1. PLEURAL
EFFUSION
PGCPN ‘11 - Group 2

2. WHAT IS PLEURAL EFFUSION?
• Unusual fluid in the lungs
• Build up of excess fluid
between the layers of the
pleura outside the lungs.

4. INCIDENCE
It is very common in
the Philippines, with
approximately 100,000
cases diagnosed each
year.

5. CATEGORIES OF PLEURAL EFFUSION
UNCOMPLICATED COMPLICATED
Fluid:
Free of Serious
Inflammation or infection
Significant Inflammation or
infection
Rarely causes
permanent Lung problems
Causes Impaired Breathing.

6. TRANSUDATIVE EXUDATIVE
Fluid Similar Has excess Protein,
blood, and/or
evidence of
inflammation and
infection.
Drainage Rarely requires
drainage unless very
large.
Maybe required
depending on its size
and the severity of
inflammation.
Caused by CHF Pneumonia and Lung
Cancer
CATEGORIES OF PLEURAL EFFUSION

7. PATHOPHYSIOLOGY
 The pleural space is bordered by the
parietal and visceral pleurae.
 PARIETAL PLEURA - covers the inner
surface of the thoracic cavity,
including the mediastinum,
diaphragm, and ribs.
 VISCERAL PLEURA - envelops all lung
surfaces, including the interlobar
fissures.

8. PATHOPHYSIOLOGY
The normal pleural space
contains approximately 1 mL of
fluid, representing the balance
between (1) hydrostatic and
oncotic forces in the visceral
and parietal pleural vessels and
(2) extensive lymphatic
drainage.
DISRUPTION OF
BALANCE

9. Pleural Effusion
The etiologic spectrum of pleural effusion is extensive.
Most pleural effusions are caused by congestive heart
failure, pneumonia, malignancy, or pulmonary embolism.
an indicator of an
underlying
disease process
May be
pulmonary
or non-
pulmonary
May be
acute or
chronic

10. The following mechanisms play a role in
the formation of pleural effusion:
 Altered permeability of the pleural membranes
(eg, inflammation, malignancy, pulmonary
embolus)
 Reduction in intravascular oncotic pressure
(eg, hypoalbuminemia, cirrhosis)
 Increased capillary permeability or vascular
disruption (eg, trauma, malignancy, inflammation,
infection, pulmonary infarction, drug
hypersensitivity, uremia, pancreatitis)
 Increased capillary hydrostatic pressure in the
systemic and/or pulmonary circulation
(eg, congestive heart failure, superior vena cava
syndrome)

11.  Reduction of pressure in the pleural space,
preventing full lung expansion (eg, extensive
atelectasis, mesothelioma)
 Decreased lymphatic drainage or complete
blockage, including thoracic duct obstruction
or rupture (eg, malignancy, trauma)
 Increased peritoneal fluid, with migration across
the diaphragm via the lymphatics or structural
defect (eg, cirrhosis, peritoneal dialysis)
 Movement of fluid from pulmonary edema
across the visceral pleura
 Persistent increase in pleural fluid oncotic
pressure from an existing pleural effusion,
causing further fluid accumulation
The following mechanisms play a role in
the formation of pleural effusion:

12. PATHOPHYSIOLOGY – SIGNS / SYMPTOMS
The net result of effusion formation is a flattening or inversion of
the diaphragm, mechanical dissociation of the visceral and
parietal pleura, and a restrictive ventilatory defect.
Common symptoms associated with pleural effusion may include:
 chest pain, difficulty breathing, painful breathing (pleurisy), and
cough (either a dry cough or a productive cough).
 Deep breathing typically increases the pain. Symptoms of fever, chills,
and loss of appetite often accompany pleural effusions caused by
infectious agents

13. DIAGNOSIS – Physical Exam
Physical findings in
pleural effusion are
variable and depend
on the volume of the
effusion. Generally,
there are no physical
findings for effusions
smaller than 300 mL.
With effusions larger
than 300 mL, findings
may include the
following:
Dullness to percussion, decreased
tactile fremitus, and asymmetrical
chest expansion, with diminished or
delayed expansion on the side of
the effusion – MOST RELIABLE
FINDINGS
Mediastinal shift away
from the effusion -
effusions of greater
than 1000 mL
Diminished or
inaudible
breath sounds
Egophony - ("e" to "a"
changes) at the most
superior aspect of the
pleural effusion
Pleural friction
rub

14.  Most often, pleural effusions are discovered
on imaging tests. Common tests used to
identify pleural effusions include:

15. DIAGNOSIS –
CHEST X-RAY
 often the first step in identifying a
pleural effusion.
 Pleural effusions appear on chest X-
rays as white space at the base of
the lung.
 If a pleural effusion is likely,
additional X-ray films may be taken
while a person lies on her side.
 Decubitus X-ray films can show if the
fluid flows freely within the chest.

