5. CATEGORIES OF PLEURAL EFFUSION
Free of Serious
Inflammation or infection
Significant Inflammation or
permanent Lung problems
Causes Impaired Breathing.
6. TRANSUDATIVE EXUDATIVE
Fluid Similar Has excess Protein,
Drainage Rarely requires
drainage unless very
depending on its size
and the severity of
Caused by CHF Pneumonia and Lung
CATEGORIES OF PLEURAL EFFUSION
The pleural space is bordered by the
parietal and visceral pleurae.
PARIETAL PLEURA - covers the inner
surface of the thoracic cavity,
including the mediastinum,
diaphragm, and ribs.
VISCERAL PLEURA - envelops all lung
surfaces, including the interlobar
The normal pleural space
contains approximately 1 mL of
fluid, representing the balance
between (1) hydrostatic and
oncotic forces in the visceral
and parietal pleural vessels and
(2) extensive lymphatic
9. Pleural Effusion
The etiologic spectrum of pleural effusion is extensive.
Most pleural effusions are caused by congestive heart
failure, pneumonia, malignancy, or pulmonary embolism.
an indicator of an
10. The following mechanisms play a role in
the formation of pleural effusion:
Altered permeability of the pleural membranes
(eg, inflammation, malignancy, pulmonary
Reduction in intravascular oncotic pressure
(eg, hypoalbuminemia, cirrhosis)
Increased capillary permeability or vascular
disruption (eg, trauma, malignancy, inflammation,
infection, pulmonary infarction, drug
hypersensitivity, uremia, pancreatitis)
Increased capillary hydrostatic pressure in the
systemic and/or pulmonary circulation
(eg, congestive heart failure, superior vena cava
11. Reduction of pressure in the pleural space,
preventing full lung expansion (eg, extensive
Decreased lymphatic drainage or complete
blockage, including thoracic duct obstruction
or rupture (eg, malignancy, trauma)
Increased peritoneal fluid, with migration across
the diaphragm via the lymphatics or structural
defect (eg, cirrhosis, peritoneal dialysis)
Movement of fluid from pulmonary edema
across the visceral pleura
Persistent increase in pleural fluid oncotic
pressure from an existing pleural effusion,
causing further fluid accumulation
The following mechanisms play a role in
the formation of pleural effusion:
12. PATHOPHYSIOLOGY – SIGNS / SYMPTOMS
The net result of effusion formation is a flattening or inversion of
the diaphragm, mechanical dissociation of the visceral and
parietal pleura, and a restrictive ventilatory defect.
Common symptoms associated with pleural effusion may include:
chest pain, difficulty breathing, painful breathing (pleurisy), and
cough (either a dry cough or a productive cough).
Deep breathing typically increases the pain. Symptoms of fever, chills,
and loss of appetite often accompany pleural effusions caused by
13. DIAGNOSIS – Physical Exam
Physical findings in
pleural effusion are
variable and depend
on the volume of the
there are no physical
findings for effusions
smaller than 300 mL.
With effusions larger
than 300 mL, findings
may include the
Dullness to percussion, decreased
tactile fremitus, and asymmetrical
chest expansion, with diminished or
delayed expansion on the side of
the effusion – MOST RELIABLE
Mediastinal shift away
from the effusion -
effusions of greater
than 1000 mL
Egophony - ("e" to "a"
changes) at the most
superior aspect of the
14. Most often, pleural effusions are discovered
on imaging tests. Common tests used to
identify pleural effusions include:
15. DIAGNOSIS –
often the first step in identifying a
Pleural effusions appear on chest X-
rays as white space at the base of
If a pleural effusion is likely,
additional X-ray films may be taken
while a person lies on her side.
Decubitus X-ray films can show if the
fluid flows freely within the chest.
16. DIAGNOSIS – CT SCAN
Compared to chest X-
rays, CT scans produce
pleural effusions and
18. DIAGNOSIS - THORACENTESIS
should be done in almost all patients who have pleural fluid that
is ≥ 10 mm in thickness on CT, ultrasonography, or lateral
decubitus x-ray and that is new or of uncertain etiology.
In general, the only patients who do not require thoracentesis are
those who have heart failure with symmetric pleural effusions and
no chest pain or fever; in these patients, diuresis can be tried,
and thoracentesis avoided unless effusions persist for ≥ 3 days.
1. Chemical composition including protein, lactate dehydrogenase
(LDH), albumin, amylase, pH, and glucose
2. Gram stain and culture to identify possible bacterial infections
3. Cell count and differential
4. Cytopathology to identify cancer cells, but may also identify
some infective organisms
5. Other tests as suggested by the clinical situation – lipids, fungal
culture, viral culture, specific immunoglobulins
19. DIAGNOSIS – LIGHT’S CRITERIA
Transudate - produced through pressure filtration without capillary injury
Exudate - "inflammatory fluid" leaking between cells.
Transudative pleural effusions - caused by systemic factors that alter the pleural
equilibrium, or Starling forces. The components of the Starling forces–hydrostatic pressure,
permeability, oncotic pressure (effective pressure due to the composition of the pleural
fluid and blood)–are altered in many diseases, e.g., left ventricular failure, renal failure,
hepatic failure, and cirrhosis.
