TUBERCULOSIS PLEURAL

EFFUSION - MANAGEMENT
􀂄 Introduction : ETB – 15-20%
􀂄 Pleural effusion – 20% in non HIV
􀂄 Under reporting because of AFB negative in
fluid
􀂄 In HIV patients: EPTB – 20%
􀂄 PTB + EPTB – 50%
􀂄 Pleural Effusion – 20%
􀂄 It is more common in young populations.
Now tendency to affect aged patients.
(IndianJMedical Res)
PATHOGENESIS
􀂄 Typically 4-7 months following initial
infection with TB.
􀂄 Rupture of small subpleural focus
􀂄 Delayed hypersensitivity reaction
􀂄 Possibility the intense inflammation
obstructs the lymphatic pores in the
parietal pleura which causes
accumulation of protein in pleural
cavity.
CLINICAL
MANIFESTATION
􀂄 Most commonly manifests as an acute
illness
􀂄 Cough 70% , usually non productive
􀂄 Chest pain 75%
􀂄 Usually unilateral
􀂄 Bil – Occurs in 10%
NATURAL HISTORY OF
UNTREATED EFFUSION
􀂄 90% usually subside spontaneously
􀂄 Effusion usually resolve and all other
symptoms disappear within 2-4 months
􀂄 Follow up over time – 40-60% develop
tuberculosis
􀂄 Size of original effusion and the
presence or
absence of small radiologic residual pleural
disease do not correlate with subsequent
tuberculosis
􀂄 Residual pleural thickening common
sequelae ~ 50%.
DIAGNOSIS
􀂄 Diagnosis depends on the
demonstration of tubercle bacilli –
􀂄 In sputum
􀂄 Pleural fluid
􀂄 Pleural biopsy specimen
􀂄 Granuloma in pleura
􀂄 The diagnosis can also be established
with reasonable certaintly by ADA ↑
TUBERCULIN TEST
􀂄 Positive in 60-75% patients, many of
negative
patients will become tuberculin positive in
6-8
week
􀂄 Negative tuberculin – HIV patients &
malnutrition
􀂄 There may sequestration of PPD
reactive
lymphocytes in the pleural space.
􀂄 A circulating adherent cell suppresses
the
sensitized T- lymphocytes
Sputum Examination
􀂄 Even in absence of underlying infiltrate
􀂄 Sputum AFB & culture – 55%
RADIOLOGY
􀂄 Parenchymal infiltrates – 20%
􀂄 The classic patterns of primary
tuberculosis
in the form of non cavitary, lower lobe
parenchymal infiltrates.
􀂄 CT Scan – 40% parenchyma
involvement
􀂄 Encysted effusion usually occurs
during ATT
treatment
􀂄 Most often encystment occurs in the
costoparietal regions ( Post aspects)
PLEURAL FLUID – ANALYSIS
􀂄 Often protein > 5.0 gm/ dl
􀂄 Usually more than 50% lymphocytes
􀂄 If symptoms less than 2 weeks then
pleural
fluid may reveal poly.
􀂄 Eosinophil > 10% usually excludes the
diagnosis of tuberculosis pleuritis.
􀂄 Mesothelial cells < 3% .
􀂄 HIV infected patients with tuberculosis
pleuritis may have significant number of
mesothelial cells in the pleural fluids.
ADA
􀂄 Enzyme that catalyzes the conversion
of
adenosinie to inosine.
􀂄 1978 – Pirus et al
􀂄 ADA-1 – All cells
􀂄 ADA -2 – Only in monocytes
􀂄 Majority of ADA in tuberculosis pleural
fluid
is ADA -2
􀂄 Higher the pleural fluid ADA level, the
more
likely patient is to have tuberculosis.
ADA (contd.)
􀂄 Level of cut-off value
􀂄 High Specificity – 83%
􀂄 Sensitivity – 77-100%
􀂄 L: N > 0.75 – Specificity ↑
􀂄 High ADA – empyema
􀂄 - Rheumatoid arthritis
􀂄 But do not have pleural fluid
lymphocytosis
􀂄 Cut off value < 40
􀂄 40-60
ADA ( contd.)
􀂄 Although the use of a ratio of the ADA -
1
to ADA -2 less than 0: 42 will slightly
increase the sensitivity and specificity of
ADA, the separation of ADA into its
isoenzyme is not necessary.
􀂄 ADA level maintained at ambient
temperature. It decreases with time. But
addition of glycerol, sodium sulfate–Stable
at room temperature for 3 months.
INTERFERON – GAMMA
􀂄 Produced by CD4
􀂄 Sensitivity & specificity > 94%
