BRIEF DESCRIPTION

I. TOPIC 1: PLEURAL EFFUSION

A. Description:

 A pleural effusion, is an excessive accumulation of fluid in the pleural space, indicates an

imbalance between pleural fluid formation and removal. Accumulation of pleural fluid is not a
specific disease, but rather a reflection of underlying pathology.
 A pleural effusion is a buildup of fluid in the pleural space, an area between the layers of tissue
that line the lungs and the chest wall
 Types of Pleural Effusion
 Transudative pleural effusion is caused by fluid leaking into the pleural space. This is from
increased pressure in the blood vessels or a low blood protein count.

Characteristic of Transudative Effusion

 Occurs Primarily in non-inflammatory
conditions
 Low protein, low-cell-counted fluid
 Clear to faint yellow, no odor
 pH 7.40-7.55
 Specific Gravity <1.015
 Protein Content <3g/100ml
 Glucose level equal serum plasma

 Exudative effusion is caused by blocked blood vessels or lymph vessels, inflammation,

infection, lung injury, and tumors.

Characteristic of Exudative Effusion

 Often turbid, bloody, or purulent
 pH<7.30
 Specific gravity >1.016
 Protein content>3g/100ml
 Glucose level <60mg/dl
 High-protein fluid

Light's Criteria are used to determine whether a pleural effusion is exudative or transudative

Satisfying any one criterium means it is exudative:

 Pleural Total Protein/Serum Total Protein ratio > 0.5

 Pleural lactate dehydrogenase/Serum lactate dehydrogenase ratio > 0.6
 Pleural lactate dehydrogenase level > 2/3 upper limit of the laboratory's reference range
of serum lactate dehydrogenase.
Light's criteria are the most sensitive for identifying exudates but have lower specificity
than other criteria. This means that some patients may be misidentified as having an exudative
pleural effusion when they actually have a transudative pleural effusion.

B. Incidence:

 Approximately 1.5 million pleural effusions are diagnosed in the United States each year
 The incidence of pleural effusion among ICU patients is estimated to be 22.19 ± 17%
 Tuberculosis is one of the most frequent causes of pleural effusion. Although, the incidence has
steadily declined in some countries (4.8 cases/100,000 population), the prevalence of tuberculous
pleural effusion remains steady with respect to the total number of TB cases (14.3%-19.3%)
 According to the study of European Respiratory Journal Incidence of pleural effusion was 6.74%
(29/430) in CKD patients and 5.88% (2/34) in post-transplant patients.
 According to Indian Journal of Immunology and Respiratory Medicine, there were 35 males and
15 females. Average age is 46±11.6 years. The majority of these patients belong to the age group
of 41-50 years (38%).
 According to the lung center of the Philippines, the Phil health case rates of pleural effusion is
14,200
 C. Etiology:
The most common causes of pleural effusion are congestive heart failure, cancer, pneumonia,
and pulmonary embolism. 

The most common causes of transudative (watery fluid) pleural effusions include:

 Heart failure
 Nephrotic Syndrome
 Cirrhosis with ascites

Exudative (protein-rich fluid) pleural effusions are most commonly caused by:

 Parapneumonic effusion
 Malignancy
 Pulmonary Embolism
 Collagen vascular disease
 Pancreatitis
 Tuberculosis
 Postcardiac injury syndrome

Other less common causes of pleural effusion include:

Transudative 500, 583, 607-608,607f

 Peritoneal dialysis

 Urinothorax

 Atelectasis

 Pulmonary embolism

 Myxedema

Exudative

 Chylothorax

 Uremia

 Esophageal perforation

 Asbestos-related disease

 Drug-induced reactions

 Viral infection

 Yellow nail syndrome

 Sarcoidosis

D. Risk Factors:
Common risk factors in the development of pleural effusion are as follows:

 Increased serum VEGF, TNF-α and C3 levels are identified as important risk factors for
presence of pleural effusions in POEMS syndrome
 Pre-existing lung damage or disease
 Chronic smokers
 Neoplasia (e.g. lung cancer patients)
  Alcohol abuse
 Liver cirrhosis
 Use of certain medications (e.g. dasatinib in the treatment of patients with chronic
myelogenous leukaemia and immunosuppressive medicine)
 Occupational exposure to asbestos
 Heart failure
 As a complication of some surgical procedures (e.g. Nuss procedure for correction of
pectus excavatum)
Surgery-related risk factors include the following:

