1. MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED
SCIENCES
(MUHAS)
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SCHOOL OF NURSING
CASE STUDY PRESENTATION
TOPIC: MANAGEMENT OF PLEURAL EFFUSION
PRESENTER: MELKIOR PETER S.
REG: NO. 2010-04-03030
SUPERVISOR: MKOKA, DICKSON
DR. MSELLE, LILIAN
STEPHENE, KIBUSI

2. CASE DESCRIPTION
Physiology of the normal lung
The lungs are soft, spongy, cone-shaped organs located in the chest cavity.
They are separated by the mediastinum and the heart. There are 3 lobes on the
right lung and 2 lobes on the left lung.
The lungs are supplied with blood via the pulmonary and bronchial circulations.
• Pulmonary circulation: supplied from the pulmonary artery and provides
for gas exchange function of the lungs.
• Bronchial circulation: distributes blood to the conducting airways and
supporting structures of the lung.
Layers of the lung
Parietal Pleura -Lines the thoracic cavity, including the thoracic cage,
mediastinum, and diaphragm. Contains sensory nerve endings that can detect
pain
Pleural space- thin, transparent, serous membrane which lines the thoracic cavity
a potential space between the parietal pleura and visceral pleura
Visceral pleura- Lines the entire surface of the lung. Contains no sensory nerve
endings that detect pain
Pleural fluid
Serous fluid that allows for the parietal pleura (outer lining) and visceral pleura
(inner lining) to glide over each other without separation, contains about 5-15ml
of fluid at one time. It is produced by the parietal pleura and absorbed by the
visceral pleura as a continuous process and has an alkaline pH of 7.64
Excessive amounts of such fluid can impair breathing by limiting the expansion
of the lungs during respiration (pleural effusion)
More specific terminology may be used when the nature of the fluid is known.
Hydrothorax is a collection of serous (most often transudative but also
exudative) fluid, while pus in the pleural cavity is referred to as a pyothorax or
empyema. Additional terms are used for blood (hemothorax) and chyle
(chylothorax)

3. Pathophysiology
Pleural fluid is formed and removed slowly, at an equivalent rate, and has a
lower protein concentration than lung and peripheral lymph. It can accumulate
by one or more of the following mechanisms
• Increased hydrostatic pressure in the microvascular circulation: clinical
data suggest that an elevation in capillary wedge pressure is the most
important determinant in the development of pleural effusion in
congestive heart failure.
• Decreased oncotic pressure in the microvascular circulation due to
hypoalbuminemia, which increases the tendency to form pleural
interstitial fluid.
• Increased negative pressure in the pleural space, also increasing the
tendency for pleural fluid formation; this can happen with a large
atelectasis
• Separation of the pleural surfaces, which could decrease the movement of
fluid in the pleural space and inhibit pleural lymphatic drainage; this can
happen with a trapped lung.
• Increased permeability of the microvascular circulation due to
inflammatory mediators, which would allow more fluid and protein to
leak across the lung and visceral surface into pleural space; this has been
documented with infections such as pneumonia.
• Impaired lymphatic drainage from the pleural surface due to blockage by
tumor or fibrosis.
• Movement of ascitic fluid from the peritoneal space through either
diaphragmatic lymphatics or diaphragmatic defects.
Types of effusion
A. Transudate
Fluid substance that has passed through a membrane or has been extruded from
a tissue it is of high fluidity and has a low content of protein, cells, or solid
materials derived from cells. It caused by fluid leaking into the pleural space.
This is caused by increased pressure in, or low protein content in, the blood
vessels . A transudate is a clear fluid, similar to blood serum . It reflect a
systemic disturbance of body, the common causes are CHF and liver or kidney
diseases.