􀂄 It retains diagnostic efficacy in HIV
patients
􀂄 IFN - γ is more specific than ADA
chiefly
due to low levels of IFN in lymphoma and
empyma.
􀂄 Expensive not used routinely.
PCR
􀂄 PCR is certainly not superior to either
the
pleural fluid ADA or interferon gamma
levels
􀂄 Sensitivity ~ 80%
􀂄 Specificity is not 100%
􀂄 False positive may occur due to DNA
contamination
􀂄 Nonviable organism
􀂄 Latent infection
􀂄 Reactivation due to imunosuppression
caused
by primary malignant involvement of
pleura.
Lysozyme
􀂄 Released from lysozyme containing
cells –
granulocytes, monocytes, macrophages.
􀂄 The value of lysozyme levels in the
diagnosis of tuberculosis effusion,
however,
is controversial
􀂄 ADA : Lysozyme , has been found to
be useful in differentiating tuberculosis
from empyema. A thresholds value
above 3.3 has been shown to be highly
specific for tuberculosis pleural effusion.
􀂄 ADA : Lysozyme , has been found to
be useful in differentiating tuberculosis
from empyema. A thresholds value
above 3.3 has been shown to be highly
specific for tuberculosis pleural effusion.
PLEURAL BIOPSY
􀂄 The demonstration of granuloma in the
parietal pleura suggests TB
􀂄 Other common causes of granuloma
fungal disease
RA
Sarcoidosis
􀂄 Acid fast stain is positive in 25%.
Culture for AFB positive – 60% .
Combination of three test. Positive in
91%.
􀂄 Standard recommendation for biopsy
􀂄 If ADA > 70 L:N > 0.75 – No biopsy
􀂄 If ADA – 40-70 : L:N > 0.75
Presumptive diagnosis of tuberculosis
Biopsy if clinical picture is not
supportive of tuberculosis
􀂄 ADA < 40- Clinical picture suggestive
of
tuberculosis – Pleural biopsy
DISADVANTAGES
􀂄 USG guided ( Tru cut ) biopsy of pleura
􀂄 Air leakage
Involvement of pleura is not uniform, so
􀂄 Needle breakage
closed biopsy may miss actual site of
􀂄 May not be diagnostic
lesions.
􀂄 Abrams needle wide bore, needs skin
􀂄 Closed biopsy with cope or an abrams
incision
needle can obtain adequate specimen and
􀂄 Nonspecific changes upto as high as
achieve 57-80% diagnostic rate in
68% have been reported in the closed
tuberculosis pleuritis.
biopsy.
USG GUIDED TRU CUT
BIOPSY
Advantages
􀂄 It can localize the minimal or loculated
effusion
􀂄 it can demonstrate focal pleural
thickening
􀂄 sensitivity for pleural tuberclosis – 86%
TREATMENTS
Goals
􀂄 To prevent the subsequent
development of active tuberculsosis
􀂄 To relieve symptoms
􀂄 to prevent development of a fibrothorax
ATT
􀂄 Average patient becomes afebrile
without 2 week
􀂄 Complete resorption of fluid 6-12
weeks
􀂄 The incidence of pleural thickening at
6-
12 months -50%
CORTICOSTEROIDS
􀂄 No role of systemic steroids
􀂄 If more than mildly symptomatic
􀂄 A therapeutic thoracentesis is
recommended
􀂄 Severe symptoms & diagnosis has
been
established – Steroids
Surgical procedure
􀂄 Large pleural effusion – thoracentesis,
Decortication rarely necessary
Tuberculosis Empyema
􀂄 ICTD + ATT
HIV & TUBERCULOSIS
PLEURAL EFFUSION
􀂄 Incidence – CD4 < 200- 0 ↓
􀂄 CD> 200 - ↑
􀂄 Overall incidence - ±↑↓
􀂄 Duration of illness longer
􀂄 Chest pain less common
􀂄 Systemic manifestation – Fever,
anemia,
lymphadenopathy, organomegaly –
common
􀂄 Mantoux test often negative (40%)
􀂄 AFB smear in pleural fluid -25%
􀂄 If CD4 count < 100. 50% positive fluid
AFB smear
positive
􀂄 Significant number of mesothelial cells
in their
pleural fluid
􀂄 Biopsy – Granuloma on pleural biopsy
are less well
formed
􀂄 In pleural fluid ,the level of albumin are
relatively
low
􀂄 The level of ADA in patients without
AIDS are
comparable.
Pleural Effusions

