MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES (MUHAS) The image cannot be display ed. Your computer may not hav e enough memory to open the image, or the image may hav e been corrupted. Restart y our computer, and then open the file again. If the red x still appears, y ou may hav e to delete the image and then insert it again. SCHOOL OF NURSINGCASE STUDY PRESENTATIONTOPIC: MANAGEMENT OF PLEURAL EFFUSIONPRESENTER: MELKIOR PETER S.REG: NO. 2010-04-03030SUPERVISOR: MKOKA, DICKSON DR. MSELLE, LILIAN STEPHENE, KIBUSI
CASE DESCRIPTIONPhysiology of the normal lungThe 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 theright lung and 2 lobes on the left 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.Layers of the lungParietal Pleura -Lines the thoracic cavity, including the thoracic cage,mediastinum, and diaphragm. Contains sensory nerve endings that can detectpainPleural space- thin, transparent, serous membrane which lines the thoracic cavitya potential space between the parietal pleura and visceral pleuraVisceral pleura- Lines the entire surface of the lung. Contains no sensory nerveendings that detect painPleural fluidSerous fluid that allows for the parietal pleura (outer lining) and visceral pleura(inner lining) to glide over each other without separation, contains about 5-15mlof fluid at one time. It is produced by the parietal pleura and absorbed by thevisceral pleura as a continuous process and has an alkaline pH of 7.64Excessive amounts of such fluid can impair breathing by limiting the expansionof the lungs during respiration (pleural effusion)More specific terminology may be used when the nature of the fluid is known.Hydrothorax is a collection of serous (most often transudative but alsoexudative) fluid, while pus in the pleural cavity is referred to as a pyothorax orempyema. Additional terms are used for blood (hemothorax) and chyle(chylothorax)
PathophysiologyPleural fluid is formed and removed slowly, at an equivalent rate, and has alower protein concentration than lung and peripheral lymph. It can accumulateby one or more of the following mechanisms • Increased hydrostatic pressure in the microvascular circulation: clinical data suggest that an elevation in capillary wedge pressure is the most important determinant in the development of pleural effusion in congestive heart failure. • Decreased oncotic pressure in the microvascular circulation due to hypoalbuminemia, which increases the tendency to form pleural interstitial fluid. • Increased negative pressure in the pleural space, also increasing the tendency for pleural fluid formation; this can happen with a large atelectasis • Separation of the pleural surfaces, which could decrease the movement of fluid in the pleural space and inhibit pleural lymphatic drainage; this can happen with a trapped lung. • Increased permeability of the microvascular circulation due to inflammatory mediators, which would allow more fluid and protein to leak across the lung and visceral surface into pleural space; this has been documented with infections such as pneumonia. • Impaired lymphatic drainage from the pleural surface due to blockage by tumor or fibrosis. • Movement of ascitic fluid from the peritoneal space through either diaphragmatic lymphatics or diaphragmatic defects.Types of effusion A. TransudateFluid substance that has passed through a membrane or has been extruded froma tissue it is of high fluidity and has a low content of protein, cells, or solidmaterials derived from cells. It caused by fluid leaking into the pleural space.This is caused by increased pressure in, or low protein content in, the bloodvessels . A transudate is a clear fluid, similar to blood serum . It reflect asystemic disturbance of body, the common causes are CHF and liver or kidneydiseases.