4. B. Exudate
Pale yellow and cloudy substance, influenced by local factors where fluid
absorption is altered (inflammation, infection, cancer)
Rich in protein (serum protein greater than 0.5), ratio of pleural fluid LDH and
serum LDH is >0.6
Pleural fluid LDH is more the two-thirds normal upper limit for serum
Rich in white blood cells and immune cells, always has a low pH
Common causes are pneumonia, cancer, and trauma
Clinical manifestation
The clinical manifestations of pleural effusion are variable and often are related
to the underlying disease process. The most commonly associated symptoms are
progressive dyspnea, cough, and pleuritic chest pain.
Dyspnea
The most common symptom associated with pleural effusion and is related more
to distortion of the diaphragm and chest wall during respiration than to
hypoxemia. In many patients, drainage of pleural fluid alleviates symptoms
despite limited improvement in gas exchange. Drainage of pleural fluid may also
allow the underlying disease to be recognized on repeat chest radiographs. Note
that dyspnea may be caused by the condition producing the pleural effusion,
such as underlying intrinsic lung or heart disease, obstructing endobronchial
lesions, or diaphragmatic paralysis, rather than by the effusion itself.
Cough
Cough in patients with pleural effusion is often mild and nonproductive. More
severe cough or the production of purulent or bloody sputum suggests an
underlying pneumonia or endobronchial lesion.
Chest pain
The presence of chest pain, which results from pleural irritation, raises the
likelihood of an exudative etiology, such as pleural infection, mesothelioma, or
pulmonary infarction.
Pain may be mild or severe. It is typically described as sharp or stabbing and is
exacerbated with deep inspiration. Pain may be localized to the chest wall or
referred to the ipsilateral shoulder or upper abdomen, usually because of
diaphragmatic involvement.

5. Methods Used to Investigate Pleural Disease
Medical History
Patients with pleural effusions should be studied systematically. As a first step a
complete medical history should be taken with special emphasis on the patient’s
history of exposure to asbestos, current and recent medications, and the prior or
current presence of entities such as heart disease, tuberculosis, neoplastic
disease, and connective tissue disease. Secondly, a complete physical
examination should be performed. Based on the overall picture provided by the
clinical variables, medical history, physical examination, results of basic
laboratory tests, and of any additional tests ordered because of a suspected
diagnosis, it is possible to establish a diagnosis before thoracentesis and order
the pertinent tests.
Radiographic Techniques
An effusion of more than 75 mL is often visible on chest radiographs. Pleural
effusions can be either free flowing or loculated and either typically or
atypically sited (subpulmonic, fissural, or mediastinal) sited. The amount of
fluid varies. When there is a doubt in the case of small effusions the existence of
pleural fluid should be confirmed by chest ultrasound or radiographically using
a lateral decubitus projection on the affected side. Anomalies in the lung
parenchyma can help to confirm the suspected diagnosis, and computed
tomography can contribute useful additional information.
Thoracentesis
Pleural fluid should always be investigated using thoracentesis except when the
suspected effusion is clearly secondary to a specific underlying disease (for
example heart failure). The morbidity associated with thoracentesis carried out
by an experienced operator is low. In the case of small effusions, thoracentesis
can be undertaken if the distance between the horizontal line of the pleural
effusion and the chest wall is more than 1 cm on an ipsilateral decubitus view.
Otherwise, ultrasound guidance is necessary. The most common complications
are vagal reaction (10%-14%) and pneumothorax (3%-8%). A chest radiograph
is not essential after thoracentesis except when complications such as
pneumothorax are suspected
The following properties of the fluid sample are analyzed: color, appearance
(pus in the case of empyema, milky with lipid effusion, and bloody in
hemothorax), and smell (putrid in infections caused by anaerobic
microorganisms, and ammoniac in the case of urinothorax). Hemorrhagic fluid
is more likely in effusions caused by malignancy, trauma, or pulmonary
embolism.

6. Thoracoscopy.
A thoracoscope facilitates examination of the pleural cavity and biopsy of the
parietal and visceral pleura under visual guidance. Thoracoscopy can be
performed with local anesthesia and sedation. The diagnostic yield for cancer is
over 90%, and this procedure is particularly recommended in patients with a
history of asbestos exposure (because of the possibility of mesothelioma). If
clearly malignant lesions are observed, pleurodesis can be carried out
immediately during the procedure
Cytology.
Pleural fluid cytology is among the tools offering the highest yield for
diagnosing malignancy. The sensitivity of this test ranges from 40% to 87%
depending mainly on the cytologist’s training, the extent of pleural involvement,
and tumor type (yield is higher in adenocarcinoma). Cytology of sequential
specimens increased yield up to 30% in some studies. Immunocytochemical
techniques use various antibodies to differentiate between epithelial and
mesothelial cells.
Thoracotomy.
Thoracotomy is only indicated in very specific situations and only when other
diagnostic methods have failed.
Computed tomography.
Computed tomography is used to investigate the mediastinum and the lung
parenchyma, to detect pleural masses, and as a guide for biopsies. When used
appropriately, this technique can also help to establish a diagnosis of pleural
effusion secondary to pulmonary embolism. If the clinical findings or results of
laboratory tests point to an abdominal disease as the cause of the patient’s
condition, abdominal imaging with computed tomography or ultrasound can be
used to rule out such disease.
Therapeutic measures
Therapeutic thoracentesis
Any pleural effusion large enough to cause severe respiratory symptoms should
be drained regardless of the cause and regardless of concomitant disease-specific
treatment. Relief of symptoms is the main goal of therapeutic drainage in these
patients. The only absolute contraindication to thoracentesis is active cutaneous
infection at the puncture site. Some relative contraindications include severe
bleeding diathesis, systemic anticoagulation, and a small volume of fluid.