Kara Lee Gallagher

USC School of Medicine
 Definition
• Increased amount of fluid within the
pleural cavity
– Stedman’s Medical Dictionary
• Accumulation of fluid between the layers
of the membrane that lines the lungs and
the chest cavity
– Medline Plus
 Epidemiology
• United States
– 1 million cases annually
• Internationally
– 320/100,000 in industrialized countries
 Pathophysiology
• Normal: 1 mL of pleural fluid
– Balance between hydrostatic/oncotic forces
and lymphatic drainage
• Abnormal: Pleural effusion
– Disruption of balance
 Clinical History
• Dyspnea
• Chest pain
 Physical Exam
• Decreased breath sounds
• Dullness to percussion
• Decreased tactile fremitus
• Egophony
• Pleural friction rub
 Types
• Hydrothorax
• Hemothorax
• Chylothorax
• Pyothorax or Empyema
 Classification
• Transudate
– Ultrafiltrate of plasma
– Small group of etiologies
• Exudate
– Produced by host of inflammatory conditions
– Large group of etiologies
 Workup: Thoracentesis
• Light’s criteria: Transudate vs. Exudate
– Pleural fluid protein / serum protein > 0.5
– Pleural fluid LDH / serum LDH > 0.6
– Pleural fluid LDH > 2/3 ULN serum LDH
 Workup: Thoracentesis
• Other criteria: Transudate vs. Exudate
– Pleural fluid LDH > 0.45 ULN serum LDH
– Pleural fluid cholesterol > 45 mg/dL
– Pleural fluid protein > 2.9 g/dL
 Workup: Laboratory
• LDH > 1000 IU/L
– Empyema, Malignancy, Rheumatoid
• Glucose < 30 mg/dL
– Empyema, Rheumatoid
• Glucose between 30 – 50 mg/dL
– Lupus, Malignancy, TB
 Workup: Laboratory
• Lymphocytes > 85%
– Chylothorax, Lymphoma, Rheumatoid, TB
• Lymphocytes between 50 – 70%
– Malignancy
• Mesothelial cells > 5%
– TB unlikely
• ADA > 43 U/mL
– Supports TB
 Workup: Imaging

• Upright Chest X-Ray

– Blunting of costophrenic angles
• Supine Chest X-Ray
– Increased density over lower lung fields
• Lateral decubitus Chest X-Ray
– Layering
Workup: Imaging
Workup: Imaging
 Workup: Imaging
• Ultrasound
– Aids in identification of loculated effusions
– Aids in differentiation of fluid from fibrosis
– Aids in identification of thoracentesis site
– Available at bedside
 Workup: Imaging
• CT Scan
– Aids in differentiation of
• Lung consolidation vs. Pleural effusion
• Cystic vs. Solid lesions
• Peripheral lung abscess vs. Loculated emypema
– Aids in identification of
• Necrotic areas
• Pleural thickening, nodules, masses
• Extent of tumor
Work up: Imaging
 Treatment
• Treat underlying etiology
• Therapeutic thoracentesis
 Questions?
Image sources cited in notes
 King Saud University
College of Nursing
Medical-Surgical Nursing Dept.
1427/1428H-2006/2007G

PLEURAL EFFUSION

Dr. Najat El-Morsy.

Lecturer. Magda Bayoumi.
Presentation case by:
Zahra’a Hussin Al-Draisi
I.D. number: 426201546
 Demographic data

Name : Falha Rabah AL-Rashidi.

Age : 50 years.
Sex : Female.
Occupation : Housewife.
Marital status : Marries.
Education : Illiteracy.
Admission date : 10/02/1428H.
Medical diagnosis : Right lower lobe abscess, Diabetes
Mellitus, Pleural Effusion.
 History

a- Past history and allergies :

Rheumatoid arthritis and non allergies.
b- Present history :
-Chief complaint :
Right side lower chest pain.
-Description of patient’s condition :
Chest pain, referred to shoulder, severe in cough, and
occur suddenly. Productive cough yellow sputum.
Connecting tube : I.V. line.
Oxygen therapy : simple mask.
 History continue……

Assessment and observations for any abnormalities

detected :
- During physical examination :
Right lung lower lobe abscess.
-Throughout lab. Investigations :
Citrated plasma :
PT (15.4 H), PT+INR (1.23 H), APTT (37.3 H).
Full blood count :
WBC(6 L), <RBC(3.13 L), <HGB(95 L), <HCT(26.7 L),
MCV(85.3 L), MCH(30.4 L), MCHC (normal),>RDW(15.5 H)
 History continue…….

