MANAGEMENT OF

MASSIVE PLEURAL EFFUSION

P i t h e r S a n d y T u l a k
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“Intra” pleural
2 Space

There are 2 pleural membranes

involved in respiration

• visceral pleura

• parietal pleura

The Parietal pleura lines the inside of the thoracic cavity. The visceral
Pleura adheres to the outside of the lung.
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Parietal pleura Visceral pleura

cover the inner surface of envelope all surfaces of
the thoracic cavity,
the lungs, including the
including the diaphragm,
and ribs. interlobar fissures.

At the Hilum
where pulmonary vessels, bronchi, and nerves enter
the lung tissue, the parietal pleura is continuous
with the visceral pleura.
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4 PLEURAL SPACE

The pleura consists of 2 layers

1 – parietal pleura
2 – visceral pleura

The space between the 2 layers is called the

pleural space

Normal width of the pleural space is

10-20 mm
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Up to 25 ml of pleural fluid is
normally present in the
pleural space, an amount not
detectable on conventional
chest radiographs.
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6
PLEURAL EFFUSION

• Pleural effusion is an abnormal accumulation of fluid in the pleural space.

• The 5 major types of pleural effusion are:
• Transudate,
• Exudate,
• Empyema,
• Hemorrhagic pleural effusion or hemothorax and
• Chylous or chyliform effusion.
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PLEURAL EFFUSION 1/4/2020

Pleural effusion: inflammation of the pleura, accompanied by

collection of fluid in the pleural space.
Normal Pleural fluid: 0.3
ml/kg BW
Protein: 1.5 g/dL
pH: alkaline (7.60)
Cells: 1700 cells/ml (75%
macrophages, 23%
lymphocytes & 2%
mesothelial cells)
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PLEURAL EFFUSION 1/4/2020

Pleural fluid is produced by the parietal

pleura and absorbed by the visceral pleura as
a continuous process
Pleural space should be virtually fluid free
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PLEURAL EFFUSION 1/4/2020

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
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10 CAUSES
TRANSUDATIVE EXUDATIVE (usually unilateral)
(usually bilateral ) Parapneumonic effusion
Congestive heart failure Tuberculosis
Cirrhosis Connective tissue disorders
Nephrotic syndrome Malignancy
Constrictive pericarditis Pancreatitis
Peritoneal dialysis Subphrenic abscess
Severe dengue
CHYLOUS Radiation pleuritis
Congenital chylothorax
Post-traumatic
HEMOTHORAX
Blunt trauma
Malignancy
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11 EVALUATION

• History: • Physical:
• Dyspnea
• Dullness to percussion
• Pleuritic chest pain
• Cough
• Decreased breath sounds
• Fever • Absent tactile fremitus
• Hemoptysis • Other findings: ascites, JVP,
• Wt. loss peripheral edema, friction rub,
• Trauma unilateral leg swelling
• Hx. of cancer
• Cardiac surgery
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DEVELOPMENT OF PLEURAL EFFUSION 1/4/2020

12 pulmonary capillary pressure (CHF)

capillary permeability (Pneumonia)
intrapleural pressure (atelectasis)
plasma oncotic pressure (hypoalbuminemia)
pleural membrane permeability (malignancy)
lymphatic obstruction (malignancy)
diaphragmatic defect (hepatic hydrothorax)
thoracic duct rupture (chylothorax)
* KEY SYMPTOM -------> SHORTNESS OF BREATH

FLUID FILLING THE PLEURAL SPACE MAKES IT HARD FOR THE LUNGS TO FULLY
EXPAND, CAUSING THE PATIENT TO TAKE MANY BREATHS SO AS TO GET
ENOUGH OXYGEN.

* IF PARIETAL PLEURA IS IRRITATED -------> MILD PAIN OR A SHARP STABBING

PLEURITIC TYPE OF PAIN.

