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  • 1. PLEURISY Presented by: TARIQ GILL
  • 2. Ground rules
  • 3. OBJECTIVES At the end of session the audience will be able to: Define Pleurisy Explain the Sign and Symptoms of Pleurisy Understand the causes of Pleurisy Explain how to diagnosis Pleurisy Understand the Management of Pleurisy TARIQ GILL 3
  • 4. Pleurisy Facts
  • 5. What is Pleurisy ? • Pleurisy describes the chest pain syndrome characterized by a sharp chest pain that worsens with breathing. • Pleurisy is caused by inflammation of the linings around the lungs (the pleura), a condition also known as pleuritis. There are two layers of pleura: one covering the lung (termed the visceral pleura) and the other covering the inner wall of the chest (the parietal pleura). These two layers are lubricated by pleural fluid. TARIQ GILL 5
  • 6. • Pleurisy is frequently associated with the accumulation of extra fluid in the space between the two layers of pleura. This fluid is referred to as a pleural effusion. • The pain fibers of the lung are located in the pleura. When this tissue becomes inflamed, it results in a sharp pain in the chest that is worse with breathing. Other symptoms of pleurisy can include cough, chest tenderness, and shortness of breath. TARIQ GILL 6 Continued What is Pleurisy ?
  • 7. Pleurisy facts • Pleurisy involves inflammation of the tissue layers (pleura) lining the lungs and inner chest wall. • Pleurisy is often associated with the accumulation of fluid between the two layers of pleura, known as pleural effusion. • Pleurisy is caused by a variety of conditions, such as infections, TB, congestive heart failure, cancer, pulmonary embolism, and collagen vascular diseases. • Symptoms of pleurisy include pain in the chest, which is aggravated by breathing in, shortness of breath, and local tenderness. TARIQ GILL 7
  • 8. • The diagnosis of pleurisy is made by the characteristic chest pain and physical findings on examination of the chest. The sometimes-associated pleural accumulation of fluid (pleural effusion) can be seen by imaging studies (chest X-ray, ultrasound, or CT). • Analysis of pleural fluid aspirated from the chest can help determine the cause of the pleurisy. • Treatment of the underlying conditions is key to the proper management of pleurisy. TARIQ GILL 8 Pleurisy facts
  • 9. How does the pleura work? • The pleura is composed of two layers of thin lining tissue. The layer covering the lung (visceral pleura) and the parietal pleura that covers the inner wall of the chest are lubricated by pleural fluid. Normally, there is about 10-20 ml of clear liquid that acts as a lubricant between these layers. The fluid is continually absorbed and replaced, mainly through the outer lining of the pleura. Pressure inside the pleura is negative (as in sucking) and becomes even more negative during inspiration (breathing in). TARIQ GILL 9
  • 10. • The pressure becomes less negative during exhalation (breathing out). Therefore, the space between the two layers of pleura always has a negative pressure. The introduction of air (positive pressure) into the space (such as from a knife wound) will result in a collapse of the lung. TARIQ GILL 10 How does the pleura work?