B. ExudatePale yellow and cloudy substance, influenced by local factors where fluidabsorption is altered (inflammation, infection, cancer)Rich in protein (serum protein greater than 0.5), ratio of pleural fluid LDH andserum LDH is >0.6Pleural fluid LDH is more the two-thirds normal upper limit for serumRich in white blood cells and immune cells, always has a low pHCommon causes are pneumonia, cancer, and traumaClinical manifestationThe clinical manifestations of pleural effusion are variable and often are relatedto the underlying disease process. The most commonly associated symptoms areprogressive dyspnea, cough, and pleuritic chest pain.DyspneaThe most common symptom associated with pleural effusion and is related moreto distortion of the diaphragm and chest wall during respiration than tohypoxemia. In many patients, drainage of pleural fluid alleviates symptomsdespite limited improvement in gas exchange. Drainage of pleural fluid may alsoallow the underlying disease to be recognized on repeat chest radiographs. Notethat dyspnea may be caused by the condition producing the pleural effusion,such as underlying intrinsic lung or heart disease, obstructing endobronchiallesions, or diaphragmatic paralysis, rather than by the effusion itself.CoughCough in patients with pleural effusion is often mild and nonproductive. Moresevere cough or the production of purulent or bloody sputum suggests anunderlying pneumonia or endobronchial lesion.Chest painThe presence of chest pain, which results from pleural irritation, raises thelikelihood of an exudative etiology, such as pleural infection, mesothelioma, orpulmonary infarction.Pain may be mild or severe. It is typically described as sharp or stabbing and isexacerbated with deep inspiration. Pain may be localized to the chest wall orreferred to the ipsilateral shoulder or upper abdomen, usually because ofdiaphragmatic involvement.
Methods Used to Investigate Pleural DiseaseMedical HistoryPatients with pleural effusions should be studied systematically. As a first step acomplete medical history should be taken with special emphasis on the patient’shistory of exposure to asbestos, current and recent medications, and the prior orcurrent presence of entities such as heart disease, tuberculosis, neoplasticdisease, and connective tissue disease. Secondly, a complete physicalexamination should be performed. Based on the overall picture provided by theclinical variables, medical history, physical examination, results of basiclaboratory tests, and of any additional tests ordered because of a suspecteddiagnosis, it is possible to establish a diagnosis before thoracentesis and orderthe pertinent tests.Radiographic TechniquesAn effusion of more than 75 mL is often visible on chest radiographs. Pleuraleffusions can be either free flowing or loculated and either typically oratypically sited (subpulmonic, fissural, or mediastinal) sited. The amount offluid varies. When there is a doubt in the case of small effusions the existence ofpleural fluid should be confirmed by chest ultrasound or radiographically usinga lateral decubitus projection on the affected side. Anomalies in the lungparenchyma can help to confirm the suspected diagnosis, and computedtomography can contribute useful additional information.ThoracentesisPleural fluid should always be investigated using thoracentesis except when thesuspected effusion is clearly secondary to a specific underlying disease (forexample heart failure). The morbidity associated with thoracentesis carried outby an experienced operator is low. In the case of small effusions, thoracentesiscan be undertaken if the distance between the horizontal line of the pleuraleffusion and the chest wall is more than 1 cm on an ipsilateral decubitus view.Otherwise, ultrasound guidance is necessary. The most common complicationsare vagal reaction (10%-14%) and pneumothorax (3%-8%). A chest radiographis not essential after thoracentesis except when complications such aspneumothorax are suspectedThe following properties of the fluid sample are analyzed: color, appearance(pus in the case of empyema, milky with lipid effusion, and bloody inhemothorax), and smell (putrid in infections caused by anaerobicmicroorganisms, and ammoniac in the case of urinothorax). Hemorrhagic fluidis more likely in effusions caused by malignancy, trauma, or pulmonaryembolism.
Thoracoscopy.A thoracoscope facilitates examination of the pleural cavity and biopsy of theparietal and visceral pleura under visual guidance. Thoracoscopy can beperformed with local anesthesia and sedation. The diagnostic yield for cancer isover 90%, and this procedure is particularly recommended in patients with ahistory of asbestos exposure (because of the possibility of mesothelioma). Ifclearly malignant lesions are observed, pleurodesis can be carried outimmediately during the procedureCytology.Pleural fluid cytology is among the tools offering the highest yield fordiagnosing malignancy. The sensitivity of this test ranges from 40% to 87%depending mainly on the cytologist’s training, the extent of pleural involvement,and tumor type (yield is higher in adenocarcinoma). Cytology of sequentialspecimens increased yield up to 30% in some studies. Immunocytochemicaltechniques use various antibodies to differentiate between epithelial andmesothelial cells.Thoracotomy.Thoracotomy is only indicated in very specific situations and only when otherdiagnostic methods have failed.Computed tomography.Computed tomography is used to investigate the mediastinum and the lungparenchyma, to detect pleural masses, and as a guide for biopsies. When usedappropriately, this technique can also help to establish a diagnosis of pleuraleffusion secondary to pulmonary embolism. If the clinical findings or results oflaboratory tests point to an abdominal disease as the cause of the patient’scondition, abdominal imaging with computed tomography or ultrasound can beused to rule out such disease.Therapeutic measuresTherapeutic thoracentesisAny pleural effusion large enough to cause severe respiratory symptoms shouldbe drained regardless of the cause and regardless of concomitant disease-specifictreatment. Relief of symptoms is the main goal of therapeutic drainage in thesepatients. The only absolute contraindication to thoracentesis is active cutaneousinfection at the puncture site. Some relative contraindications include severebleeding diathesis, systemic anticoagulation, and a small volume of fluid.