** SOME PATIENTS WILL HAVE A DRY COUGH.

Occasionally ------> no symptoms at all.
* This is more likely when the effusion results from:
recent abdominal surgery, cancer, or tuberculosis.
* Tapping on the chest will show stony dullness, and decrease breath
sound
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15 DIAGNOSIS OF PLEURAL EFFUSTION

• x ray
 The fluid itself can be seen at the bottom of the
lung or lungs, hiding the normal lung structure.
 If heart failure is present, the x-ray shadow of
the heart will be enlarged.
Ultrasound may disclose a small effusion that
caused no abnormal findings during chest
examination.
C.T. scan is very helpful if the lungs themselves
are diseased.
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16 OR
TOTAL LUNG ATELECTASIS

Total Atelectasis Massive pleural effusion

Heart and mediastinum Heart and mediastinum
shifted toward whited out hemithorax shifted away from whited
out hemithorax
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Massive effusion is defined as:
“effusion that radiologically fills about 2/3 or more of the thoracic cavity”
Frequently related with malignity
Worsening of the quality of life is mostly related to cardiac and
pulmonary functions.
Drainage of massive pleural effusion has corrective effects on
hemodynamic and pulmonary functions
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18 ETIOLOGY OF NONLARGE, LARGE, AND MASSIVE

PLEURAL EFFUSIONS
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19 PRIMARY MALIGNANCY IN CASES OF MALIGNANT

EFFUSION
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20 TREATMENT

• The main goals in the treatment of pleural effusions are :

• The removal of the effusion,
• The improvement in symptoms and
• The prevention of re-accumulation.
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21 MANAGEMENT OF MASSIVE PLEURAL EFFUSIONS

•Management depends on :
• Degree of symptoms (performance status)
• Curability of the tumor, and
• The expected life span
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MANAGEMENT ALGORITHM OF THE OF LUNG 1/4/2020

22
CANCER PRIMARY MALIGNANT PLEURAL
EFFUSIONS.
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23 MANAGEMENT OF MASSIVE PLEURAL EFFUSIONS

• In a patient in poor condition with short life span (< 3 months),

observation or repeated tapping (therapeutic thoracocentesis) is
preferred, with the likelihood that 100% of the effusions will recur
within the month.
• Pleural effusions in patients with extremely chemosensitive
tumors (lymphomas, testiculartumors, small cell lung cancer) can be
ignored as most will disappear with systemic chemotherapy.
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24 THERAPEUTIC THORACENTESIS

• Relief of symptoms is the main goal of

therapeutic drainage in these patients.
• The only absolute contraindication to
thoracentesis is active cutaneous infection at the
puncture site.
• Some relative contraindications include severe
bleeding diathesis, systemic anticoagulation, and a
small volume of fluid.
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CHEST TUBE
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26 INDICATIONS

• Pneumothorax • Malignant pleural effusion

• in any ventilated patient • Empyema and complicated parapneumonic
• tension pneumothorax after initial needle
pleural effusion
relief
• Traumatic haemopneumothorax
• persistent or recurrent pneumothorax
• Postoperative—for example, thoracotomy,
after simple aspiration
• large secondary spontaneous pneumothorax oesophagectomy, cardiac surgery
in patients over 50 years
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27 CONTRAINDICATIONS

• No absolute contraindications
• Coagulopathy (consider correcting if non-emergent)
• Prior chest surgery (consider adjusting site)
• Rib fractures
• Loculations
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28 LOCATION

• Insertion site should be no lower than 5th intercostal

space. This avoids intra-abdominal placement
• Place between anterior and midaxillary lines
• Direct anteriorly or posteriorly for pneumothorax
• Direct posteriorly for effusions
• Avoid inserting into fissure by directing the tube
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29 PATIENT POSITION

• The preferred position for drain insertion is on the bed,

slightly rotated, with the arm on the side of the lesion
behind the patient’s head to expose the axillary area.
• An alternative is for the patient to sit upright leaning
over an adjacent table with a pillow or in the lateral
decubitus position.
• Insertion should be in the “safe triangle”
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31 THORACIC DRAINAGE CATHETER WITH

