Pleural Effusions

Normal lung pleural effusion

 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.
 Pleura
-serous fluid that allows for the parietal pleura
(outer lining) and visceral pleura (inner
lining) to glide over each other without
separation (Porth, 2005, p. 639)
-contains about 5-15ml of fluid at one time
-Pleural fluid is produced by the parietal
pleura and absorbed by the visceral pleura
as a continuous process. (Drummond Hayes, 2001, p.
32)
-about 100-200ml of fluid circulates though
the pleural space within a 24-hour period
(Brubacher & Holmes Gobel, 2003)
-has an alkaline pH of about 7.64 (Drummond Hayes,
2001, p. 33)
 Layers of the lung
Pleural Space
• thin, transparent, Rib
serous membrane Cage

which lines the thoracic

cavity
• a potential space
between the parietal Lung
pleura and visceral
pleura

Picture used with permission Allibone, 2006

 Layers of the lung
Parietal Pleura
• Lines the thoracic
Rib
cavity, including the Cage
thoracic cage,
mediastinum, and
diaphragm
• Contains sensory Lung

nerve endings that

can detect pain
Picture used with permission Allibone, 2006
 Layers of the lung
Visceral Pleura
• Lines the entire
Rib
surface of the lung Cage
• Contains NO sensory
nerve endings that
detect pain
Lung

Picture used with permission Allibone, 2006

 Review question:

Pleuritic chest pain indicates

inflammation or irritation of the
parietal pleura or visceral pleura?

(click on the correct answer)

 Think again!

The visceral pleura contains no

nerve endings for detecting pain.
 Correct!

The parietal pleura contains

sensory nerve endings that
can detect pain.
 Review question:
The pleural space typically
contains how much fluid?
5-15ml
50-100ml
100-200ml
 Think again!

about 100-200ml of fluid circulates though

the pleural space within a 24-hour period
 Correct!

• 5-15ml of fluid are present at one time

• The pleural space is a potential space between
the parietal pleura and visceral pleura, allowing
them to glide over each other without separation
 The normal 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.
 The normal lung
• Intrapulmonary • Intrapleural pressure
pressure -Negative pressure is
-the pressure within created in the pleural
the alveoli space as the thoracic
-as the chest cage enlarges and the
expands on lungs recoil during
inspiration the
intrapulmonary normal inspiration
pressure becomes -negative
more negative, which pressure may be lost if
causes air to be fluid collects in the
sucked into the lungs. pleural space, making
(Allibone, 2006, p. 56) the lung unable to
expand fully.
(Allibone, 2006, p. 56)
 The normal lung
• cells within the pleura are primarily mesothelial
cells that line the surfaces of the pleural
membranes and some white blood cells (WBC).
• The visceral pleura absorbs fluid, which then
drains into the lymphatic system and returns to
the blood
• Protein in the circulation and balanced
pressures keep excessive amounts of fluid from
seeping out of the blood vessels into the pleural
space
(Pumonary Channel, 2007)
 Let’s review

Click on the words Rib

below to send them to cage
their correct position
within the diagram.
Lung

Pleural Space

Visceral Pleura

Parietal Pleura

Picture used with permission Allibone, 2006

 Let’s review
Fluid is absorbed by the:

Parietal Pleura
Pleural Space
Visceral Pleura
 Think Again - - -

• Pleural fluid is produced by the parietal pleura

• The pleural space is a potential space between the
parietal pleura and visceral pleura
• Negative pressure is created in the pleural space
 Correct!!!

