A pleural effusion occurs when excess fluid accumulates in the pleural cavity, resulting in impaired breathing. Various types of pleural effusions exist depending on the fluid composition and cause. Common causes include heart failure, cirrhosis, infections, tumors, and trauma. Diagnosis involves physical exam, chest x-ray, ultrasound, and diagnostic thoracentesis. Treatment depends on the underlying cause but may include antibiotics, diuretics, thoracentesis, chest tubes, pleurodesis, or indwelling catheters. Complications can include lung scarring, pneumothorax, empyema, and sepsis.

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 .

28. Thoracoscopy

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