TROCAR
• Catheter is provided with trocar for
easy penetration, placement and handling
• Proximal end fitted with tapered
connector for easy connection to the
drainage bottle
• Size : 8, 10, 12, 14, 16, 18, 20, 22, 24, 28,
32, 36, 40 FG
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32 CHEST TUBE

• Chest tube allows

continuous, large
volume drainage of air
or liquid from the
pleural space
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Second Chamber 1/4/2020

33
When there is fluid it’s time for a second chamber.

2 1
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Third Chamber
34
if the fluid is thick or just needs extra help to drain
3rd chamber.

1 water seal chamber

2 drainage chamber
3 suction chamber

2 1 3
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35

PIGTAIL
CATHETER
THORACENTESIS
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36 PIGTAIL CATHETER

• Pigtails are the intercostal catheter (ICC) insertion,

another choice in the drainage of pleural effusions
• The preferred location is the 4th or 5th intercostal
space, above the rib (intercostal vessels run under the
rib) in the mid axillary line well clear of the nipple.
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37
Relative sizes of the average intercostal
distance in the adult (fifth intercostal
space, mid-axillary line), two commonly
used :
• chest tube sizes (24 F and 32 F), and
• the 8.3 F pigtail catheter.
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38 PIGTAIL CATHETER
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39 PIGTAIL CATHETER

• optimal placement is in the

safety triangle, bordered by the
lateral edge of the pectoral
muscle, the lateral edge of the
latisimus dorsi and a line along
the fifth intercostal space at
the level of the nipple.
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40 PIGTAIL CATHETER

• Remove the syringe from the

needle and pass the guide wire
in just enough to clear the
needle.
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41 PIGTAIL CATHETER

Make a small incision in the skin adjacent to the

guide wire just as in central line insertion, then pass
the dilator over the wire and into the pleural space.
You should feel the dilator “ give way” once you
are in. Check that the guide wire is moving freely
in and out of the dilator throughout this process to
avoid kinking the wire.
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42 PIGTAIL CATHETER

• Remove the syringe from the needle and pass

the guide wire in just enough to clear the needle.
Most of the guide wire should be hanging out. If
inserted too far it will be difficult to direct the
pigtail catheter superiorly into the apex of the
thorax.
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43 COMMON PATIENT POSITIONS FOR CHEST DRAIN

INSERTION
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44
TRIANGLE OF SAFETY
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46
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52 PLEURODESIS
(PLEURAL SCLEROSIS)
• Pleural sclerosis (pleurodesis) is considered for patients with uncontrolled and recurrent
symptomatic malignant effusions
• A sclerosing agent is instilled into the pleural cavity via a tube thoracostomy to produce a
chemical serositis and subsequent fibrosis of the pleura.
• Pleural sclerosis should be attempted only if the lung expands fully after fluid removal.
• The visceral and parietal pleura need to be approximated closely, obliterating the pleural
cavity so that fibrotic healing achieves pleural symphysis
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53 THE STEPS OF CHEMICAL PLEURODESIS

• Pleural fluid is drained out using small bore intercostal tube.

• Lung re-expansion is confirmed by chest X-ray.

• Wait until pleural fluid drainage is less than 150 ml daily.
• Sclerosant is instilled after premedication.
• Patient is rotated to ensure even spread of the sclerosant.
• Repeat chest X-ray is taken 24 hours later to reconfirm lung expansion.
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54 SCLEROSANTS FOR PLEURODESIS

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55
SCLEROSING AGENTS FOR PLEURODESIS/SUCCESS RATE.
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56 FAILURE OF PLEURODESIS

• Failure of pleurodesis occurs in cases of :

• partial reexpansion of the lung, the fluid could not be drained
due to multiple loculations.
• Incomplete lung reexpansion may be due to a thickened
visceral peel (“trapped lung”), pleural loculations, proximal large
airway obstruction, or a persistent air leak.
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