• Pleural fluid is produced by the parietal

pleura and absorbed by the visceral pleura
as a continuous process.
• The visceral pleura absorbs fluid, which then
drains into the lymphatic system and returns
to the blood
 OUTCOMES
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• Describe the pathophysiology of the normal lung

• Describe the pathophysiology of a pleural effusi
on
• Describe the main causes of a pleural effusion
• Differentiate among the manifestations of fluid co
llections
• Describe the signs and symptoms of a pleural ef
fusion
• Explain diagnostic methods
• Describe the various treatment options
 Pleural effusion
• Created by an abnormal
collection of fluid in the
pleural space
• Seen in chest X-ray with
presence of about 200ml
pleural fluid
• Fluid in X-ray seen as a
dense, white shadow with
a concave upper edge
(fluid level)
(Allibone, 2006)

Click on the pleural

Used with permission (Allibone, 2006, p. 59)
effusion in the picture!
 Pleural Effusion
Fluid accumulates in the pleural space
by three mechanisms:
-increased drainage of fluid into the space
-increased production of fluid by cells in
the space
-decreased drainage of fluid from the
space
(pulmonary channel, 2007)
 Pleural Effusion
• The build-up of fluid presses on the lung,
making it difficult for the lung to expand
fully.
• Part or all of the lung may then collapse
(National Cancer Institute, 2007)
 Pleural Effusion

• Your lungs contain millions of small, elastic

air sacs called alveoli
• Normally, with each breath the air sacs take in
oxygen and release carbon dioxide
• Sometimes increased pressure in the blood
vessels in your lungs forces fluid into the air
sacs, filling them with fluid and preventing
absorption of oxygen.
(Mayo Foundation for Medical Education and Research, 2006)
 Pleural Effusions

Malignancy accounts for about 40% of

symptomatic pleural effusions, with
congestive heart failure and infection being
the other leading causes
(National Cancer Institute, 2006)
Fluid
collection
in both
lower
lobes of
the lungs
due to
CHF

Picture used with permission (Allibone, 2006, p. 59)

 Main causes of a Pleural Effusion
• Congestive Heart Failure (CHF)
• Liver failure
• Infection
• Atelectasis
• Cancer
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 Congestive Heart Failure
CHF
• As the heart fails, pressure in the vein going through the lungs starts
to rise.
• Due to the heart’s inability to move blood from the pulmonary
circulation into the arterial side of systemic circulation, there is a
decrease in cardiac output, an increase in left atrial and ventricular
end-diastolic pressures, and congestion in the pulmonary circulation.
• As the pressure increases, fluid is pushed into the air spaces
(alveoli)
• This fluid then leaks from the alveoli into the pleural space
• This fluid creates a pleural effusion and interrupts normal oxygen
movement through the lungs, resulting in shortness of breath
 CHF
• CHF is the most common cause of pleural effusion.
• Frequently the effusions are bilateral (approximately 75% of the
time) but may occur alone on either side with the right side being
more common.
• Fluid is usually straw colored, with low white blood cell counts
(<500 cells/mm3) and a mononuclear cell predominance.
• With severe congestive heart failure, fluid may persist in spite of
vigorous diuresis.
(National Lung Health Education Program, 2000)

Back
 Liver Failure

• Negative intrapleural pressure may lead to a

transudative effusion due to peritoneal fluid from ascites
moving across the diaphragm into the chest
(Current Therapy, 2001, p. 208)
 Infection

• Pneumonia
-inflammation of the lung structures,
specifically the alveoli and bronchioles
• WBCs accumulate in response to
infection and inflammation leading to
empyema
 Atelectasis
• Atelectasis is an incomplete expansion of the lung which
leads to collapse of the alveoli
• Increased negative intrapleural pressure can lead to the
collection of fluid in the portion of the lung which is not
expanding
• This can cause an effusion by fluid leaking out of the
lung and into the chest cavity
• Atelectasis typically leads to small pleural effusions not
requiring surgical intervention
 Cancer
• Impaired lymphatic drainage of the pleural space due to
obstruction by a tumor
• Typically due to the interference with the visceral pleura
(which absorbs pleural fluid)
• A tumor can obstruct pulmonary veins, preventing fluid
from being reabsorbed into the bloodstream
• A tumor can perforate the thoracic duct
• Shedding of malignant cells into the pleural space,
decreasing reabsorption of pleural fluid back into the
lymphatic system (Brubacher & Holmes Gobel, 2003, p. 1)
 Trauma

