duct). It is mainly used in the diagnosis of tuberculus or malignant pleural effusion. et al. transudate versus exudate. The ratio of pleural fluid protein to serum protein is greater than 0. The main indication is undiagnosed progressive pleural disease that cannot be approached by thoracotomy. if there is high WBC count and fluid is purulent . Pleural fluid LDH is greater than 0. a pleural effusion is likely exudative if at least one of the following exist. The ratio of pleural fluid LDH and serum LDH is greater than 0.020 > 2.012 Protein content < 2 g/dl Cholesterol content < 45 mg/dl PLEURAL BIOPSY Any unexplained exudative effusion is the indication for pleural biopsy. TRANSUDATIVE Appearance Clear Specific gravity < 1. b) Open biopsy of pleura: thoracotomy with direct biopsy of the pleura provides the best visualization of the pleura and best biopsy.6 or ⅔times the normal upper limit for serum. Other treatment methods are chest tube insertion. Diuretics and albumin replacement in severe hypoproteinemic conditions are effective approach. relies on a comparison of the chemistries in the pleural fluid to those in the blood. using Light's criteria. Transudate VS Exudate: Light's criteria An accurate diagnosis of the cause of the effusion.9 g/dl > 45 mg/dl MANAGEMENT OF PLEURAL EFFUSION TRANSUDATIVE EFFUSION It usually responds to the correction or elimination of the underlying systemic pathology such as decreased myocardial contractility. a) Needle biopsy of pleura: small specimen of parietal pleura is obtained. EXUDATIVE Cloudy > 1. The needles that are used commonly are the Cope needle and Abrams needle. pleurodesis.6 3.5 2.

It is most commonly used in the management of symptomatic pleural effusion caused by cancer. d-penicillamine. methotrexate.fix the drain with a transparent dressing which allows the inspection of drain site for leaking or kinking. Large bore transparent silicon or pvc tubes (>24 fr) about 60-70 cm in length and distal perforations over 18-20 cm are optimum specifications for thoracic drainage therapy. minocycline and talk. Topical analgesia-200 to 250 mg lidocaine is useful in the reduction of pain during pleurodesis. cyclophosphamide. Systemic steroid therapy is often suggested as it mitigate the acute exudative symptoms and to prevent fibrothorax. Methods to produce pleural symphysis includes surgical abrasion and the application of intrapleural chemicals such ac doxycycline. It is wise to administer intravasal volume by isotonic volume replacement to prevent hypovoluemic circulatory syncope. OTHER NON BACTERIAL INFLAMMATORY DISEASES The main drug of choice are the corticosteroids. ciclosporin etc. The insertion of chest tube is conventionally performed in the lateral decubitus position. MALIGNANT EFFUSION Percutaneous irradiation in pleural malignancy is used almost exclusively as an adjunct to palliative therapy to the tuimor that obstructing the pleuropulmonary lymphatic clearance system. keeping a 3-4 cm safety distance from the diaphragm. Drainage should not exceed 1l/h. suction level of 10-20 cm H2o is used. The factors that influences the efficacy of the treatment are: . chloroquine. In monolocular effusions the safe and reliable standard entry point for these instruments would be the fifth and sixth intercoastal space in the mid or anterior axillary line. LOCAL INTERVENTIONS CHEST TUBE DRAINAGE In cases where there is large exudates. A radical surgery is considered in advance stages of carcinoma which includes the resection of extrapleuralpneumectomy. The therapeutic benefit of thoracoscopicdebridement with peeling of massive fibrin memberanes and loculations has not been validated but it was proved effective in clinical trials.whole lung irradiation for the management of malignant lymphoma. the chest tube draining is the best method. For routine use. LONG TERM CONTROL (PLEURODESIS) It is the process of fusing the parietal and visceral pleurae wiyh fibrotic reaction that prevents further pleural fluid formation. resection of diaphragm etc.It can be diagnosed effectively by endoscopic biopsy techniques. non-steroidal anti-inflammatory drugs and group of drug called disease modifying anti-rheumatic drugs (dmards) that includes azathioprine. but in thick exudates or malexpansion of lungs a suction level of 40 cm H2O is used. In patients with severe breathing difficulty it is carried out in upright position. Premedication with atropine is indicated to avoid vaso-vagal syncope.