Tube thoracostomy (chest tube)Tube thoracostomy allows continuous, largevolume drainage of air or liquidfrom the pleural space.Specific indications for placement of a chest tube include spontaneous oriatrogenic pneumothorax (especially if large and symptomatic), hemothorax,penetrating chest trauma, complicated parapneumonic effusion or empyema,chylothorax, and pleurodesis of symptomatic pleural effusions.Complicated parapneumonic effusions and frank empyema require drainagewith a large-bore chest tube (28–36 F) to control the local pleural inflammatoryreaction, which may not otherwise respond to intravenous antibiotics. Inmultiloculated complicated effusions, image-guided placement of small-borecatheters (10–14 F) should be considered.If appropriate drainage is not obtaineddespite correct positioning of the tubes (verified with chest CT), fibrinolytictherapy can be used. Agents such as streptokinase, urokinase, and alteplase canlyse fibrin and improve drainage.Subsequent management of the CT must be individualized to the patient, takinginto consideration the reason for CT placement, whether or not the patient hashad pulmonary resection, and whether the patient is mechanically ventilated.Premature CT removal, as well as unnecessary delays in CT removal, leads toincreased hospital stays and costs.Pleural sclerosisPleural sclerosis (pleurodesis) is considered for patients with uncontrolled andrecurrent symptomatic malignant effusions, and rarely, in cases of benigneffusions after failure of medical treatment. A sclerosing agent is instilled intothe pleural cavity via a tube thoracostomy to produce a chemical serositis andsubsequent fibrosis of the pleura. Pleural sclerosis should be attempted only ifthe lung expands fully after fluid removal. The visceral and parietal pleura needto be approximated closely, obliterating the pleural cavity so that fibrotic healingachieves pleural symphysis.The overall success rate with fibrosing agents (ie, talc, doxycycline, andtetracycline) is 75%, compared with a complete success rate of only 44% forantineoplastic agents (ie, bleomycin). Talc is the most effective agent, with acomplete success rate of 93%. Pleurodesis failure is usually the result ofsuboptimal technique or inability to approximate the pleural surfaces.Surgical therapyVideo assisted thoracoscopic surgery is very useful in managing incompletelydrained parapneumonic effusions. With thoracoscopy, the loculi in the pleuracan be disrupted, the pleural space can be completely drained, and the chest tubecan be optimally placed.
