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LCP Pleural Effusion Group Report March 12 2014

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PLEURAL
EFFUSION
PGCPN ‘11 - Group 2
WHAT IS PLEURAL EFFUSION?
• Unusual fluid in the lungs
• Build up of excess fluid
between the layers of the
pleura outside the lungs.
LCP Pleural Effusion Group Report March 12 2014
INCIDENCE
It is very common in
the Philippines, with
approximately 100,000
cases diagnosed each
year.
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.
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

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LCP Pleural Effusion Group Report March 12 2014

  • 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

Editor's Notes

  1. PARIETAL – Thoracic cavity VISCERAL - lungs
  2. The pleural space plays an important role in respiration by coupling the movement of the chest wall with that of the lungs in 2 ways. First, a relative vacuum in the space keeps the visceral and parietal pleurae in close proximity. Second, the small volume of pleural fluid, which has been calculated at 0.13 mL/kg of body weight under normal circumstances, serves as a lubricant to facilitate movement of the pleural surfaces against each other in the course of respirations. This small volume of fluid is maintained through the balance of hydrostatic and oncotic pressure and lymphatic drainage, a disturbance of which may lead to pathology.
  3. Pleural effusion is an indicator of an underlying disease process that may be pulmonary or non-pulmonary in origin and may be acute or chronic.
  4. Diagnosing the cause(s) of a pleural effusion often begins with determining whether the fluid is transudate or exudate. This is important because the results of this fluid analysis may provide a diagnosis and determine the course of treatment. 
  5. Verify consent – kasi this is an invasive procedure Appropriate position – SITTING WITH ARMS AND HEAD ON PADDED TABLE or SIDE LYING POSITION ON UNAFFECTED SIDE = this position spreads the ribs and enlarging the intercostal space for needle insertion Instruct the client.. – movement and coughing during the procedure may cause damage to the lung or pleura Monitor VS – esp yung PR & BP kasi nag aaspirate tayo ng fluids, baka magkaroon ng HYPOVOLEMIC shock yung patient
  6. Apply a dressing.. – to prevent air from entering the pleural space and to allow the pleural puncture to heal During the first.. – frequent assessment is important to detect possible complications such as pneumothorax Obtain – chest xray is ordered to detect possible pneumothorax
  7. CTT may also be needed when a patient has had a severe injury to the chest wall that causes bleeding around the lungs or accidentally puntured allowing air to gathered outside the lungs causing its collapsed
  8. Position – a suggested position is SEMI-DECUBITUS ON THE BED AT 45 degrees WITH THE ARM BEHIND THE HEAD SO AS TO EXPOSE THE AXILLARY AREA. The drain should ideally be inserted in the SAFE TRIANGLE which is delineated by the lateral border of the pectoralis major (sa may breast part), the anterior border of the latissimus dorsi (saa may likod) and a line horizontal with the nipple. Most clinicians insert the tube via an incision at this 4th or 5th intercostal space in the ANTERIOR AXILLARY or MIDAXILLARY LINE. Assist respiratory status.. – frequent assessment is necessary to monitor respiratory status and the effect of the chest tube. Ensure tubing.. – these could interfere with drainage Check the water seal properly.. – the water level should fluctuate with respiratory effort. If it does not, the system may not be patent or intact. Periodic air tbubbles in the water seal chamber are normal and indicate the trapped air is being removed from the chest. Measure drainage every 8hours and marking the levels on the drainage chamber. Report drainage if it is cloudy, red, warm, free flowing. Red, free flowing drainage indicates hemorrhage and cloudiness may indicate an infection.
  9. performed to prevent recurrence of pneumothorax or recurrent pleural effusion
  10. Consider the use of pre – to alleviate anxiety and reduce pain associated with pleurodesis Position patient comfortably – in SITTING POSITION with good access to the chest drain and the site. Ensure a recent – ensure that the chest drain is correctly positioned and the lung is fully expanded