• Increased capillary permeability as a

result of inflammation
• Fluid (most often, blood) may collect in
the lung cavity as a result of trauma to
the lung
 Pleural fluid types
• Transudate
• Exudate
• Empyema
• Chyle
• Hemothorax
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 Transudate
• Clear, pale yellow, watery substance
• Influenced by systemic factors that alter the
formation or absorption of fluid
• Increase in hydrostatic pressure
• Decrease in plasma oncotic pressure
• Contains few protein cells
• Common causes: CHF and liver or kidney
disease
 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: pneumonia, cancer, and trauma
 Empyema

• Pus
• Yellow, cloudy, and foul odor
• Most likely due to pneumonia, lung
abscess, infected chest wounds
• Has a pH > 7.2
(Drummond Hayes, 2001, p. 33)
 Chyle

• Milky fluid
• Consists of lymph and fat
• Chyle leaks from the thoracic duct
-due to lymphatic obstruction
(tumor) or trauma
• High triglyceride levels found in fluid
analysis
 Hemothorax
• Blood
• Usually results from chest injury
• A blood vessel ruptures into the pleural space or
a bulging area into the aorta (aortic aneurysm)
leaks blood into the pleural space
• Can occur as a result of bleeding from the ribs,
chest wall, pleura, and the lung
 Let’s review
• Which is NOT a type of fluid that may
cause a pleural effusion?
-empyema
-chylothorax
-pneumothorax
-hemothorax
This is a fluid that may cause a
Pleural Effusion

• Empyema (pus),
Chylothorax (chyle), and
hemothorax (blood) are all
fluids that may result in a
pleural effusion.
 Correct, this is not a fluid!

• Pneumothorax is a
collection of air in the
pleural cavity.
 Signs and symptoms
• Dyspnea
• Cough, usually non-productive
• Pleuritic chest pain
• Chest pressure
• Hypoxemia
• Decreased breath sounds on the affected side
• Some people may exhibit no symptoms!
 Diagnosis
• Chest radiograph (x-ray)
-able to distinguish >200ml of fluid
• Chest ultrasound
-locates small amounts or isolated loculated
pockets of fluid
-able to give precise position of accumulation
• Computed Tomography (CT) scan
-Differentiates between fluid collection, lung
abcess, or tumor
 Diagnosis
Fluid analysis confirms a pleural effusion
Normal pleural fluid has the following characteristics:
• clear ultrafiltrate of plasma
• pH 7.60-7.64
• protein content less than 2% (1-2 g/dL)
• fewer than 1000 WBCs per cubic millimeter
• glucose content similar to that of plasma
• lactate dehydrogenase (LDH) level less than 50% of plasma and
sodium
• potassium and calcium concentration similar to that of the interstitial
fluid
(Abrahamian, 2005, p. 2 of 28)
 Non-surgical
Treatment Options

• Thoracentesis
• tPA
• Chemical Pleurodesis
• Pleurx catheter
 Thoracentesis
• A needle is inserted into
the chest wall to
remove the collection of
fluid
• 50-100ml of fluid is sent
for analysis
• Determines the type of
fluid (transudate or
exudate)
Picture used with permission (Allibone, 2006, p. 60)
 Thoracentesis

• Not a permanent solution, fluid may

reaccumulate after a few days
• Will temporarily relieve symptoms
• Potential complications include bleeding,
infection, and pneumothorax
 tPA (alteplase)
• Thrombolytic enzyme
• Converts plasminogen to the enzyme plasmin,
which degrades fibrin clots
• Lyses thrombi and emboli
• May be administered into the chest tube catheter
to restore patency and improve drainage
• The patient is instructed to move positions
frequently to distribute the medication
throughout the lung
 Chemical Pleurodesis
• Sclerosing agents used: Talc, bleomycin,
or doxycyline
• Administered through a chest tube to
create inflammation and subsequent
fusion of the parietal and visceral pleura
• Fluid is then unable to accumulate in this
potential space
 Chemical Pleurodesis
• The goal of chemical pleurodesis is to cause an
irritation between the two layers covering the
lung.
• The sclerosant irritates the pleurae which results
in inflammation and causes the pleurae to stick
together.
• The procedure can be done at the bedside or in
the operating room.
• Do not administer with any anti-inflammatory
agents
 Pleurx Catheter
• Small, flexible tube
inserted into the chest to
drain fluid from around
the lungs
• Contains a one-way valve
that prevents air from
entering and fluid from
leaking out when capped
• Allows for intermittent
home drainage using a
vacuum bottle
Picture used with permission from Denver Biomedical
 Pleurx Catheter

