This document discusses massive pleural effusions (MPE), which are excessive accumulations of fluid in the pleural space seen on chest x-rays. Common causes of MPE include malignancy, tuberculosis, and chronic alcoholic pancreatitis. Diagnostic tests for MPE include thoracentesis, analysis of pleural fluid, imaging-guided biopsies, and bronchoscopy. Management involves drainage of fluid, treatment of underlying causes, and pleurodesis to prevent recurrence in cases of malignancy. Precautions must be taken when draining large volumes of pleural fluid to prevent re-expansion pulmonary edema.
2. • EXCESSIVE ACCUMULATION OF FLUID IN THE PLEURAL SPACE OR
• CHEST ROENTGENOGRAMS SHOW OPACITY OF ABOUT TWO-THIRDS
AND ABOVE
• THE DIAGNOSTIC DILEMMA: RELATED TO DISORDERS OF THE LUNG
OR PLEURA, OR TO A SYSTEMIC DISORDER.
• THE COMMONLY SYMPTOM DYSPNEA, DRY COUGH, PLEURITIC
CHEST PAIN.
MASSIVE PLEURAL EFFUSION (MPE)
4. DIAGNOSTIC TEST
• THORACENTESIS SHOULD BE PERFORMED FOR ALMOST ALL
MASSIVE PLEURAL EFFUSIONS.
• LABORATORY EXAMINATION TO DISTINGUISH TRANSUDATE
FROM AN EXUDATE, MICROBIOLOGICAL STUDIES, AND
CYTOLOGICAL ANALYSIS.
• IMMUNO HISTOCHEMISTRY INCREASED DIAGNOSTIC ACCURACY.
• TUBERCULOSIS AND MALIGNANCY ARE THE TWO MOST
COMMON CAUSES OF MASSIVE PLEURAL EFFUSION.
5. DIAGNOSTIC TEST…cont
• FIBEROPTIC BRONCHOSCOPY, IN THE SETTING OF A PLEURAL
EFFUSION WITH ANOTHER ABNORMALITY ON CHEST
RADIOGRAPHY GIVES A DIAGNOSTIC YIELD OF CLOSE TO 50%.
• IMAGE-GUIDED PLEURAL BIOPSY IS THE INVESTIGATION OF
CHOICE IN CASES OF MALIGNANT MESOTHELIOMA, WITH A
SENSITIVITY OF 86% AND A SPECIFICITY OF 100%.
• PERCUTANEOUS PLEURAL BIOPSIES AS A BLIND
PERCUTANEOUS NEEDLE BIOPSY OR THROUGH
THORACOSCOPY OR OPEN THORACOTOMY ARE OF GREATEST
VALUE IN THE DIAGNOSIS OF GRANULOMATOUS AND
MALIGNANT DISEASES OF THE PLEURA.
6. • DRAINAGE TO SYMPTOMATIC RELIEF.
• MALIGNANT EFFUSIONS ARE USUALLY DRAINED TO PALLIATE
SYMPTOMS AND MAY REQUIRE PLEURODESIS TO PREVENT
RECURRENCE.
• GIVE THERAPY FOR SPECIFIC CAUSE.
• INSERTION OF AN INTERCOSTAL DRAIN (EITHER SMALL OR LARGE
BORE CATHETER) FOR MODERATE AND LARGE EFFUSION.
MANAGEMENT
• PLEURODESIS FOR REPEATED EFFUSIONS BY CHEMICAL (TALC,
BLEOMYCIN, TETRACYCLINE/DOXYCYCLINE), OR SURGICAL.
7. MANAGEMENT, cont:
• PLEURODESIS SUCCESS IN 70-93% OF CASES.
• AN ALTERNATIVE IS TO PLACE A PLEURX PLEURAL CATHETER OR
ASPIRA DRAINAGE CATHETER. THIS IS A 15FR CHEST TUBE WITH A
ONE-WAY VALVE FOR ABOUT 30 DAYS AND THEN IT IS REMOVED
WHEN SPONTANEOUS PLEURODESIS HAPPENED.
• A REVIEW OF THE ENGLISH LITERATURE FOR 1168 PATIENTS FOR
MALIGNANT PLEURAL EFFUSIONS FROM 1966 TO 1994 SHOWED
THAT TALC WAS THE MOST EFFECTIVE SCLEROSING AGENT, WITH A
COMPLETE SUCCESS RATE OF 93%.
10. SPECIAL PRECAUTION
• PREVENTION OF RE-EXPANTION PULMONARY EDEMA AND VAGAL
REFLEX WHEN EVACUATION OF PLEURAL FLUID.
• THERE ARE RELATION BETWEEN THE VOLUME OF PLEURAL FLUID
REMOVED, PLEURAL PRESSURES, PLEURAL ELASTANCE, AND SPEED
OF FLUID EVACUATION.
• GRADUAL EVACUATION FOR MINIMIZE OR SMOOTH CONTACT OF
THE TWO PLEURAS.
• CHEST DISCOMFORT OR END-EXPIRATORY PLEURAL PRESSURE LESS
THAN 20 CM H2O MAY AS AN INDICATOR FOR TERMINATION.
11. GENERAL MANAGEMENT OF CHEST DRAIN
• PERFORM HAND HYGIENE
• OPEN DRAIN PACKAGING IN AN ASEPTIC, 'NO-TOUCH' MANNER
• PREPARE DRAIN AS PER MANUFACTURER’S INSTRUCTIONS
• PASS STERILE END OF TUBING TO DOCTOR INSERTING DRAIN WHEN
THEY ARE READY
• APPLY SUCTION TO DRAIN IF ORDERED
• SECURE DRAIN AND TUBING AND PATIENT
• CHEST DRAINS SHOULD NOT BE CLAMPED UNLESS ORDERED BY
MEDICAL STAFF
12. SPECIAL MANAGEMENT OF CHEST DRAIN
1. START OF SHIFT CHECKS
2. PATIENT ASSESSMENT
3. PAIN
4. DRAIN INSERTION SITE
5. WSD UNIT AND TUBING
6. SUCTION
7. DRAINAGE
8. AIR LEAK (BUBBLING)
9. OSCILLATION (SWING,
UNDULATION)
10. EQUIPMENT BY THE BEDSIDE
11. PATIENT POSITIONING
12. PATIENT TRANSPORT
13. SPECIMEN COLLECTION
14. CHEST DRAIN DRESSINGS
15. CHANGING THE CHAMBER
16. TROUBLESHOOTING
17. REMOVAL OF CHEST DRAINS
