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Pleural effusion

PLEURAL EFFUSION,DEFINITION,TYPES,AETIOLOGY ,CLINICAL MANIFESTATIONS,DIAGNOSTIC MESSURES,MANAGEMENT

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CREATED BY
UNAIS MD HARISON THAIKKAT
ALMAS COLLEGE OF NURSING
KOTTAKKAL, ML]ALAPPURAM
 A pleural effusion is excess fluid that
accumulates in the pleural cavity, the fluid-
filled space that surrounds the lungs. This
excess can impair breathing by limiting the
expansion of the lungs. Various kinds of
pleural effusion, depending on the nature of
the fluid and what caused its entry into the
pleural space, are hydrothorax (serous
fluid), hemothorax (blood), urinothorax (urin
e), chylothorax (chyle), or pyothorax (pus).
A pneumothorax is the accumulation of air in
the pleural space, and is commonly called a
"collapsed lung."
Pleural effusion
Pleural effusion: inflammation of the pleura,
accompanied by collection of fluid in the
pleural space.
Normal Pleural fluid: 0.3
ml/kg BW
Protein: 1.5 g/dL
pH: alkaline (7.60)
Cells: 1700 cells/ml (75%
macrophages, 23%
lymphocytes & 2%
mesothelial cells)
By the origin of the fluid:
 Serous fluid (hydrothorax)
 Blood (haemothorax)
 Chyle (chylothorax)
 Pus (pyothorax or empyema)
 Urine (urinothorax)
By pathophysiology:
 Transudative pleural effusion
 Exudative pleural effusion