In cases of empyema with uncontrolled sepsis or progression to thefibroproliferative phase, a full thoracotomy with decortication is performed withremoval of all the fibrous tissue and evacuation of all the pus from the pleuralspace. Decortication in this situation will eliminate the septic source and allowthe lung to expand.Other surgical methods for managing MPETwo surgical procedures which could be considered by the physician when apatient has a MPE are a pleurectomy or placement of a pleuroperitoneal shunt.The shunt is placed surgically and consists of a tube or passage allowing thefluid from the effusion to move from the pleural space to the peritoneal spacewhere it is hoped the fluid will be slowly absorbed. Many times this procedure isdone if the patient failed chemical pleurodesis. It requires manual pumping ofthe shunt and could have complications from blockage of the shuntThe other surgical procedure considered only in patients who can withstand along surgical procedure and with a good life expectancy is a pleurectomy. Apleurectomy involves removal of the parietal pleura and manual irritation of thevisceral pleura causing formation of adhesions and scar tissue and therefore nomore fluid build up in the space. This is a major surgical procedure done undergeneral anesthesia as an open chest case. A partial pleurectomy could be donevia a thoracoscope. Patients having this procedure would need to be monitoredand cared for as any thoracotomy patient would with high risk for pneumoniaand deep vein thrombosis.Management of chest tube(UWDS)Once a chest tube is inserted, it is important for nursing staffs to ensure that thepatient and the drain is closely monitor. However, wide variations have beenobserved, which are based on local policies and individual preference rather thanevidenced based protocols. Below are the management of patient with chest tubedrainages.PositioningThe patient should be placed in a semi-recumbent position with regular positionchanges in order to encourage drainage and prevent stiffening of the shoulderjoints. These might enhance breathing and expectoration, as well as allowingfull lung expansion and possibly preventing complications of prolongedimmobilizationDrain patencyDrainage can be impeded by excessive coiling, dependent loops, kinked orblocked tubes, and which potentially might lead to tension pneumothorax orsurgical emphysema. The tubing should be lifted regularly to drain the fluid intothe collection bottle if the coilings cannot be avoided. The effects of clamping,
milking and striping of chest tubes are controversial and are usually not advised.Replacement of tubing is usually advised if blockage is detected.Lung damage from the sharp pressure changes generated during stripping oftubing might be resulted. Although clamping of drains are still observed andpracticed in cases where there are no longer any air leakage and whenreplacement of tubing or bottle is necessary, this is not recommended in themajor international guidelinesObservationPatient’s vital signs, respiratory rate, oxygen saturation as well as the presenceof tidaling and bubbling in chest drainage system should be closely monitored.Any deterioration or distress of the patient should be reported immediately Pain managementThere are currently no definite guidelines on pain assessment and pain controlwith regard to chest drainage. The pain could be substantial and might affectcoughing, ventilation, sleep as well as re-expansion of the lung. Nurses shouldbe aware of the potential need for prescribed on-demand pain killers or informclinicians about the possible requirements.Recording and observing drainageThe drainage system should be kept below the patient’s chest level to preventfluid re-entering the pleural space. Volume, color, tidaling, bubbling of drainagefluid and level of suction pressure should be regularly evaluated and recorded onpatient’s chest drain chart(if suction used). The frequency of recording will varydepending on the condition of the patients and their underlying disease(s).Drain security and wound managementUsing of tape to secure connections has been controversial with no apparentclear recommandation. Some researchers advocated that taping the connectionscan avoid potential disconnection but others argued that taped tube may maskdisconnections. The use of transparent, water-proof and secure tapings might benecessary in a busy and congested ward environment. The insertion site shouldbe checked everyday to ensure that the wound is dry and clean, with no loosensutures or visible side hole(s) of chest tube (i.e. slipping out). Presence of orincreasing surgical emphysema, pus, or excessive bleeding around insertion sitesshould also be noted.Potentially dangerous conditions that require urgent attention- Large amount of bubbling in the water seal chamber, which might signify alarge patient air leak or a leak in a system-Large amount of bloody discharge might indicate haemothorax or trauma tounderlying organs
