INTRODUCTION:

Pleural effusion, the collection of fluid in the pleural space is not a disease but it is a sign of various other serious disorder. The client with lung disorders are a challenge to nurse providing care. Normally the pleural space contains 5 to 15 ml of fluid which act as a lubricant that allows the pleural surface to move without friction. It may be a complication of heart failure, tb, pneumonia, pulmonary and viral infections etc.

MEANING:
Any abnormal amount of pleural fluid in the pleural space is called pleural effusion. It is the collection in excess of physiological amounts, i.e. More than 30 50 ml.

NORMAL PHYSIOLOGY OF PLEURAL FUID

Each lung is covered by a thin membrane called the visceral pleura, which adheres closely to the alveoli of the lungs. The ribs and connective tissues of the chest wall are covered on the inner surface by a similar membrane called the parietal pleura. It covers not only the ribs but also mediastinum and the diaphragm. There is a space between the visceral and parietal pleura that averages 10- 20 mm in width and is filled with pleural fluid. This pleural fluid enters the pleural space across both the visceral and parietal pleurae, particularly when the interstitial pressure within either the lung or chest wall is increased. The main route for pleural fluid removal is small holes within the parietal pleura called stomata. The parietal stomata connects with intercoastal lymphatic vessels under the ribs that drain posteriorly into the medistinum. In the mediastinum, the pleural fluid drains into the thoracic duct, a large lymphatic channel within the chest, which empties into the left subclavian vein. Abnormalities of increased fluid production or blockade of drainage can cause pleural fluid to accumulate. The lymphatic exit rate may be decreased by obstruction of the parietal pleural stomas, inhibition of lymphatic contractility, infiltration of draining parasternal lympnodes and rising systemic venous pressure into which the lymph drains.

CAUSES OF PLEURAL EFFUSION:

Pleural effusion can be classified or pathlogicprocess are explained basis on the causative factors of each. Depends upon the cause it is divided into the following: Transudative pleural effusion Exudative pleural effusion

TRANSUDATIVE PLEURAL EFFUSION

Any pleral effusion that forms when the integrity of the pleural space is undamaged is called transudative pleural effusion. A pleural fluid total concentration less than 50 % of the serum level and LDH value less than 60 % of the serum value indicate the presence of a transudative pleural effusion. In the absence of serum values , an absolute pleural fluid LDH level less than 2/3rd normal for serum suggests the presence of a transudate. The primary cause for pleural effusion is the abnormality in (increase)hydrostatic pressure and (decrease) oncotic pressure. Following are the certain diseases that results in pleural effusion. a) CONGESTIVE HEART FAILURE: This is the most important cause of transudativepleural effusion. Approximately half of the patients with congestive heart failure will develop transudative effusion, which is bilateral in 88% of cases. Elevation of pressure in the left atrium and pulmonary veins is the hallmark of congestive heart failure. Elevated pulmonary venous pressure Increased interstitial fluid in lungs Increased lung water decompress into pleural space Limited capability to remove fluid through the intercoastal vein (increased systemic venous pressure)

The capacity of pleural lymphatic drainages has exceeded Pleural effusion b) RENAL DISEASES Nephrotic syndrome and renal failure are the important causes in which hypoproteinemia and fluid overload results in gross asitis, pleural effusion, pericardial effusion and generalized peripheral edema.In nephritic syndrome, there is leakage of protein and results in decreased oncotic pressure within the blood to hold appropriate amount of fluid within the blood vessels. These patients becomes edematous and fluid leakes into the lung interstitium and pleural space. In patients with nephrosis, protein s which keeps blood from clotting is deficient from leaking into the urine. It results in the formation of pulmonary throboemboli, which causes exudation that contains large number of rbcs. Another rare cause is the obstruction of venacava, usually incase of thrombosis.