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Pleural effusion

  • 1. CREATED BY UNAIS MD HARISON THAIKKAT ALMAS COLLEGE OF NURSING KOTTAKKAL, ML]ALAPPURAM
  • 2.  A pleural effusion is excess fluid that accumulates in the pleural cavity, the fluid- filled space that surrounds the lungs. This excess can impair breathing by limiting the expansion of the lungs. Various kinds of pleural effusion, depending on the nature of the fluid and what caused its entry into the pleural space, are hydrothorax (serous fluid), hemothorax (blood), urinothorax (urin e), chylothorax (chyle), or pyothorax (pus). A pneumothorax is the accumulation of air in the pleural space, and is commonly called a "collapsed lung."
  • 4. Pleural effusion: inflammation of the pleura, accompanied by collection of fluid in the pleural space. Normal Pleural fluid: 0.3 ml/kg BW Protein: 1.5 g/dL pH: alkaline (7.60) Cells: 1700 cells/ml (75% macrophages, 23% lymphocytes & 2% mesothelial cells)
  • 5. By the origin of the fluid:  Serous fluid (hydrothorax)  Blood (haemothorax)  Chyle (chylothorax)  Pus (pyothorax or empyema)  Urine (urinothorax)
  • 6. By pathophysiology:  Transudative pleural effusion  Exudative pleural effusion
  • 7.  The most common causes of transudative pleural effusions in the United States are heart failure and cirrhosis  Nephrotic syndrome, leading to the loss of large amounts of albumin in urine and resultant low albumin levels in the blood and reduced colloid osmotic pressure, is another less common cause of pleural effusion
  • 8.  . Pulmonary emboli were once thought to cause transudative effusions, but have been recently shown to be exudative.[
  • 9.  Conditions associated with transudative pleural effusions include:[2]  Congestive heart failure  Liver cirrhosis  Severe hypoalbuminemia  Nephrotic syndrome  Acute atelectasis  Myxedema  Peritoneal dialysis  Meigs' syndrome  Obstructive uropathy  End-stage kidney disease
  • 10.  Exudative pleural effusion occur I the case of iflammatory reactios  The mechanism for the exudative pleural effusion is probably related to increased permeability of the capillaries in the lung, which results from the release of cytokines or inflammatory mediators (e.g. vascular endothelial growth factor) from the platelet-rich blood clots. The excessive interstitial lung fluid traverses the visceral pleura and accumulates in the pleural space.
  • 11.  Conditions associated with exudative pleural effusions:[2]  After heart surgery (from incomplete evacuation of blood resulting in retained blood syndrome)  Parapneumonic effusion due to pneumonia  Malignancy (either lung cancer or metastases to the pleura from elsewhere)  Infection (empyema due to bacterial pneumonia)  Trauma  Pulmonary infarction  Pulmonary embolism  Autoimmune disorders  Pancreatitis  Ruptured esophagus (Boerhaave's syndrome)  Rheumatoid pleurisy  Drug-induced lupus
  • 12.  Red blood cell counts are elevated in cases of bloody effusions (for example after heart surgery or hemothorax from incomplete evacuation of blood).  Amylase levels are elevated in cases of esophageal rupture, pancreatic pleural effusion, or cancer.  Glucose is decreased with cancer, bacterial infections, or rheumatoid pleuritis.  pH is low in empyema (<7.2) and may be low in cancer.  If cancer is suspected, the pleural fluid is sent for cytology. If cytology is negative, and cancer is still suspected, either a thoracoscopy, or needle biopsy[3] of the pleura may be performed.  Gram staining and culture should also be done.  If tuberculosis is possible, examination for Mycobacterium tuberculosis (either a Ziehl–Neelsen or Kinyoun stain, and mycobacterial cultures) should be done. A polymerase chain reaction for tuberculous DNA may be done, or adenosine deaminase or interferon gamma levels may also be checked.
  • 13.  1)Osmotic hydraulicpressure  Congestive heart failure  Sup vena caval obstruction  Constrictive pericarditis  Cirrhosis with ascitis  Hypo albumenemia  Salt retaining syndrome  Hydrnephrosis  Nephrotic syndrome
  • 14. 2)infections  Para pneumonic effusion(bacterial)  Bacterial empayema  TB  Fungi  Parasites  Viruses&myco plasma
  • 15. 3)Neo plasms  Primary & meta static tumors  Lymphoma & lukemia  Benign&malignant tumors in pleura  Intra abdominal tumors 4)vascular diseases  Pulmonary embolism  Wegner granulomatous
  • 16. 3)Neo plasms  Primary & meta static tumors  Lymphoma & lukemia  Benign&malignant tumors in pleura  Intra abdominal tumors 4)vascular diseases  Pulmonary embolism  Wegner granulomatous
  • 17. 5)intra abdominal diseases  Pancreatitis & pancreatic pseudo cyst  Sub diaphragmatic abcess  Malignancy with ascitis  Meigs syndrome  Hepatic cirrosis with ascitis 6)trauma  Hemothorax  Esophageal rupture  Intra abdominal surgery  chylothorax
  • 18. 7)miscellaneous  Drug induced  Uremic pleuritis  Myxedema  Yellow nail syndrome  Familial meditaerranian fever
  • 20.  * key symptom -------> shortness of breath  Fluid filling the pleural space makes it hard for the lungs to fully expand, causing the patient to take many breaths so as to get enough oxygen.  * If parietal pleura is irritated -------> mild pain or a sharp stabbing  pleuritic type of pain.  ** Some patients will have a dry cough.
  • 21.  Fever  Night sweating  Wt loss
  • 22.  Occasionally ------> no symptoms at all.  * This is more likely when the effusion results from:  recent abdominal surgery, cancer, or tuberculosis.  * Tapping on the chest will show stony dullness, and decrease breath sound
  • 23.  History collection  Physical examination Diagnostic evaluation
  • 24.  x ray  The fluid itself can be seen at the bottom of the lung or lungs, hiding the normal lung structure.  If heart failure is present,  the x-ray shadow of the heart will be enlarged
  • 26. Ultrasound may disclose a small effusion that caused no abnormal findings during chest examination. C.T. scan is very helpful if the lungs themselves are diseased
  • 27. CT scan of chest showing loculated pleural effusion in left side. Some thickening of pleura is also noted .
  • 29. Pleural Biopsy Most helpful in evaluating for TB Limited utility for CA (40-50% positive) Repeat cytology x 3 Sarcoid, fungal: might be helpful
  • 31. 1. Treatment based on the cause 2. Transudative effusions are managed by treating the underlying medical disorder 3. The management of exudative effusions depends on the underlying etiology of the effusion
  • 32.  Pharmacologic management of pleural effusion depends on the condition’s etiology. For example, medical management includes nitrates and diuretics for congestive heart failure and pulmonary edema, antibiotics for parapneumonic effusion and empyema, and anticoagulation for pulmonary embolism 1) Antibiotics,  Ampicillin and sulbactam (Unasyn)  Imipenem and cilastatin (Primaxin)  Clindamycin (Cleocin)
  • 33. 2) Vasodilators Nitroglycerin (Nitrostat, Nitro-Bid, Nitro-Dur, Nitrolingual) 3)diuretics Furosemide (Lasix) 4)Anti coagulant Heparin
  • 34. 1)Therapeutic Thoracentesis 1. Therapeutic thoracentesis is used to remove larger amounts of pleural fluid to alleviate dyspnea and to prevent ongoing inflammation and fibrosis in parapneumonic effusion 2) Tube Thoracostomy Although small, freely flowing parapneumonic effusions can be drained by therapeutic thoracentesis, complicated parapneumonic effusions or empyemas require drainage by tube thoracostomy.
  • 35.  Traditionally, large-bore chest tubes (20-36F) have been used to drain the thick pleural fluid and to break up loculations in empyemas.  3) Pleurodesis 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, effectively obliterating the potential pleural space
  • 36.  Pleurodesis is most often used for recurrent malignant effusions, such as in patients with lung cancer or metastatic breast or ovarian cancer 4) Indwelling Tunneled Pleural Catheters TPC can be inserted as an outpatient procedure and can be intermittently drained at home, minimizing the amount of time spent in the hospital for patients with short prognoses
  • 38.  •Implement medical regimen: Prepare and position patient for thoracentesis and offer support throughout the procedure.  •Monitor chest tube drainage and water-seal system; record amount of drainage at prescribed intervals.  • Administer nursing care related to the underlying cause of the pleural  • Assist patient in pain relief. Assist patient to assume positions that are least painful. Administer pain medication as prescribed and needed to continue frequent turning and ambulation.  •If the patient is to be managed as an outpatient with a pleural catheter for drainage, educate the patient and family about management and care of the catheter and drainage system. effusion
  • 40.  Ineffective breathinnng pattern rellated to accumulation of fluid in pleural space  Impaired gas exchannging related toalveolarcapillarymembbrane changes and respiratory fatigue  Activity intolerance related to mismatch in oxygen supplay and demand  Acute pain related to lnflammation of pleura
  • 41. The potential complications associated with pleural effusion are:  lung scarring,  pneumothorax (collapse of the lung) as a complication of thoracentesis,  empyema (a collection of pus within the pleural space), and  sepsis (blood infection) sometimes leading to death