- Increasing dyspnoea, increased heart rate, lowered blood pressure & lowoxygen saturation: may signify recurrent pneumothorax (after drain removal) orinsufficient drainage or tube blockage- Absence of gentle bubbling in suction control bottle/ chamber may indicatedisconnection of the suction pressure or inadequate suction force to counteractthe large air leakage.Case study(patient description)Name of patient....................................................................mr xFile number.......................................................................A725690Sex .....................................................................................maleAge .................................................................................18 yearsAdmission .........................................................15/01/2013Referal from .....................................................moiOccupation ...............................................................noneEducation .............................................................form 4 liver at Jitegemee sec.Patient chief complainsOn admission mr x was complaining, difficult in breathing, worse on lying flatfor 1 week accompained with chest tightness, dry cough with exessive nightsweets.Review of systeamsNeurological systeam-noneCardiovascular systeam –capillary refil <3 secondsRespiratory systeam- dyspnea, paroxysmal nocturnal dyspnea, chest pain (P-pain in right thorax during deep inspiration and movements Q- Sharp pain RNon-radiating, S-4/10 T- relieved by shallow breathing, orthopnea of 2 pillows,RR 56b/min, chest tightness, chest tube drains 750mlsTracheal centrally located, chest expansion symmetrical, dullness on percussionat right side of the lung and decreased air entry.Intergumentary system- night sweets, skin intact, left lower limb amputated(AKA).Reproductive system- none
History of present illnessMr x is a known patient of osteosarcoma, AKA (above knee amputation) doneon 22/08/2012 left lower limb at MOI.Now known to be metastatic osteosarcoma in which the right lung is affectedOn assesment,Tracheal was centrally located, symetrical chest expansion, reduced breathsounds on ascultation of the right side chest, dull percussion which suspect thepresence of fluid on right side lungChest tube placed drains haemorrhagic fluid (600mls)Dyspneic with RR 56b/min, on oxygen therapy 8mlsPlanning on admission dayChest x- rayCT scanHIV serologySerum electrolyteFull blood picture (FBP)CatheterizationIV fluids NS 1L alternate RL 1L/24hrIV ceftriaxone 1gm OD 7/7On 16/01/2013Patient still complaining difficult in breathingDyspnic, continue with O2 therapyAnother complain of chest pain worse in deep inspiration P: right thorax Q: Sharp pain R: non-radiating S: 6/10 T: upon deep inspiration, relieved after shallow breathing).Chest tube drains 4700mls/24hrs, patient dehydratedIVF given 3litres DNS/24hrsIV Diclofenac 75 mg 8hourly 5/7Capillary refill <3 seconds, skin intact GCS 15/15BP- 139/100, PR -109, RR- 47, SPo2-92%
On 19/01/2013Patient still on difficult breathing, Leakage on chest tubePlanningContinue with O2 and IV fluids (DNS and RL)Fix the tube well, Continue with analgesicsChest tube reinserted on 20th /01/2013 and drains 750mls of hemorrhagic pleuralfluid/12hrsAntibiotic given IV metronidazole 500mg 8hourly, IV ceftriaxone 1gm od 3/7Past medical historyNo history of chronic illness at past, no surgical history, its 1st admission onhospitalFamily social historyMr x is a form 4 liver, not working, not alcoholic and he has no history ofsmoking. Not allergic to any drug or other substances.Second child in 4 child family, lives with his mother at Kinondoni.Interpretation of findingsChest x-rayOpaque densities on the right lower lobe& blunting of costophrenic angle, which shows the accumulation of fluid thatconfirms pleural effusionCT scanHomogenous opacification of the right hemithorax leading to shift ofmediastinal to the left side.The left lung is normal and normal thoracic cageMassive right side pleural effusion probably metastatic originNursing care plan 1. Ineffective breathing pattern related to decreased lung expansion (accumulation of liquid), as evidenced by dyspnea, changes in depth of breathing, accessory muscle useInterventionsMaintain a comfortable position is usually elevated headboardGiven oxygen through a cannula (8mls)
2. Acute Pain r/t accumulation of fluid in the pleural space and rubbing of thoracostomy tube to the lungsInterventions-The presence of pain, the scale and intensity of pain was well assessed-The client taught about pain management and relaxation with distraction-Chest tube secured to restrict movement and avoid irritation-Given prescribed analgesics i.e diclofenac 75mg od 5/73. Risk for nutrition imparement, less than body requirement telated to inability to ingest adequate nutrients Interventions -Patient relative i.e his father encouraged to give him energy reaching food stuff together with energy supplement so that he can get enough energy. -Administer DNS as prescribed to the patient to increase energy lost.4. Risk for fluid volume deficit related to chest tube drainage. Interventions -encourage the patient to drink enough water to suplement the one lost by chest tube drainage -IV fluids given to Mr Allen i.e RL & DNS to replace fluid lost in drainage system monitored in 24hours.5. Risk for infection related to the presence of fluid in the pleural space and the insition site. Interventions -the patient dressed at the insition site when it is wetted, probably after 2 to 3 days -Given antibiotics as prescribed i.e IV metronidazole 500mg 8 hourly, IV ceftiaxone 1gm 3/7.
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