7. Tube thoracostomy (chest tube)
Tube thoracostomy allows continuous, largevolume drainage of air or liquid
from the pleural space.
Specific indications for placement of a chest tube include spontaneous or
iatrogenic pneumothorax (especially if large and symptomatic), hemothorax,
penetrating chest trauma, complicated parapneumonic effusion or empyema,
chylothorax, and pleurodesis of symptomatic pleural effusions.
Complicated parapneumonic effusions and frank empyema require drainage
with a large-bore chest tube (28–36 F) to control the local pleural inflammatory
reaction, which may not otherwise respond to intravenous antibiotics. In
multiloculated complicated effusions, image-guided placement of small-bore
catheters (10–14 F) should be considered.If appropriate drainage is not obtained
despite correct positioning of the tubes (verified with chest CT), fibrinolytic
therapy can be used. Agents such as streptokinase, urokinase, and alteplase can
lyse fibrin and improve drainage.
Subsequent management of the CT must be individualized to the patient, taking
into consideration the reason for CT placement, whether or not the patient has
had pulmonary resection, and whether the patient is mechanically ventilated.
Premature CT removal, as well as unnecessary delays in CT removal, leads to
increased hospital stays and costs.
Pleural sclerosis
Pleural sclerosis (pleurodesis) is considered for patients with uncontrolled and
recurrent symptomatic malignant effusions, and rarely, in cases of benign
effusions after failure of medical treatment. A sclerosing agent is instilled into
the pleural cavity via a tube thoracostomy to produce a chemical serositis and
subsequent fibrosis of the pleura. Pleural sclerosis should be attempted only if
the lung expands fully after fluid removal. The visceral and parietal pleura need
to be approximated closely, obliterating the pleural cavity so that fibrotic healing
achieves pleural symphysis.
The overall success rate with fibrosing agents (ie, talc, doxycycline, and
tetracycline) is 75%, compared with a complete success rate of only 44% for
antineoplastic agents (ie, bleomycin). Talc is the most effective agent, with a
complete success rate of 93%. Pleurodesis failure is usually the result of
suboptimal technique or inability to approximate the pleural surfaces.
Surgical therapy
Video assisted thoracoscopic surgery is very useful in managing incompletely
drained parapneumonic effusions. With thoracoscopy, the loculi in the pleura
can be disrupted, the pleural space can be completely drained, and the chest tube
can be optimally placed.

