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
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)
Lung
Rib Cage
Lung
Rib Cage
Review question:
Pleuritic chest pain indicates inflammation or irritation of the parietal pleura or visceral pleura?
(click on the correct answer)
Think again!
Correct!
The parietal pleura contains sensory nerve endings that can detect pain.
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
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)
Lets review
Click on the words below to send them to their correct position within the diagram. Rib cage
Lung
Parietal Pleura
Picture used with permission Allibone, 2006
Lets 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
Correct!!!
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) 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)
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
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
Lets review
Which is NOT a type of fluid that may cause a pleural effusion? -empyema -chylothorax -pneumothorax -hemothorax
Empyema (pus), Chylothorax (chyle), and hemothorax (blood) are all fluids that may result in a pleural effusion.
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
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)
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
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
Cap
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
Pleurx
Pleurx Catheter
Click on the link below for more information: http://www.denverbiomedical.com
Used with permission from Denver Biomedical
Lets review
Which treatment option requires NO use of anti-inflammatories?
(click on the correct answer)
Think again!
Good Job!
Chemical Pleurodesis This creates inflammation and subsequent fusion of the parietal and visceral pleura Anti-inflammatories will counteract this reaction.
Congratulations!
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.