  • 11. Sign and Symptoms of Pleurisy • Symptoms and Complications Associated with Pleuritis • There are many symptoms and complications associated with pleuritis that can occur at any time and are not always treatable. The following are possible symptoms and complications that may be present when pleuritis is affecting the individual: • Shortness of breath – One of the main symptoms will always be difficulty breathing as this complication will affect the lungs. The pleuritis may have low or severe influence on the ability to breathe and this makes it very difficult to be able to do many things because of the shortness of breath. TARIQ GILL 11
  • 12. Sign and Symptoms • Cough – Coughing is common in sufferers of pleuritis as the disease deals with the lungs and often induces coughing episodes. The coughs will generally cause a great deal of pain for those who have pleuritis, as the disease will cause the inflamed lining of the lungs to rub against other tissues and organs which could become rather painful. • Fever and Chills – Fevers and chills are very common as well in individuals with pleuritis, as the buildup of fluid can also be toxic and cause the body to heat up from the complications. Difficulty breathing may not get enough oxygen to the blood, causing the body to feel like it is getting colder. This artificially boosts body heat in an attempt to recover the warmth that the body thinks that it is missing. TARIQ GILL 12
  • 13. • Breathing Issues – Rapid, shallow breathing may be present as the body tries to get enough oxygen to work correctly. This is the type of breathing that people experience on the top of tall mountains or in locations where there is very little oxygen to breathe, such as smoke filled rooms during a fire. The body may try to do this when the fluid buildup has occurred with pleuritis. • Unexplained Weight Loss – Unexplained weight loss is a very unusual indicator that pleuritis is present in the body. This can be due to several different reasons but it is most likely because the body does not know how to cope with the pleuritis. This can also be due to the fact that it can become painful to eat when the pleuritis is present and the pain does not allow for proper digestion of food ingested. TARIQ GILL 13 Sign and Symptoms
  • 14. Sign and Symptoms TARIQ GILL 14 • Sore throat – A sore throat is very common and makes it possible to look for problems such as pleuritis when other symptoms are present. This could be due to several reasons including the spread of the pleuritis problem near the esophagus. This infection occurring near the trachea can usually make the throat feel very sore. • Pain and Swelling of Joints – Joints swelling with pain are often caused by arthritis and arthritis is one of the underlying causes of pleuritis in some patients. It is very important to look into the available options to treat this pain to help alleviate the symptoms and possibly prevent the further spread of pleuritis through arthritis.
  • 15. • Collapsed Lung – When a lung weakens to a point that it no longer can support itself, it collapses. This is something that can occur in patients with pleuritis as it does cause weakening of the lungs. Many people look into the available options to treat pleuritis to prevent this from happening because a collapsed lung may not work anywhere near as well as a fully working lung. Collapsed lungs often need to be removed as well to prevent various other complications. • Complications from the Underlying Disease – The underlying diseases that cause pleuritis can essentially cause many other complications which could worsen the extent of pleuritis as well. Make sure to look into the options of treating these underlying diseases to help decrease the possibility of extraneous complications. TARIQ GILL 15 Sign and Symptoms
  • 16. Cyanosis in pleurisy with effusion due to respiratory insufficiency is caused by lung collapse and limitation of its respiratory surface
  • 17. Pleural Effusion TARIQ GILL 17
  • 18. 18TARIQ GILL
  • 19. 19TARIQ GILL
  • 21. What causes pleurisy? • Pleurisy can be caused by any of the following conditions: • Infections: bacterial (including those that cause tuberculosis), fungi, parasites, or viruses • Inhaled chemicals or toxic substances: exposure to some cleaning agents like ammonia • Collagen vascular diseases: lupus, rheumatoid arthritis • Cancers: for example, the spread of lung cancer or breast cancer to the pleura TARIQ GILL 21
  • 22. • Tumors of the pleura: mesothelioma or sarcoma • Congestion: heart failure • Pulmonary embolism: blood clot inside the blood vessels to the lungs. These clots sometimes severely reduce blood and oxygen to portions of the lung and can result in death to that portion of lung tissue (termed lung infarction). This, too, can cause pleurisy. • Obstruction of lymph channels: as a result of centrally located lung tumors TARIQ GILL 22 What causes pleurisy?
  • 23. • Trauma: rib fractures or irritation from chest tubes used to drain air or fluid from the pleural cavity in the chest • Certain drugs: drugs that can cause lupus-like syndromes (such as hydralazine [Apresoline], Procan [Pronestyl, Procan-SR, Procanbid - these brands no longer are available in the U.S.], phenytoin [Dilantin], and others) • Abdominal processes: such as pancreatitis, cirrhosis of the liver, gallbladder disease, and damage to the spleen. • Pneumothorax: air in the pleural space, occurring spontaneously or from trauma. TARIQ GILL 23 What causes pleurisy?