 Lower preoperative oxygen saturation

 Presence of postoperative infection
 Smaller conduit size
 Longer duration of cardiopulmonary bypass

E. Clinical Manifestations:

 Chest pain
 Dry, nonproductive cough
 Dyspnea (shortness of breath, or difficult, labored breathing)
 Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)
 The clinical presentation of pleural effusion depends on the amount of fluid present and the
underlying cause. Many patients have no symptoms at the time a pleural effusion is discovered.
Possible symptoms include pleuritic chest pain, dyspnea, and a dry, nonproductive cough. The chest
pain associated with pleural effusion is caused by pleural inflammation of the parietal pleura
resulting from movement-related friction between the two pleural surfaces. Pleuritic chest pain may
be localized or referred. The pain is usually sharp and is exacerbated by movement of the pleural
surfaces, as with deep inspiration, coughing, and sneezing. The pain eases with strapping of the chest
or on accumulation of fluid.

F. Medical Management:

 Treatment of pleural effusion is based on the underlying condition and whether the effusion is
causing severe respiratory symptoms, such as shortness of breath or difficulty breathing.
 Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive
heart failure or other medical causes. A malignant effusion may also require treatment
with chemotherapy, radiation therapy or a medication infusion within the chest.
 A pleural effusion that is causing respiratory symptoms may be drained using therapeutic
thoracentesis or through a chest tube (called tube thoracostomy).
 For patients with pleural effusions that are uncontrollable or recur due to a malignancy despite
drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be
instilled into the pleural cavity through a tube thoracostomy to create a fibrosis (excessive fibrous
tissue) of the pleura (pleural sclerosis).
 Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and tetracycline) is 50
percent successful in preventing the recurrence of pleural effusions.
 Thoracentesis. If the effusion is large, the physician may take more fluid than they need for testing, just
to ease the symptoms.
 Tube thoracostomy (chest tube). The physician makes a small cut in the chest wall and puts a plastic
tube into the pleural space for several days.
 Pleural drain. If pleural effusions keep coming back, the physician may put a long-term catheter
through the skin into the pleural space.
 Pleurodesis. The physician injects an irritating substance (such as talc or doxycycline) through a chest
tube into the pleural space. The substance inflames the pleura and chest wall, which then bind tightly to
each other as they heal. Pleurodesis can prevent pleural effusions from coming back in many cases.
 Pleural decortication. Surgeons can operate inside the pleural space, removing potentially dangerous
inflammation and unhealthy tissue. To do this, the surgeon may make small cuts (thoracoscopy) or a
large one (thoracotomy).
 G. Diagnostic Procedures:

Physical examination
 Physical findings are signs of volume gain, reduced tactile vocal fremitus, dullness on percussion,
shifting dullness, and diminished or absent breath sounds. Shifting dullness will be absent with
massive and loculated effusions. Massive pleural effusions present with respiratory embarrassment
and signs of mediastinal shift. Other findings may be related to associated systemic disease.
Pleural Fluid Testing
Pleural fluid testing is used to help diagnose the cause of fluid buildup in your chest cavity (pleural
effusion). An initial set of tests typically includes:

 Fluid protein, albumin, or LD level

 Cell count
 Fluid appearance

Results from these are compared to results from a blood specimen to determine whether the fluid is a
transudate or an exudate.

