3. OBJECTIVE
Post session participatant will be able to:
Understand the meaning of MPE,epidemiology,
pathopysiology ,signs and symptoms,various
investigation ,different type of treatment modalities
nursing management and intervention.
4. INTRODUCTION
Malignant pleural effusion(MPE)is the abnormal collection of exudative fluid in
the pleural space due to the presence of malignant cells in the pleural space
and or pleural membrane.
It indicates an advanced or disseminated neoplasm
Affect 15% of all cancer patients
As overall survival rate of 3-12 months after diagnosis of MPE
6. EPIDEMIOLOGY
ADULT POPULATION
Both lung and breast cancer account for 50-655of all malignant effusions
Lymphomas, tumors of the genitourinary tract and gastrointestinal tract account for further 25%
Tumors of unknown primary are responsible for 15%of all malignant pleural effusions
PAEDIATRIC POPULATION
Lymphomas or leukemias account for 50% of MPE
Remains 50%-mix of tumors such as Neuroblastoma, Wilms tumor and Germcell neoplasms
7. PATHOPHYSIOLOGY
MPE CAN RESULT FROM 3 METHODS OF METASTASIS
1.The direct invasion of pleura with malignant cells by neighboring organs like
the lung, breast, and chest wall.
2.The spread of visceral pleura by the embolization of malignant cells, with
invasion of the pulmonary vascular system
3.The spread of parietal pleura by the hematogenous spread of distant organ
metastasis
8. CLINICAL PRESENTATION
CLINICAL FEATURES
Asymptamatic-25% of case
Dyspnea and cough
Chest pain-dull ache(rather than pleuritic)
Constitutional symptoms-weight loss, Malaise , Anorexia, Nausea and emesis
Hemoptysis seen in bronchial carcinoma patients
Cachexia and lymphadenopathy due to cancer
Any history of Malignancy, Heart failure, Renal disease ,Pneumonia and TB
Drugs-Methotrexate or Amiodarone
Social-occupational exposure ex; Asbestos, Smoking
9. PHYSICAL EXAMINATION
.GENERAL
>Ill-looking, Weight loss, Pallor, Peripheral lymph nodes
.RESPIRATORY SYSTEM
>Increase respiratory rate and use of accessory muscles of respiration
>Asymmetrical chest expansion or even bulging of the intercostal spaces
>Dullness with percussion and a decreased breath sounds
>Trachea may deviate if there is an associated mediastinal shift
>Pleural friction rub can be heard in massive effusions
10. FINDINGS
CHEST X –RAY
>80%-MODERATE TO LARGE PLEURAL EFFUSION(500-2000ML)
>10%-MILD EFFUSION(<500ML)
>10%-MASSIVE PLEURAL EFFUSION(occupying the entire hemithorax)
11. FINDINGS(CONT)
ULTRASOUND
DIAGNOSTIC PURPOSE
.Identify and quantifying small volume of effusion
.pleural thickening >1cm
.Diaphragmatic nodularity or thickening>7mm
Pleural nodularity/irregularity
THERAPUTIC PURPOSES
.Safe Thoracocentesis or chest tube insertion
12. FINDINGS(CONT)
CT SCAN
FEATURES; Loculation
.Parietal pleural thickening
.Circumferential pleural thickening
.Nodular plural thickening
.Lymph node involvement
-It should be done all for MPE of unknown origin
-can be used biopsy lesions
• CT SCAN
FEATURES;
13. FINDINGS(CONT)
PET CT SCAN
-Useful for early detection of pleural Metastases but relatively low specificity
-high degree of accuracy in distinguishing benign from malignant effusion
-Hypermetabolism can be seen in either the pleura or pleural effusion
14. FONDINGS(CONT)
MRI
-Good value in delineating malignancy in pleural space
-better than chest CT for determining chest wall or diaphragmatic invasion
15. FINDINGS(CONT)
PLEURAL FLUID ANALYSIS
-Samples are obtained by Thoracentesis (blindly or USG guided)
-A minimum of 50ml is needed for analysis
-Large volume of 100-200ml are needed for cell block and molecular testing
Test to run;
Total and differential cell count
Chemical analysis(total protein, LDH ,H, Glucose, Albumin)
Microbiological study
Cytological analysis
16. FINDINGS(CONT)
The rate of increases with repeated thoracentesis Diagnosis
-with in first thoracentesis success rate of cytological diagnosis is 65%
-2nd thoracentesis add 27%success rate
-3rd thoracentesis only add 5%
For MPE-other biochemical analysis
-Low glucose(<60mg/dl)
-low pH(<7.20)
-high pleural fluid Amylase
17. FINDINGS(CONT)
Cytology