  • 24. How is pleurisy diagnosed? • The pain of pleurisy is very distinctive. The pain is in the chest and is usually sharp and aggravated by breathing. However, the pain can be confused with the pain of: • inflammation around the heart (pericarditis), or • heart attack (myocardial infarction) • To make the diagnosis of pleurisy, a doctor examines the chest in the area of pain and can often hear (with a stethoscope) the friction that is generated by the rubbing of the two inflamed layers of pleura with each breath. The noise generated by this sound is termed a pleural friction rub. TARIQ GILL 24
  • 25. • (In contrast, the friction of the rubbing that is heard with pericarditis occurs synchronous with the heartbeat and does not vary with respiration.) With large amounts of pleural fluid accumulation, there can be decreased breath sounds (less audible respiratory sounds heard through a stethoscope) and the chest is dull sounding when the doctor drums on it (termed dullness upon percussion). TARIQ GILL 25 How is pleurisy diagnosed?
  • 26. • A chest X-ray taken in the upright position and while lying on the side is a tool in diagnosing fluid in the pleural space. It is possible to estimate the amount of fluid collection by findings on the X-ray. Occasionally, as much as 4-5 liters of fluid can accumulate inside the pleural space. • Ultrasound is a very method of detecting the presence of pleural fluid. • A CT scan can be very helpful in detecting very small amounts of fluid and trapped pockets of pleural fluid, as well as in determining the nature of the tissues surrounding the area. TARIQ GILL 26 How is pleurisy diagnosed?
  • 27. • Removal of pleural fluid with a needle and syringe (aspiration) is essential in diagnosing the cause of pleurisy. The fluid's color, consistency, and clarity are analyzed in the laboratory. The fluid analysis is defined as either an "exudate" (high in protein, low in sugar, high in LDH enzyme, and high white cell count; characteristic of an inflammatory process) or a "transudate" (containing normal levels of these body chemicals). TARIQ GILL 27 How is pleurisy diagnosed?
  • 28. • Causes of exudative fluid include infections (such as pneumonia), cancer, tuberculosis, and collagen diseases (such as rheumatoid arthritis and lupus). • Causes of transudative fluid are congestive heart failure and liver and kidney diseases. Pulmonary emboli can cause either transudates or exudates in the pleural space. • The fluid can also be tested for the presence of infectious organisms and cancer cells. In some cases, a small piece of pleura may be removed for microscopic study (biopsied) if there is suspicion of tuberculosis (TB) or cancer. TARIQ GILL 28 How is pleurisy diagnosed?
  • 29. • Biopsy – A biopsy of the pleura may be examined when cancer or tuberculosis is suspected. This can help determine what course of action to take with the pleuritis to prevent further damages and infection of the locations. TARIQ GILL 29 How is pleurisy diagnosed?
  • 30. How is pleurisy treated? TARIQ GILL 30 • External splinting of the chest wall and pain medication can reduce the pain of pleurisy. Treatment of the underlying disease, of course, ultimately relieves the pleurisy. For example, if a heart, lung, or kidney condition is present, it is treated. Removal of fluid from the chest cavity (thoracentesis) can relieve the pain and shortness of breath. Sometimes fluid removal can make the pleurisy temporarily worse because without the lubrication of the fluid, the two inflamed pleural surfaces can rub directly on each other with each breath.
  • 31. • If the pleural fluid shows signs of infection, appropriate treatment involves antibiotics and drainage of the fluid. If there is pus inside the pleural space, a chest drainage tube should be inserted. This procedure involves placing a tube inside the chest under local anesthesia. The tube is then connected to a sealed chamber that is connected to a suction device in order to create a negative pressure environment. TARIQ GILL 31 How is pleurisy treated?
  • 32. • In severe cases, in which there are large amounts of pus and scar tissue (adhesions), there is a need for "decortication." This procedure involves examining the pleural space under general anesthesia with a special scope (thoracoscope). Through this pipelike instrument, the scar tissue, pus, and debris can be removed. Sometimes, an open surgical procedure (thoracotomy) is required for more complicated cases. TARIQ GILL 32 How is pleurisy treated?
  • 33. • In cases of pleural effusion that result from cancer, the fluid often reaccumulates. In this setting, a procedure called pleurodesis is used. This procedure entails instilling an irritant, such as bleomycin, tetracycline, or talc powder, inside the space between the pleural layers in order to create inflammation. This inflammation, in turn, will adhere or tack the two layers of pleura together as scarring develops. This procedure thereby obliterates the space between the pleura and prevents the reaccumulation of fluid. TARIQ GILL 33 How is pleurisy treated?