 Transudate—this is most frequently caused by congestive heart failure or cirrhosis. If the fluid is

determined to be a transudate, then usually no more tests on the fluid are necessary.

 Exudate—additional testing is often ordered to diagnose the cause and may include:
 Tests to measure pleural fluid glucose, lactate, amylase, triglyceride levels and tests
for tumor markers such as CEA may be done, though the usefulness of these tests is not
clear.
 Microscopic examination – a laboratory professional places a sample of your fluid on a slide
and examines it using a microscope, counting any white blood cells (WBCs) and red blood
cells (RBCs) and looking for bacteria or fungi.
 Cytology – a laboratory professional may use a special centrifuge (cytocentrifuge) to
concentrate your fluid’s cells on a slide. The slide is treated with a special stain and
evaluated for abnormal cells, such as malignant cells (cancer cells).
 Gram stain – used to look for bacteria or fungi using a microscope; there should be no
organisms present in your pleural fluid.
 Bacterial culture and susceptibility testing – used to identify any bacteria that may be
present in your pleural fluid and to guide antimicrobial therapy
 Fungal tests – may include fungal culture and susceptibility testing
 Adenosine deaminase – may help detect tuberculosis (TB)
 Less commonly, tests may be used to identify infections caused by viruses, mycobacteria
(AFB testing), and parasites.

Chest X-ray
 Standard posteroanterior and lateral chest radiography remains the most important technique for
initial diagnosis of pleural effusion.

Ultrasonography thorax
 The ultrasonographic image of pleural effusion is characterized by an echo-free space between the
visceral and parietal pleura. Ultrasonography is useful in cases of loculated pleural effusion for
confirmation of the diagnosis and for marking a site for thoracocentesis. Even small amounts of
pleural effusion can be detected accurately by ultrasonography.

CT thorax
 Computed tomography (CT) scanning with its cross-sectional images can be used to evaluate
complex situations in which the anatomy cannot be fully assessed by plain radiography or
ultrasonography. CT can be useful in helping to select the site of drainage of an empyema,
differentiating empyema from lung abscess, and identifying the location of the chest tube in failed
empyema drainage.

F-18 fluorodeoxyglucose positron emission tomography

 F-18 fluorodeoxyglucose positron emission tomography seems promising for differentiating between
benign and malignant pleural diseases, with a sensitivity of 97% and a specificity of 88.5%.28,29
However, inflammatory processes, such as a rheumatoid effusion and tuberculosis, may also be
positive
Thoracocentesis and cytobiochemical fluid analysis
 Thoracocentesis should be performed in all patients with more than a minimal pleural effusion (ie,
larger than 1 cm in height on lateral decubitus radiography, ultrasonography, or CT) of unknown
origin. Aspiration should not be performed for bilateral effusions in a clinical setting strongly
suggestive of a pleural transudate, unless there are atypical features or the patient fails to respond to
therapy. Diagnostic pleural tap with biochemical, cytological, and microbiological examination of
the fluid is needed for correct diagnosis
Percutaneous pleural biopsy
 Percutaneous pleural biopsies are of greatest value in the diagnosis of granulomatous and malignant
diseases of the pleura. They are performed on patients with undiagnosed exudative effusions and
nondiagnostic cytology, and when there is clinical suspicion of tuberculosis or malignancy.

Thoracoscopy
 Open thoracotomy, once the gold standard, has given way to less invasive video-assisted
thoracoscopic surgery. Thoracoscopy should be considered when less invasive tests have failed to
give a diagnosis.