In chest wall
where fluid is
accumulating

Picture used with permission from Denver Biomedical

 Pleurx Catheters
• Catheters are typically drained every one to two days
• Keeping the lung fairly free of fluid, will most likely
permanently stop the fluid from building up, so that the
catheter can be removed.
• The catheter may remain until fluid quits draining from
the lung
• The length of time a catheter will remain varies from
patient to patient, ranging from a few weeks to several
months.
 Pleurx Catheter
• Beneficial for patients who are independent and able
to perform self drainage
• Minimizes the time spent in the hospital
• Patients are instructed to drain up to 1,000ml of fluid
at one time
• Patients are instructed to call MD if drainage is <50ml
on three consecutive sessions
• Patients are able to wear usual clothing and continue
usual activities
 Cap
Pleurx Catheter
• Easy to connect
vacuum container
• Some patients
experience pain upon
drainage, slowing the
drainage with the
clamp or stopping
briefly may relieve
this pain
Photos by Kady Rejret, 2007
 Pleurx

Photo by Kady Rejret, 2007

 Pleurx Catheter Benefits
• Reduces hospital length of stay
• Reduces costs
• Improves quality of life
• 46% pleurodesis in 29 days (median)
• Provides effective palliation of symptoms of pleural effusions
• Often implanted on an outpatient basis
• May be used with most trapped lung patients
• Minimizes pain
• Placed under local anesthetic
(Denver Biomedical, 2004)
 Pleurx Catheter

Click on the link below

for more information:
http://www.denverbiomedical.com
Used with permission from Denver Biomedical
 Let’s review
Which treatment option requires
NO use of anti-inflammatories?
(click on the correct answer)

• Thoracentesis
• tPA
• Chemical Pleurodesis
• Pleurx Catheter
Think again!
Good Job!
• Chemical Pleurodesis
• This creates
inflammation and
subsequent fusion of
the parietal and
visceral pleura
• Anti-inflammatories
will counteract this
reaction.
 Congratulations!

dy Rejret, RN,
Ka
BSN

You have successfully

completely this tutorial!
 References
Allibone, L. (2006). Assessment and management of patients with pleural effusions.
Nursing Standard vol20 no22, 55-64
Abrahamian, F. M. (2005). Pleural Effusion. Retrieved March 22, 2007 from
http://www.emedicine.com
Brubacher, S. & Holmes Gobel, B. (2003). Use of the pleurx pleural catheter for the
management of malignant pleural effusions. Clinical Journal of Oncology Nursing 7
(1), 1-4
Denver Biomedical. (2004). Retrieved March 25, 2007 from
http://www.denverbiomedical.com
Drummond Hayes, D. (2001). Stemming the tide of pleural effusions. Nursing
Management 32(12), 29-35
Mayo Foundation for Medical Education and Research. (2006). Retrieved April 11, 2007
from http://www.mayoclinic.com/health
National Cancer Institute. (2006). Retrieved March 23, 2007 from http://www.cancer.gov
National Lung Health Education Program. (2000). Retrieved April 11, 2007 from
www.nlhep.org
Porth,C.M. (2005). Pathophysiology: Concepts of Altered Health States (7th ed.)
Lippincott.
Rejret, K. (2007). Personal Photograph.
Unattributed clipart: Microsoft Office, 2006.