-The frequency of positive pleural fluid cytologic tests is depends on the tumor type and number of
specimens
-Most patient with adenocarcinomas with positive cytology but it is 25% of patient with Hodgkin
disease
-immunohistochemical stains of malignant cells are used to confirm a diagnosis and to specify tumor
type
-cytology can provide enough DNA to access mutational analysis for
Epidermal Growth Factor Receptor(EGFR)
18. FINDINGS(CONT)
TUMER MARKERS IN Pleural Fluids
-common markers;
.cytokeratin 19 fragment, CA 153,CA 125 and CEA
-CEA-lung cancer( 59%),GI cancer(71%)
High levels of TM with negative cytology may indicate need for confirmatory test
with biopsy
19. FINDINGS(CONT)
PLEURAL BIOPSY
-Indicate when cytology is negative but
MPE is still highly suspected
Contraindications
-Bleeding, anticoagulation
-chest wall infection
-lack of patient cooperation
Modalities
Percutaneous needle biopsy(blindly or CT guided)
thoracoscopy(medical or video assisted)
20. FINDINGS(con)
Ct scan guided percutaneous pleural biopsy
-sensitivity of about 80%
-specificity of 100%
.Thoracoscopy
-Directly biopsy abnormal or suspicious areas
-Enables performance of all the necessary test
to identify the origin of the malignant tumor
-can be use to pass a chest tube
21. TREATMENT OF MPE
TREATMENT IS PALLIATIVE
-Length of survival depends upon stages and type of primary tumour
Median survival is 3-12 months
PRINCIPLES OF TREATMENT
-Address the effusion(evacuation and prevention of recurrence)
- Address the primary tumour
Treatment options
MPE is determined by
-Symptoms and performance status of the patient
-Primary tumour type and its response to systemic therapy
-Degree of lung re expansion following pleural fluid evacuation
22. TREATMENT OF MPE
Treatment options include
-Observation
-Therapeutic pleural aspiration(Thoracentesis)
-Intercostal tube drainage(tube thoracostomy) and pleurodesis
-Thoracoscopy and pleurodesis
-Placement of an indwelling pleural catheter(IPC)
Asymptomatic patient do no require treatment but should be
observed as MPE may become symptomatic and require palliative
treatment
23. TREATMENT OF MPE
Symptomatic patient
-MPE is not curable and all treatment option is palliative
-management of MPE should be individualized
-all treatment should be consider the type of malignancy, patient symptoms, life
expectancy, functional status ,quality of life and goals of therapy
>relief of dyspnoea
>permanent control of fluid accumulation
>prevent the need of reintervention
>Reduced hospitalization and length of stay
24. TREATMENT OF SYMPTOMATIC MPE
THERAPEUTIC PLEURAL ASPIRATION(THORACOCENTESIS)
>Provide transient relief of symptoms
>avoid hospitalization for patient with Terminally ill
>a high rate of recurrence of effusion at 1 month hence is not recommended id
life expectancy is >1 month
>The volume to drain will be guided by patient symptoms( cough, chest
discomfort)and
>should be limited to 1.5 L on a single occasion
26. TREATMENT OF SYMPTOMATIC MPE
CHEST TUBE DRAINAGE(TUBE THORACOSTOMY) AND CHEMICAL PLEURODESIS
Preferred option for patient with MPE(except for patient with very short life Expectancy)
Pleural fluid is drained with a small bore chest tube followed by chemical pleurodesis
Pleurodesis is the artificial obliteration of the pleural space by chemically(sclerosants)or
physically(pleural abrasion)stimulating an inflammatory reaction between the two pleural
membranes
It is to prevent recurrence
27. TREATMENT OF SYMPTOMATIC MPE
CHEST TUBE INSERTION
>Educate the patient on procedure
>Obtain consent
>tray-basic set, dressing materials ,cleaning agents
Chest tube(Fr 10-14) and under water drainage seal
>positioning the patient
>after the chest tube insertion confirm correct placement
.pleural fluid following adequately
.fluid oscillating in tube when not draining
.improvement in symptoms
.chest x ray
28. TREATMENT OF SYMPTOMATIC MPE
DRAINING OF PLEURAL FLUID
Maximum of 1.5L on insertion first occasion
remaining fluid –drained 1.5 L 2hrly
Remove tube if there is full lung expansion
COMPLICATION OF CHEST TUBE THORACOTOMY
.Re expansion pulmonary edema