Fiberoptic bronchoscopy
 Tuberculosis and malignancy are the two most common causes of an undiagnosed pleural effusion,
and transbronchial biopsy may be diagnostic. LeRoux, in reviewing his experience with chest
malignancies, infers that fiberoptic bronchoscopy, in the setting of a pleural effusion with another
abnormality on chest radiography gives a diagnostic yield of close to 50%

H. Pharmacological Management:

• Antibiotics if there is an infection

• Steroids and nonsteroidal anti-inflammatory drugs to relieve pain and reduce inflammation or

swelling

• Diuretics to help the body get rid of extra fluid by increasing the amount of urine it makes

• Bronchodilators to widen the airways in the lungs and allow for more air flow

I. Surgical Management:

Nontunneled Pigtail Drainage Catheter Placement

 Complicated pleural effusion refers to fluid collections that are not resolved without drainage of the
pleural fluid. Exudate, empyema, and hemothorax are considered as complicated effusions; they are
the most common indications for drainage catheter placement
 Pleural fluid drainage should to be started immediately and up to 1500 mL of fluid can be removed.
After removing the pleural fluid, a chest radiograph or postprocedural CT scan should be obtained to
confirm the appropriate position of the pigtail catheter and evaluate possible complications including
pneumothorax.

Pleurodesis
 The goal of a pleurodesis procedure is to drain the excess fluid and then eliminate the pleural space
so fluid can no longer accumulate there. 
 Pleurodesis offers a more permanent solution than the other common procedures for treating pleural
effusions.
 A thoracentesis procedure drains excess fluid but does not seal the pleural space, while the insertion
of a pleural catheter requires regular home maintenance, potentially for the rest of a patient’s life.
 A pleurodesis procedure typically involves a hospital stay of three to seven days, though a newer
method being tried by some specialists requires only a brief overnight stay. Before the procedure,
patients are usually medicated with a narcotic for pain and a benzodiazepine, such as Xanax, for
comfort.
 The first step of a pleurodesis procedure is to drain the excess fluid from the pleural space. The next
step is to irritate the two layers of the pleural lining, which provokes inflammation and scarring. The
scar tissue fuses the two pleural layers together, eliminating the space between them.

Types of Pleurodesis

Chemical Pleurodesis
 During chemical pleurodesis, talcum powder can be inserted into the pleura
using thoracoscopy tools, or it can be mixed with fluid into a talc slurry and inserted through a chest
tube. Once the talc is sufficiently distributed, the doctor then removes it.
Mechanical Pleurodesis

 Another way to cause the layers of the pleura to fuse together is to irritate them with a rough pad,
gauze or a mechanical rotary brush instead of inserting a chemical substance.

 Though this method may involve a more invasive surgical procedure, the results of a 2015
study suggest mechanical pleurodesis may provide greater symptom relief than chemical
pleurodesis.

 Talc is a type of clay mineral, and it has historically been the main ingredient in baby powder. The
talc used for pleurodesis is medical grade, sterile and asbestos-free.

Rapid Pleurodesis

 One disadvantage of the common talc pleurodesis procedure is the week-long hospital stay often
required for recovery.
 It uses a pleural catheter and chemical pleurodesis and this method allows most patients to be
discharged from the hospital within 48 hours.
 A 2014 randomized trial and a 2016 retrospective analysis determined a rapid pleurodesis protocol
can be as effective as the common chemical pleurodesis procedure most doctors currently follow.

Video-assisted thoracoscopic surgery (VATS)

 A minimally-invasive approach that is completed through 1 to 3 small (approximately ½ -inch)

incisions in the chest. Also known as thoracoscopic surgery, this procedure is effective in managing
pleural effusions that are difficult to drain or recur due to malignancy. Sterile talc or an antibiotic
may be inserted at the time of surgery to prevent the recurrence of fluid build-up.
 Thoracotomy (Also referred to as traditional, “open” thoracic surgery)
 A thoracotomy is performed through a 6- to 8-inch incision in the chest and is recommended for
pleural effusions when infection is present. A thoracotomy is performed to remove all of the fibrous
tissue and aids in evacuating the infection from the pleural space. Patients will require chest tubes
for 2 days to 2 weeks after surgery to continue draining fluid.

Thoracentesis
 Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs
and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from
the pleural space to help you breathe easier.