The device consists of a double valved pump with an afferent (pleural) and efferent (peritoneal) tube. Indications are failure of pleurdesis (trapped lungs and chylothorax). adventitious breath sounds and dyspnoea. which produces an intense inflammatory reaction that promotes adhesion formation between the two layers . Patient outcome:  Demonstrates effective coughing and increased air exchange.  Assist the patient to a sitting position with head slightly flexed. NURSING MANAGEMENT 1) Ineffective airway clearance related to retained secretions and excessive mucous as evidenced by ineffective cough.  Remove secretions by encouraging coughing or by suctioning  Regulate the fluid intake to optimize the fluid balance and liquefy the secretions. PLEURECTOMY (PLEURAL STRIPPING) Surgical stripping of the parietal pleura away from visceral pleura. Complete removal of pleural fluid  Full lung expansion  Equal pleural distribution of the agent and continous drainage after instillation until the fluid production ceases. shoulders relaxed and knees flexed to improve the respiratory status.fluid moves from the pleural space to the pump chamber and then to peritoneal cavity. decreased breath sounds and abnormal pulse oximetry.PERITONEAL SHUNTING In refractory chronic transudative and exudative effusions a pleuroperitoneal Denver shunt can be used. Ultrasound follow up is essential to confirm the efficacy of the treatment. PLEURO -. 2) Impaired gas exchange related to fluid collection in lungs and pleural space as evidenced by drainage chest from chest tube.  Experiences normal breath sounds Interventions  Auscultate breath sounds and note the area of decreased or absent breath sound and for the presence of adventitious sounds for evaluating the effectiveness to treatment. . the patient manually pumps on the reservoir daily to move fluid from the pleural space to the peritoneal space. It may be inserted using local anesthesia without important complications.

the symptoms will be relieved after the treatment of underlying disorder and patient can resume the actions of daily living once he is asymptomatic. Interventions  Monitor respiratory and oxygenation status to allow early recognition of significant changes in respiratory status. the health professionals should attend to their needs and treatment methods is focused on the symptomatic relief and . pleuritc related to inflammatory process Outcome: Verbalize reduction in pain Interventions  monitor the respiratory rate. In patients with non-malignant pleural effusion. Benign asbestos pleural effusion generally resolves leaving behind some residual on the chest radiograph. But in patients with malignant pleural effusion. Patients with carcinoma of lungs.  Keep the drainage container below the chest level to prevent tension pneumothorax. 3) Acute pain.  provide the patient optimal pain relief with prescribed analgesics.  institute and modify the pain control measures on the basis of patient’s response.  Monitor for bubbling of the suction chamber of the chest tube drainage system. depth and rhyrhm of respiration. stomach and ovary tend to have survival time of only a few months from the time pleral effusion has diagnosed: patients with breast cancer may survive longer.  Position to alleviate dyspnoea to increase the comfort of the patient. PROGNOSIS: The diagnosis of a malignant pleural effusion signals a poor prognosis.  Initite and maintain supplemental oxygen to treat hypoxemia.  Ensure that all tubing connections are securely attached and taped to prevent air leaks.  position the patient to alleviate the symptoms of dyspnoea. REHABILITATION AND FOLLOW-UP The rehabilitation of the patients with pleural effusion mainly depends on the underlying cause of the disorder.  auscultate breath sounds and note the area of decreased or absent breath sound and for the presence of adventitious sounds.Outcome: Demonstrates full lung expansion with normal oxygen saturation.

