Prepared By:

Honey May R. Vicente

Objectives:
To review the etiology and basic pathophysiology
concepts related to pleural effusion.
To understand indications for thoracentesis.
To outline a systematic approach to diagnosing a cause
of effusion.
To be able to differentiate exudative from transudative
effusions.
To understand the basic principles of initial management
of pleural effusions.


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

Picture used with permission Allibone, 2006

Rib
Cage
Lung
thin, transparent,
serous membrane
which lines the thoracic
cavity
a potential space
between the parietal
pleura and visceral
pleura


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
Picture used with permission Allibone, 2006

Lung
Rib
Cage
Layers of the lung
Visceral Pleura
Lines the entire
surface of the lung
Contains NO sensory
nerve endings that
detect pain
Picture used with permission Allibone, 2006
Lung
Rib
Cage
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)
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)
Used with permission (Allibone, 2006, p. 59)
Click on the pleural
effusion in the picture!
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
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Congestive Heart Failure
CHF
As the heart fails, pressure in the vein going through the lungs
starts to rise.
Due to the hearts 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

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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






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)
-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
Picture used with permission from Denver Biomedical
In chest wall
where fluid is
accumulating
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
Some patients
experience pain upon
drainage, slowing the
drainage with the
clamp or stopping
briefly may relieve
this pain

Cap
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)