 Thoracentesis is a basic and valuable procedure not only to obtain a fluid sample for differentiating
transudate from exudate, but to remove the fluid in a patient with a large volume of effusion for
symptomatic relief

 Therapeutic Thoracentesis
 If therapeutic thoracentesis is necessary, the sheath is attached to an extension tubing system, which
is connected to a vacuum bottle. In general, removal of < 1500 mL pleural effusion is recommended to
avoid the risk of reexpansion pulmonary edema.25 Once thoracentesis is completed, the sheath is
removed at end expiration; the skin entry site should be covered using an antimicrobial ointment with
sterile occlusive dressing.

 Diagnostic Thoracentesis
Indicated for almost all patients who have pleural fluid that is new or of uncertain etiology and is ≥
10 mm in thickness on computed tomography (CT) scan, ultrasonography, or lateral decubitus x-ray

Thoracotomy (Also referred to as traditional, “open” thoracic surgery)

 A thoracotomy is performed through a 6- to 8-inch incision in the chest and is recommended for
pleural effusions when infection is present. A thoracotomy is performed to remove all of the fibrous
tissue and aids in evacuating the infection from the pleural space. Patients will require chest tubes
for 2 days to 2 weeks after surgery to continue draining fluid.

J. Nursing Management:

 Identify and treat the underlying cause

 Monitor breath sounds
 Place the client in a high Fowler’s position
 Encourage coughing and deep breathing
 Prepare the client for thoracentesis
 If pleural effusion is recurrent, prepare the client for pleurectomy or pleurodesis as prescribed
 The nurse’s role in the care of the patient with a pleural effusion includes implementing the medical
regimen
 The nurse prepares and positions the patient for thoracentesis and offers support throughout the
procedure
 Pain management is a priority, and the nurse assists the patient to assume positions that are least
painful if chest tube is inserted for talc instillation
 Encourage to perform pulmonary exercises such as deep breathing, effective coughing and use of
spirometry
 Monitor the client respiratory status frequently. Obtain ABG if necessary
 Ensure chest tube patency by observing for fluctuations in the tubing. Record the amount, color, and
consistency of any tube drainage.
 Provide physical and emotional support to the patient and their family
 If the patient is to be managed as an outpatient with a pleural catheter for drainage, the nurse
educates the patient and family about management and care of the catheter and drainage system.

References

Karkhanis, V. S., & Joshi, J. M. (2012). Pleural effusion: diagnosis, treatment, and
management. Open access emergency medicine : OAEM, 4, 31–52.
https://doi.org/10.2147/OAEM.S29942
Medline Plus (n.d). Pleural Effusion. Retrieved from:
https://medlineplus.gov/ency/article/000086.htm
Selby, K. (2018). Pleurodesis. Retrieved from
https://www.asbestos.com/treatment/surgery/pleurodesis/
Yu H. (2011). Management of pleural effusion, empyema, and lung abscess. Seminars in
interventional radiology, 28(1), 75–86. https://doi.org/10.1055/s-0031-1273942
Cleveland Clinic (2008). Pleural Effusion Causes, Signs and Treatment. Retrieved from
https://my.clevelandclinic.org/health/diseases/17373-pleural-effusion-causes-signs—treatment
Myatt, Rebecca (2014). Diagnosis and management of patients with pleural effusions. Nursing
Standard, 28(41), 51–58. doi:10.7748/ns.28.41.51.e8849
Black, Joyce M. and Hawks, Jane H. Medical-Surgical Nursing. Clinical Management for
Positive Outcomes. Pp 1872-1873
 Arup Laboratories. Body Fluid Reference Intervals and/or Interpretive Information for Select
Analytes. Available online at https://www.aruplab.com/bodyfluids. Accessed July 2020.
Light, R. W., Macgregor, I., Luchsinger, P. C., Ball, W. C. Pleural effusions: the diagnostic
separation of transudates and exudates. Annals of Internal Medicine 1972, 77 (4): 507-13