16. DIAGNOSIS – CT SCAN
Compared to chest X-
rays, CT scans produce
more detailed
information about
pleural effusions and
other lung
abnormalities.

17. DIAGNOSIS - ULTRASOUND
Ultrasound can help
guide drainage and
identify whether
pleural effusions are
free-flowing.

18. DIAGNOSIS - THORACENTESIS
 should be done in almost all patients who have pleural fluid that
is ≥ 10 mm in thickness on CT, ultrasonography, or lateral
decubitus x-ray and that is new or of uncertain etiology.
 In general, the only patients who do not require thoracentesis are
those who have heart failure with symmetric pleural effusions and
no chest pain or fever; in these patients, diuresis can be tried,
and thoracentesis avoided unless effusions persist for ≥ 3 days.
1. Chemical composition including protein, lactate dehydrogenase
(LDH), albumin, amylase, pH, and glucose
2. Gram stain and culture to identify possible bacterial infections
3. Cell count and differential
4. Cytopathology to identify cancer cells, but may also identify
some infective organisms
5. Other tests as suggested by the clinical situation – lipids, fungal
culture, viral culture, specific immunoglobulins

19. DIAGNOSIS – LIGHT’S CRITERIA
 Transudate - produced through pressure filtration without capillary injury
 Exudate - "inflammatory fluid" leaking between cells.
 Transudative pleural effusions - caused by systemic factors that alter the pleural
equilibrium, or Starling forces. The components of the Starling forces–hydrostatic pressure,
permeability, oncotic pressure (effective pressure due to the composition of the pleural
fluid and blood)–are altered in many diseases, e.g., left ventricular failure, renal failure,
hepatic failure, and cirrhosis.
 Exudative pleural effusions - caused by alterations in local factors that influence the
formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary
embolism, and viral infection).

20. Medical Management:
 Antibiotics
 Analgesics
 Diuretics
 Cardiotonic Drugs
 Thoracentesis
 CTT
 Pleurodesis
MEDICAL/SURGICAL MANAGEMENT,
DRUGS, AND TREATMENT

21. Thoracentesis
aspiration of fluid or air
from the pleural cavity.
instillation of medication
into the pleural space
MEDICAL/SURGICAL MANAGEMENT,
DRUGS, AND TREATMENT

22. NURSING MANAGEMENT –
Thoracentesis
 Verify a signed informed consent
 Assist client to an appropriate
position
 Instruct client not to move during the
procedure including no coughing or
deep breathing.
 Provide comfort
 Maintain asepsis
 Monitor vital signs during the
procedure – also monitor pulse
oximetry if client is connected to it.

23.  Apply a dressing over a puncture and position the
client on the unaffected side. Instruct the client to
stay in this position for at least 1 hour.
 During the first several hours after thoracentesis
frequently assess and document vital signs, oxygen
saturation, respiratory status including respiratory
excursion, lung sounds, cough and hemoptysis and
puncture site for bleeding or crepitus.
 Obtain a chest x-ray
NURSING MANAGEMENT –
Thoracentesis

24. Chest Tube Thoracostomy
 done to drain fluid, blood and air from
the space around the lungs. whether
the accumulation is the result of rapid
traumatic filling or insidious malignant
seepage, placement of a chest tube
allows for continuous, large volume
drainage until the underlying pathology
can be more formally addressed.
MEDICAL/SURGICAL MANAGEMENT,
DRUGS, AND TREATMENT

25.  Ensure a signed consent for chest tube insertion
 Position as indicated for the procedure
 Assist with chest tube insertion as needed
 Assist respiratory status at least every 4 hours.
 Maintain a closed system.
 Ensure tubing with no kinks or not compressed
 Check the water seal frequently.
 Palpate the area around the chest tube site for subcutaneous
emphysema or crepitus.
 Encourage client for coughing and deep breathing
 Assist with frequent position changes and sitting and ambulation
as allowed
NURSING MANAGEMENT –
Closed Tube Thoracostomy

26. Pleurodesis
 also known as Pleural Sclerosis.
Involves instilling an irritant into the
pleural space to cause inflammatory
changes that result in bridging fibrosis
between the visceral and parietal
pleural surfaces.
MEDICAL/SURGICAL MANAGEMENT,
DRUGS, AND TREATMENT

27.  Ensure informed consent
 Record baseline vital signs
 Consider the use of pre medication
 Position patient comfortably
 An existing effusion should be completely
drained before the procedure
 Ensure a recent chest x-ray
 Observe for excessive pain and breathlessness
 Patient ambulation is possibly helpful to ensure
good spread of the slurry
NURSING MANAGEMENT –
Pleurodesis

28. THANK YOU!