8. In cases of empyema with uncontrolled sepsis or progression to the
fibroproliferative phase, a full thoracotomy with decortication is performed with
removal of all the fibrous tissue and evacuation of all the pus from the pleural
space. Decortication in this situation will eliminate the septic source and allow
the lung to expand.
Other surgical methods for managing MPE
Two surgical procedures which could be considered by the physician when a
patient has a MPE are a pleurectomy or placement of a pleuroperitoneal shunt.
The shunt is placed surgically and consists of a tube or passage allowing the
fluid from the effusion to move from the pleural space to the peritoneal space
where it is hoped the fluid will be slowly absorbed. Many times this procedure is
done if the patient failed chemical pleurodesis. It requires manual pumping of
the shunt and could have complications from blockage of the shunt
The other surgical procedure considered only in patients who can withstand a
long surgical procedure and with a good life expectancy is a pleurectomy. A
pleurectomy involves removal of the parietal pleura and manual irritation of the
visceral pleura causing formation of adhesions and scar tissue and therefore no
more fluid build up in the space. This is a major surgical procedure done under
general anesthesia as an open chest case. A partial pleurectomy could be done
via a thoracoscope. Patients having this procedure would need to be monitored
and cared for as any thoracotomy patient would with high risk for pneumonia
and deep vein thrombosis.
Management of chest tube(UWDS)
Once a chest tube is inserted, it is important for nursing staffs to ensure that the
patient and the drain is closely monitor. However, wide variations have been
observed, which are based on local policies and individual preference rather than
evidenced based protocols. Below are the management of patient with chest tube
drainages.
Positioning
The patient should be placed in a semi-recumbent position with regular position
changes in order to encourage drainage and prevent stiffening of the shoulder
joints. These might enhance breathing and expectoration, as well as allowing
full lung expansion and possibly preventing complications of prolonged
immobilization
Drain patency
Drainage can be impeded by excessive coiling, dependent loops, kinked or
blocked tubes, and which potentially might lead to tension pneumothorax or
surgical emphysema. The tubing should be lifted regularly to drain the fluid into
the collection bottle if the coilings cannot be avoided. The effects of clamping,

9. milking and striping of chest tubes are controversial and are usually not advised.
Replacement of tubing is usually advised if blockage is detected.
Lung damage from the sharp pressure changes generated during stripping of
tubing might be resulted. Although clamping of drains are still observed and
practiced in cases where there are no longer any air leakage and when
replacement of tubing or bottle is necessary, this is not recommended in the
major international guidelines
Observation
Patient’s vital signs, respiratory rate, oxygen saturation as well as the presence
of tidaling and bubbling in chest drainage system should be closely monitored.
Any deterioration or distress of the patient should be reported immediately
Pain management
There are currently no definite guidelines on pain assessment and pain control
with regard to chest drainage. The pain could be substantial and might affect
coughing, ventilation, sleep as well as re-expansion of the lung. Nurses should
be aware of the potential need for prescribed on-demand pain killers or inform
clinicians about the possible requirements.
Recording and observing drainage
The drainage system should be kept below the patient’s chest level to prevent
fluid re-entering the pleural space. Volume, color, tidaling, bubbling of drainage
fluid and level of suction pressure should be regularly evaluated and recorded on
patient’s chest drain chart(if suction used). The frequency of recording will vary
depending on the condition of the patients and their underlying disease(s).
Drain security and wound management
Using of tape to secure connections has been controversial with no apparent
clear recommandation. Some researchers advocated that taping the connections
can avoid potential disconnection but others argued that taped tube may mask
disconnections. The use of transparent, water-proof and secure tapings might be
necessary in a busy and congested ward environment. The insertion site should
be checked everyday to ensure that the wound is dry and clean, with no loosen
sutures or visible side hole(s) of chest tube (i.e. slipping out). Presence of or
increasing surgical emphysema, pus, or excessive bleeding around insertion sites
should also be noted.
Potentially dangerous conditions that require urgent attention
- Large amount of bubbling in the water seal chamber, which might signify a
large patient air leak or a leak in a system
-Large amount of bloody discharge might indicate haemothorax or trauma to
underlying organs

10. - Increasing dyspnoea, increased heart rate, lowered blood pressure & low
oxygen saturation: may signify recurrent pneumothorax (after drain removal) or
insufficient drainage or tube blockage
- Absence of gentle bubbling in suction control bottle/ chamber may indicate
disconnection of the suction pressure or inadequate suction force to counteract
the large air leakage.
Case study(patient description)
Name of patient....................................................................mr x
File number.......................................................................A725690
Sex .....................................................................................male
Age .................................................................................18 years
Admission .........................................................15/01/2013
Referal from .....................................................moi
Occupation ...............................................................none
Education .............................................................form 4 liver at Jitegemee sec.
Patient chief complains
On admission mr x was complaining, difficult in breathing, worse on lying flat
for 1 week accompained with chest tightness, dry cough with exessive night
sweets.
Review of systeams
Neurological systeam-none
Cardiovascular systeam –capillary refil <3 seconds
Respiratory systeam- dyspnea, paroxysmal nocturnal dyspnea, chest pain (P-
pain in right thorax during deep inspiration and movements Q- Sharp pain R
Non-radiating, S-4/10 T- relieved by shallow breathing, orthopnea of 2 pillows,
RR 56b/min, chest tightness, chest tube drains 750mls
Tracheal centrally located, chest expansion symmetrical, dullness on percussion
at right side of the lung and decreased air entry.
Intergumentary system- night sweets, skin intact, left lower limb amputated
(AKA).
Reproductive system- none