Throughout diagnostic finding :

CT lung, Endoscopic studies, ECG.
Level of consciousness : conscious(15/15).
Mobility : strong.
 Medical diagnosis
Pleural condition :
Pleural conditions are
disorders that involve the
membranes covering the
lungs (visceral pleura) and
the surface of the chest wall
(parietal pleura) or
disorders affecting the
pleural space. Normally, the
pleural space contains a
small amount of fluid (5 to
15 ml), which acts as a
lubricant that allows the
pleural surfaces to move
without friction.
 Medical diagnosis continue……

Pleural effusion :
Definition : a collection of fluid in the pleural
space.
Causes : may be a complication of heart failure,
TB, pneumonia, pulmonary infections
(particularly viral infections), nephrotic
syndrome, connective tissue disease, pulmonary
embolism, and neoplastic tumors. Bronchogenic
carcinoma is the most common malignancy
associated with a pleural effusion.
 Medical diagnosis continue……

Sign and symptoms :

-Shortness of breath.
-Pain.
-Assumption of a position that decreases pain.
-Decreased chest wall excursion.
 Medical diagnosis continue……

Different medical treatment :

-Thoracentesis is performed to remove fluid, to obtain a
specimen for analysis, and to relieve dyspnea and
respiratory compromise. Thoracentesis may be
performed under ultrasound guidance. Depending on the
size of the pleural effusion, the patient may be treated by
removing the fluid during thoracentesis procedure or by
inserting a chest tube connected to a water-seal
drainage system or suction to evacuate the pleural
space and re-expand the lung.
 Medical diagnosis continue……
-Chemical irritating agents (e.g. bleomycin or talc ) are
instilled in the pleural space. With the chest tube
insertion approach, after the agent is instilled, the chest
tube is clamped for 60 to 90 minutes and the patient is
assisted to assume various positions to promote uniform
distribution of the agent and to maximize its contact with
pleural surfaces.
-Other treatments for malignant pleural effusions include
surgical pleurectomy, insertion of a small catheter
attached to a drainage bottle for outpatient management,
or implementation of a plueroperitoneal shunt.
 Medical diagnosis continue……

Special treatment for my patient’s :

Give her Diuretic drug to remove excessive fluid from the
pleural.
 Medication
Medication given to my patient’s :
Name : Hydrochlorothiazide, medication classification
(diuretics).
Dose : 200 mg.
Route : P.O.
Time : B.D.
Action : A thiazide diuretic that increases sodium and
water excretion by inhibiting sodium and chloride
reabsorption in distal segment of the nephron.
 Medication continue……
Side effect :
CNS : dizziness, headache, weakness .
GI : anorexia, nausea, vomiting, abdominal pain, diarrhea.
GU : polyuria, renal failure
Hematologic : hemolytic anemia.
Hepatic : jaundice.
 Medication continue……
Side effect continue…
Metabolic : asymptomatic hyperuricemia, hypokalemia,
hyperglycemia and impaired glucose tolerance, fluid and
electrolyte imbalances, including dilutional
hyponateremia and hypochloremia, metabolic alkalosis,
hypercalcemia, volume depletion and dehydration.
Musculoskeletal :muscle cramps.
Respiratory : respiratory distress, pneumonitis.
Skin : rash, alopecia.
 Medication continue….

Nurse role:
-To prevent nocturia, give drug in the morning.
-Monitor fluid intake and output, weight, blood pressure,
and electrolyte levels.
-Watch for signs and symptoms of hypokalemia, such as
muscle weakness and cramps.
-Drug may be used with potassiumsparing diuretic to
prevent potassium loss.
-Consult prescriber and dietitian about a high-potassium
diet. Foods rich in potassium include citrus fruits,
tomatoes, bananas, dates, and apricots.
 Medication continue….
Nurse role continue……
-Monitor glucose level, especially in diabetic patients.
-Monitor elderly patients, who are especially susceptible to
excessive diuresis.
-In patients with hypertension, therapeutic response may
be delayed several weeks.
Nursing
Nursing
Expected
management
Nursing Evaluation
Diagnosis Outcome/Goal Intervention
-Ineffective Improved -Encourage -The client can
breathing breathing patient to breath easily.
pattern R/T patterns. breathing exercise
difficult to to improve
breath. breathing, change
position that
prevent breathe
easily.
-Give antibiotic
-Pain R/T Relieve pain. and analgesic as
sputum if she -The client
prescribed, give demonstrate
want to out it. hot fluid. comfort.
-Knowledge
deficit R/T Understanding -Explanation for
of disease the cause, -The patient
lack of treatment and
exposure. processes. understand the
expected course cause of
for disease. disease.
 Nursing management continue……

The nurse role in the care of the patient with a

pleural effusion includes :
-Implementing the medical regimen.
-The nurse prepares and position 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 the least painful.
-Frequent turning and ambulation are important to facilitate
drainage the nurse administers analgesics as prescribed
and as needed.
 Nursing management continue……

-If a chest tube drainage and a water-seal system is used,

the nurse is responsible for monitoring the system’s
function and recording the amount of drainage at
prescribed intervals.
-If a patient is to be managed as an outpatient with a
pleural catheter for drainage, the nurse is responsible for
educating the patient and family regarding management
and care of the catheter and drainage system.
 References

1-Brunner & Suddarth’s Textbook of Medical-

Surgical Nursing.
2-Nursing Drug Handbook.
Thank you for your listen