Treatment varies considerably and depends on the specific cause. Alteplaseinthetreatmentof complicated parapneumoniceffusion Thetreatmentof complex parapneumoniceffusions in childrenremains controversial. No air embolismor infection was observed. RESULTS: Shunt occlusion was observed in one case (chylothorax) 4 weeksafter implantation. a potent mitogen for the vascular endothelium. is also known to be an autocrine growth factor for MPM. with some advocating less invasive. minimally invasivealternative to other surgical methods for treatment of recurrentnonmalignant pleural effusion. Malignant pleural mesothelioma (MPM) is an aggressive malignant tumor of mesothelial origin associated with asbestos exposure. Pleural effusion VEGF concentration could be useful as an aid for the diagnosis of MPM and as a prognostic factor. RECENT ADVANCES: Pleural effusion VEGF levels as a prognostic factor of malignant pleural mesothelioma. kidney or abdominal organs.. Vascular endothelial growth factor (VEGF). All systems were patent throughoutthe observation period of 1 to 40 months (mean = 13. and the patients with advanced stage MPM showed higher levels of VEGF than the early stage MPM patients. Patients with MPM had significantly higher pleural effusion VEGF levels than a population with non-malignant pleuritis or lung cancer involving malignant pleural effusion. Follow-up is essential for both the cases and the family members should be educated regarding the adherence to medical regimen.and none of the patients required further treatment for pleuraleffusion.Pleurovenous shunting (PVS) representsan alternative. CONCLUSION Pleural effusion is a common clinical finding in patients with underlying disease of the neighbouring lung or the pleural space itself. Pleurovenous shunting in the treatment of nonmalignant pleural effusion The goals of treatment of chronic nonmalignant pleural effusionare relief of dyspnea and improved quality of life. strictlymedical management and others supporting a more aggressive . There was one early death. CONCLUSIONS: Pleurovenous shunting offers an efficient. MPM has a limited response to conventional chemotherapy and radiotherapy so early diagnosis of MPM is very important.palliative aspect. It is also a manifestation of extrapulmonary disorders such as heart. which was notrelated to the procedure (hepatic failure). Cure is possible in many instances and symptomatic relief can be provided for nearly all patients with pleural effusion.All patients received Denver shuntsystems from the pleural cavity to either the subclavian orjugular vein.3 months). minimally invasive method.

2005 2. Areas with fat on the pleural layer appeared yellow under the conventional mode. Textbook of respiratory medicine.2007.8th Edition. Genofre ED.New Delhi: Saunders Elsevier. Principles of Harrison’s internal medicine.We report the first case of successful resolution of a complexparapneumoniceffusionin a 16-month-old girl with the use oftissue plasminogen activator (alteplase). 21st Edition. 17th Edition. Mason RJ. 2009 (103) 91-97 9. Vargas SF. Nadel AJ.HawksHJ. Fishman’s pulmonary disease and disorders. 1998 3. JAPI. 4th edition. 2008 4. Swami S. Teixireae LR. 7. In the majority of patients with malignant pleural diseases. Kaiser LR.London: McGraw Hill Publications. Marchi E.2005. Murray FJ. Kasper DL. Novaes PN. Lobo I. Fishman AP. offer new options for effective treatment. Philadelphia: Elsevier publications. 3rd edition. Fauci AS. Marchi E. 6. Lomgo DL. Journal of respiratory medicine. Talc pleurodesis: evidence of systemic inflammatory response to small size talc particles. 2010 5. (58) 251-52 . Missouri: Saunders Publications. 2009 (103) 595-600 8. Recentadvances.Therefore. Journal of respiratory medicine. BIBLIOGRAPHY 1.Senior RM. but orange under the autofluorescence mode. London:Churchil Livingstone. the sensitivity of AFT for detecting malignant lesions on the pleural surface was 100%. Elias AJ.approachof thoracotomy with or without decortication. Vargas FS. London:McGraw publications. Jayalakshmi TK.et al. Autofluorescence video thoracoscopy in exudative pleural effusions: Videothoracoscopy has been proven to be a safe tool to establish the diagnosis in >90% of patients with exudative pleural effusions of unknown origin. Nair G.including video-assisted thoracoscopic surgery and intrapleuralfibrinolytictherapy. Black MJ. Influence of parecoxib in experimental pleurodesis.in all cases of histologically proven malignant pleural disease the colour of the affected area of the pleura changed from white/pink to red in a darker or slighter attenuation . Introduction to Medical surgical nursing.4th Edition. 2010 Apr. Davidson S.Medical surgical n nursing. Acenico MP. infused via a catheterinthepleural space. the endoscopic appearance of pleural lesions during white light thoracoscopy is suggestive of malignancy. Linton AD. Grippi AM. Davidson’s principles and practices of medicine.

Jyothi Chakraborthy Assistant Professor Dept. Medical Surgical Nursing Manipal College Of Nursing Submitted By. Roona Jayan Roll no: 100503001 1st Year MSc Nursing MCON. Manipal . Ms.ASSIGNMENT ON MEDICAL SURGICAL NURSING PLEURAL EFFUSION Submitted To. Mrs.

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