Exudative pleural effusions - caused by alterations in local factors that influence the
formation and absorption of pleural fluid (e.g., bacterial pneumonia, cancer, pulmonary
embolism, and viral infection).
22. NURSING MANAGEMENT –
Verify a signed informed consent
Assist client to an appropriate
Instruct client not to move during the
procedure including no coughing or
Monitor vital signs during the
procedure – also monitor pulse
oximetry if client is connected to it.
23. Apply a dressing over a puncture and position the
client on the unaffected side. Instruct the client to
stay in this position for at least 1 hour.
During the first several hours after thoracentesis
frequently assess and document vital signs, oxygen
saturation, respiratory status including respiratory
excursion, lung sounds, cough and hemoptysis and
puncture site for bleeding or crepitus.
Obtain a chest x-ray
NURSING MANAGEMENT –
24. Chest Tube Thoracostomy
done to drain fluid, blood and air from
the space around the lungs. whether
the accumulation is the result of rapid
traumatic filling or insidious malignant
seepage, placement of a chest tube
allows for continuous, large volume
drainage until the underlying pathology
can be more formally addressed.
DRUGS, AND TREATMENT
25. Ensure a signed consent for chest tube insertion
Position as indicated for the procedure
Assist with chest tube insertion as needed
Assist respiratory status at least every 4 hours.
Maintain a closed system.
Ensure tubing with no kinks or not compressed
Check the water seal frequently.
Palpate the area around the chest tube site for subcutaneous
emphysema or crepitus.
Encourage client for coughing and deep breathing
Assist with frequent position changes and sitting and ambulation
NURSING MANAGEMENT –
Closed Tube Thoracostomy
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
DRUGS, AND TREATMENT
27. Ensure informed consent
Record baseline vital signs
Consider the use of pre medication
Position patient comfortably
An existing effusion should be completely
drained before the procedure
Ensure a recent chest x-ray
Observe for excessive pain and breathlessness
Patient ambulation is possibly helpful to ensure
good spread of the slurry
NURSING MANAGEMENT –
The pleural space plays an important role in respiration by coupling the movement of the chest wall with that of the lungs in 2 ways. First, a relative vacuum in the space keeps the visceral and parietal pleurae in close proximity. Second, the small volume of pleural fluid, which has been calculated at 0.13 mL/kg of body weight under normal circumstances, serves as a lubricant to facilitate movement of the pleural surfaces against each other in the course of respirations.
This small volume of fluid is maintained through the balance of hydrostatic and oncotic pressure and lymphatic drainage, a disturbance of which may lead to pathology.
Pleural effusion is an indicator of an underlying disease process that may be pulmonary or non-pulmonary in origin and may be acute or chronic.
Diagnosing the cause(s) of a pleural effusion often begins with determining whether the fluid is transudate or exudate. This is important because the results of this fluid analysis may provide a diagnosis and determine the course of treatment.
Verify consent – kasi this is an invasive procedure
Appropriate position – SITTING WITH ARMS AND HEAD ON PADDED TABLE or SIDE LYING POSITION ON UNAFFECTED SIDE = this position spreads the ribs and enlarging the intercostal space for needle insertion
Instruct the client.. – movement and coughing during the procedure may cause damage to the lung or pleura
Monitor VS – esp yung PR & BP kasi nag aaspirate tayo ng fluids, baka magkaroon ng HYPOVOLEMIC shock yung patient
Apply a dressing.. – to prevent air from entering the pleural space and to allow the pleural puncture to heal
During the first.. – frequent assessment is important to detect possible complications such as pneumothorax
Obtain – chest xray is ordered to detect possible pneumothorax
CTT may also be needed when a patient has had a severe injury to the chest wall that causes bleeding around the lungs or accidentally puntured allowing air to gathered outside the lungs causing its collapsed
Position – a suggested position is SEMI-DECUBITUS ON THE BED AT 45 degrees WITH THE ARM BEHIND THE HEAD SO AS TO EXPOSE THE AXILLARY AREA. The drain should ideally be inserted in the SAFE TRIANGLE which is delineated by the lateral border of the pectoralis major (sa may breast part), the anterior border of the latissimus dorsi (saa may likod) and a line horizontal with the nipple. Most clinicians insert the tube via an incision at this 4th or 5th intercostal space in the ANTERIOR AXILLARY or MIDAXILLARY LINE.
Assist respiratory status.. – frequent assessment is necessary to monitor respiratory status and the effect of the chest tube.
Ensure tubing.. – these could interfere with drainage
Check the water seal properly.. – the water level should fluctuate with respiratory effort. If it does not, the system may not be patent or intact. Periodic air tbubbles in the water seal chamber are normal and indicate the trapped air is being removed from the chest. Measure drainage every 8hours and marking the levels on the drainage chamber. Report drainage if it is cloudy, red, warm, free flowing. Red, free flowing drainage indicates hemorrhage and cloudiness may indicate an infection.
performed to prevent recurrence of pneumothorax or recurrent pleural effusion
Consider the use of pre – to alleviate anxiety and reduce pain associated with pleurodesis
Position patient comfortably – in SITTING POSITION with good access to the chest drain and the site.
Ensure a recent – ensure that the chest drain is correctly positioned and the lung is fully expanded