11. History of present illness
Mr x is a known patient of osteosarcoma, AKA (above knee amputation) done
on 22/08/2012 left lower limb at MOI.
Now known to be metastatic osteosarcoma in which the right lung is affected
On assesment,
Tracheal was centrally located, symetrical chest expansion, reduced breath
sounds on ascultation of the right side chest, dull percussion which suspect the
presence of fluid on right side lung
Chest tube placed drains haemorrhagic fluid (600mls)
Dyspneic with RR 56b/min, on oxygen therapy 8mls
Planning on admission day
Chest x- ray
CT scan
HIV serology
Serum electrolyte
Full blood picture (FBP)
Catheterization
IV fluids NS 1L alternate RL 1L/24hr
IV ceftriaxone 1gm OD 7/7
On 16/01/2013
Patient still complaining difficult in breathing
Dyspnic, continue with O2 therapy
Another complain of chest pain worse in deep inspiration
P: right thorax
Q: Sharp pain
R: non-radiating
S: 6/10
T: upon deep inspiration, relieved after shallow breathing).
Chest tube drains 4700mls/24hrs, patient dehydrated
IVF given 3litres DNS/24hrs
IV Diclofenac 75 mg 8hourly 5/7
Capillary refill <3 seconds, skin intact GCS 15/15
BP- 139/100, PR -109, RR- 47, SPo2-92%

12. On 19/01/2013
Patient still on difficult breathing, Leakage on chest tube
Planning
Continue with O2 and IV fluids (DNS and RL)
Fix the tube well, Continue with analgesics
Chest tube reinserted on 20th /01/2013 and drains 750mls of hemorrhagic pleural
fluid/12hrs
Antibiotic given IV metronidazole 500mg 8hourly, IV ceftriaxone 1gm od 3/7
Past medical history
No history of chronic illness at past, no surgical history, its 1st admission on
hospital
Family social history
Mr x is a form 4 liver, not working, not alcoholic and he has no history of
smoking. Not allergic to any drug or other substances.
Second child in 4 child family, lives with his mother at Kinondoni.
Interpretation of findings
Chest x-ray
Opaque densities on the right lower lobe
& blunting of costophrenic angle, which shows the accumulation of fluid that
confirms pleural effusion
CT scan
Homogenous opacification of the right hemithorax leading to shift of
mediastinal to the left side.
The left lung is normal and normal thoracic cage
Massive right side pleural effusion probably metastatic origin
Nursing care plan
1. Ineffective breathing pattern related to decreased lung expansion
(accumulation of liquid), as evidenced by dyspnea, changes in depth of
breathing, accessory muscle use
Interventions
Maintain a comfortable position is usually elevated headboard
Given oxygen through a cannula (8mls)

13. 2. Acute Pain r/t accumulation of fluid in the pleural space and rubbing of
thoracostomy tube to the lungs
Interventions
-The presence of pain, the scale and intensity of pain was well assessed
-The client taught about pain management and relaxation with distraction
-Chest tube secured to restrict movement and avoid irritation
-Given prescribed analgesics i.e diclofenac 75mg od 5/7
3. Risk for nutrition imparement, less than body requirement telated to
inability to ingest adequate nutrients
Interventions
-Patient relative i.e his father encouraged to give him energy reaching
food stuff together with energy supplement so that he can get enough
energy.
-Administer DNS as prescribed to the patient to increase energy lost.
4. Risk for fluid volume deficit related to chest tube drainage.
Interventions
-encourage the patient to drink enough water to suplement the one lost by
chest tube drainage
-IV fluids given to Mr Allen i.e RL & DNS to replace fluid lost in
drainage system monitored in 24hours.
5. Risk for infection related to the presence of fluid in the pleural space and
the insition site.
Interventions
-the patient dressed at the insition site when it is wetted, probably after 2
to 3 days
-Given antibiotics as prescribed i.e IV metronidazole 500mg 8 hourly,
IV ceftiaxone 1gm 3/7.

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2005
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