.Pneumothorax
.Subcutaneous emphysema
29. TREATMENT OF SYMPTOMATIC MPE
INSERTIONAL
IC neurovascular injury
intraparenchymal lung placement
POSITIONAL
.Tube malposition
.Blockage or dislodgement
INFECTION
.Surgical site infection
.Empyema
30. TREATMENT OF SYMPTOMATIC MPE
CHEST TUBE(INTERCOSTAL DRAINAGE AND CHEMICAL PLEURODESIS)
Sclerosing agent for pleurodesis
>Mineral-Talc(80 -90% success rate and a high safety profile)
>Anti neoplastic agent-(bleomycin 58% to 85%success rate)
>antibiotics-(tetracycline, quinacrine)
>antiseptic-(povidone iodine, silver nitrate)
>bacterial products-Corynebacterium parvum
>cytokine-INF alpha 2b
31. TREATMENT OF SYMPTOMATIC MPE(cont)
CHEMICAL PLEURODESIS
Administration of talc
.can be as aerosol during thoracoscopy with an atomizer(Talc poundage)
.can be instilled as a suspension via chest tube(Talc slurry)
Talc slurry
.There must be complete re expansion of the lungs radiographically
.Instill lidocaine solution(3mg/kg maximum-250mg)in to pleural space
.instill 4-5gm sterile graded talc in 50ml 0.9% normal saline
.clamp tube for 1-2hr
Remove intercostal tube with in24-48hr(In the absence of excessive fluid drainage<100ml/day)
Patient rotation is NOT NECESSARY after intrapleural instillation of sclerosant
32. TREATMENT OF SYMPTOMATIC MPE
PLEURODESIS
THORACOSCOPY AND PLEURODESIS
Very useful in MPE of unknown origin(pleural biopsy)
>Better drainage of pleural fluid(to dissect adhesions)
>Chemical pleurodesis(talc Pouderage)
>better success rate than talc slurry pleurodesis
33. CRITIRIA FOR SUCCESS OR FAILURE OF
PLEURODESIS
COMPLEATE SUCESSFUL PLEURODESIS
.Long term relieve of symptoms related to Effusion
.No radiographic evidence deaccumulation until death
PARTIALLY SUCESSFUL PLEURODESIS
.diminishing of symptoms related to effusion
.Partial re accumulation of fluid(should be <50% of initial radiographic evidence)
.no need for further therapeutic thoracentesis for the rest of the patient life
FAILED PLEURODESIS
.Lack of success as described above
34. CAUSES OF FAILURE OF PLEURODESIS
>TRAPPED LUNG(THICK VISERAL PLEURA)
>Loculated MPE
>persistent air leak
>bronchial obstruction
>Pulmonary embolism
>atelectasis
>pleural carcinomatis
35. TRAPPED LUNG LOCULATED MPE
>Lung remain collapsed after drainage >multiple pockets of
effusions
>from adhesions or pleural carcinomatosis
Treatment Treatment
>Long term indwelling catheter >intrapleural fibrinolysis
>pleuro-peritoneal shunt (streptokinase- urokinase)
>decortication
36. TREATMENT OF SYMPTOMATIC MPE
INDWELLING PLEURAL CATHETER DRAINAGE
Indications
>Recurrent and symptomatic malignant effusions
>MPE with trapped lung
Very short hospital stay
Limitations
>high rate of local complication-local cellulitis,
tumor seeding of tract
It is expensive(buying the vacuum drainage bottle)
37. OTHER TEATMENT OF MPE
PLEURO PERITONEAL SHUNT
>Another alternative of palliation when the lung cannot re expand or pleurodesis
is unsuccessful
.PARIETAL PLEURECTOMY
>Associated with substantial morbidity and mortality
Nowadays not recommended with advent of pleurodesis and indwelling pleural
catheters
38. NURSING MANAGEMENT
Identify and treat the underline cause
Monitor breath sounds
Place the client in a high fowler’s position
Encourage coughing and deep breathing Exercise
>prepare the client for thoracentesis
.if pleural effusion is recurrent prepare the client for pleurectomy or
pleurodesis as prescribed
39. Nursing Diagnosis
Ineffective breathing pattern related to decreased lung volume
Capacity as evidence by tachypnea
.Monitor and record vitals
.elevate head of the patient
Encourage patient to perform deep breathing Exercise
.Assist patient in the use of relaxation technique
.Administer supplemental oxygen as ordered
40. NSG Diagnosis
Impaired gas Exchange R/T alveolar-capillary membranes changes
And respiratory fatigue Secondary to pleural effusion
.Monitor respiratory rate, depth and rhythm auscultate breath sounds
.Encourage frequent position changes and deep breathing Exercise
.Provide supplemental oxygen at lowest concentration indicated
.Administer prescribed medication as ordered