  • 34. Nursing Considerations-Nursing Diagnoses • Activity intolerance • Acute pain • Anxiety • Impaired gas exchange • Ineffective airway clearance • Ineffective breathing pattern • Ineffective coping TARIQ GILL 34
  • 35. Nursing Considerations-Expected Outcomes • demonstrate energy conservation techniques express feelings of increased comfort and relief of pain • verbalize strategies to reduce anxiety • maintain adequate ventilation and oxygenation • maintain a patent airway • maintain a respiratory rate within 5 breaths of the baseline • use support systems to assist with coping. TARIQ GILL 35
  • 36. Nursing Considerations-Nursing Interventions • Monitoring • Vital signs • Respiratory status, including respiratory rate and depth and lung sounds • Intake and output • Pain level and relief Cough TARIQ GILL 36
  • 37. • Give prescribed drugs; if cough is present, administer acetaminophen with codeine as ordered. • Encourage deep breathing and coughing and use of an incentive spirometer; have the patient splint the affected side. • Assist patient to a position of comfort, possibly lying on affected side, to decrease stretching of pleurae. • Ensure a patent airway. • Encourage use of nonpharmacologic pain relief measures, such as heat, progressive muscle relaxation, and guided imagery. TARIQ GILL 37 Nursing Considerations-Nursing Interventions
  • 38. • Position the patient in high Fowler's position to maximize chest expansion and ease the work of breathing. • Auscultate lung sounds. • Administer oxygen, if ordered, based on oxygen saturation levels; assess for signs and symptoms of hypoxia when anxiety, restlessness, and agitation of new onset are noted. TARIQ GILL 38 Nursing Considerations-Nursing Interventions
  • 39. • Provide for frequent rest periods; cluster care activities to allow frequent rest periods. • Assist with passive range-of-motion (ROM) exercises; encourage active ROM exercises. • Provide comfort measures. • Assist with thoracentesis, if indicated. • Encourage the patient to verbalize feelings and concerns; provide emotional support and guidance. • Assist the patient in using positive coping strategies and relaxation techniques. TARIQ GILL 39 Nursing Considerations-Nursing Interventions
  • 40. Patient Teaching-General • Disorder, possible underlying cause, diagnosis, and treatment, including medications to control pain and coughing need to take ibuprofen or other NSAIDs with food or meals to minimize GI distress possible sedative effects if codeine is prescribed, and the need for safety measures • How to perform splinting and deep-breathing exercises • Importance of regular rest periods energy conservation measures anxiety reduction and coping strategies TARIQ GILL 40
  • 41. Patient Teaching-General • Importance of seeking early intervention for pulmonary conditions signs and symptoms of possible complications, such as increasing respiratory distress, development of productive cough, and fever, and the need to notify the practitioner immediately • Importance of adhering to recommended follow-up care to evaluate the condition and the underlying cause. TARIQ GILL 41
  • 42. Can pleurisy be prevented? • Some cases of pleurisy can be prevented, depending on the cause. For example, early intervention in treating pneumonia may prevent the accumulation of pleural fluid. In the case of heart, lung, or kidney disease, management of the underlying disease can help prevent the fluid collection. TARIQ GILL 42
  • 43. Prognosis and Outlook of Patients with Pleuritis • Many people with pleuritis will be able to make a full recovery if their underlying problems are taken care of. Proper treatment of the affliction makes it possible to really come through strong. There is a possibility of death caused by pleuritis in very unhealthy individuals if they do not make the necessary lifestyle changes needed to heal from the complications of pleuritis. TARIQ GILL 43
  • 44. 44TARIQ GILL
  • 45. References Fauci, Anthony S., et al. Harrison's Principles of Internal Medicine. 17th ed. United States: McGraw-Hill Professional, 2008. Previous contributing author and editor: Zab Mohsenifar, MD and William C. Shiel, Jr., MD, FACP, FACR Medically reviewed by James E Gerace, MD; board certified internal medicine with subspecialty in pulmonary disease • Source: key=19782 • TARIQ GILL 45
  • 46. 46TARIQ GILL