c) HEPATIC DISEASE: Transudative effusion due to hepatic dysfunction complicates hepatic cirrhosis in about 6% of the cases, with preference for the right side.Hypoalbuminaemia and asitis are the important pathogenic mechanism. Hypoalbumenemia results as a complication of aids or chronic liver disease. Pleural effusion is rarely formed until the serum albumin level is less than 1.8 mg/dl. Low protein level in the blood allows fluid to leak into the interstitial tissue and pleural space. In case of ascitis, the end stage liver disease causes transudative fluid to accumulate in the abdomen. The pleural space is under negative pressure during inspiration and because ascitc fluid is under positive pressure, any small hole in the diaphragm can resultin movement of ascetic fluid in the pleural space to form hepatic hydrothorax. d) ATELECTASIS When segments of lung collapse, intrapleural pressure becomes more negative and can produce small effusions. With relief of bronchial obstruction and postoperative pain, these effusions regress. e) LYMPHATIC OBSTRUCTION Lymphatic obstruction within the medistinum causes poor pleural fluid regressfrom the pleural space,although the pleural space is otherwise normal. The most common case is cancer that metastasizes to the mediastinum. f) FONTAN PROCEDURE With the fontan procedure, an anastomosis is created between the superior venacava, the right atrium or the inferior venacava and pulmonary artery to bypass the right ventricle ususlly in tricuspid atersia ,pleural effusion is more common after the surgery. g) RARE CAUSES Urinothorax occurs after rupture of ureter causing a urine leak into the retroperitoneal space which refluxes into the chest. A central venous line which is inappropriately placed in the pleural space can infuse large amount of transudative effusion into the pleural space. Peritoneal dialysate can migrate into the pleural cavity in patients undergoing ambulatory peritoneal dialysis. Bone marrow transplantation is also associated with pleural effusion which is transudative in nature. It is seen only in recipient of allogenic transplants and in children.

EXUDATIVE PLEURAL EFFUSION

An Exudative pleural effusion is by inflammation in the lung or pleura. This type of pleural effusion has more amount of protein and inflammatory cells present than transudative. Important

causes are: (1) infectious conditions (50 %) (2) malignant disease (25 %) (3) thromboembolic disease (19%) (4) GI disease (4%) (5) autoimmune, TB (1.55%) a) PARAPNEUMONIC Parapneumonic pleural effusion is as a result of inflammation of the lung parenchyma. Pleural effusion forms in pneumonia because of inflammation in the lungs increases interstitial lung water and pleural fluid production. It develops when the pleural fluid has high protein content to clot. The clotting cause the fibrin strand to span the visceral and parietal pleurae. The net result is collection of pleural fliud into different loculi within the pleural cavity. b) VIRAL PLEURISY Viral lung infections can cause pleural inflammation, small pleural effusions and pain. Viral infection is responsible for much higher percentage of pleural effusion without parenchymal infiltration.pleural effusion is reports to occur with infectious hepatitis, dengue hemmorhagic fever, influenza virus and patients with HIV virus. c) TUBERCULOUS PLEURISY Tuberculous pleural effusion occurs when caseous granuloma in the lung ruptures through the visceral pleural surface causing an exudative inflammatory effusion. Experiments shows that such effusions results from bodys immune reaction to tuberculin proteins.(in the presence of specific cell mediated immunity tubercle bacilli provoke an intense hyper sensitivity reaction and outporing of fluid) d) MALIGNANT Neoplastic involvement of pleura may results from direct invasion (bronchial carcinoma), hematogenousspread(various primaries), lymphatic assess(malignant lymphoma, carcinoma of the breast). Effusion with no detectable pleural invasion of pleura is called paramalignant. Diffuse malignant pleural mesothelioma is defined as autocanthous pleural malignancy arising from the residual mesothelial population and its stroma. It is almost exclusively associated with asbestos exposure. e) POSTOPERATIVE A variety of operations involving the chest or upper abdomen produce pleural fluid. Effusion following cardiac surgery usually arepredominant on the left side and tend to be bloody.Upper abdominal operations causes inflammation of the diaphragm and effusion. f) CHYLOTHORAX The thoracic duct is a lymphatic channel that runs from the abdomen through the mediastinum to enter the abdomen through the mediastinum to enter the left subclavian vein. Disruption of the

thoracic duct anywhere along the course of duct ca cause leakage of chyle into the mediastinum,which may rupture into the pleural space and can cause a chylothorax. The most common causes are trauma, surgery and malignancy. g) HEMOTHORAX It is the presence of blood in the pleural space. Although it is seen most commonly seen after a penetrating or blunt chest trauma, a number of medical conditions can also lead to these disorders. h) CONNECTIVE TISSUE DISORDERS Pleural effusions are seen in connective tissue disorders like systemic lupus erythomatous, rheumatoid arthritis etc. i) BILIOUS PLEURAL EFFUSION It is due to a fistula from the biliary tree to the pleral space. The fistula may be secondary to trauma, suppurative complication due to infection. The pleural fluid appears bilious and treatment consists of re-establishment of biliary drainage. j) DRUG INDUCED PLEURAL EFFUSION Pleural effusion is associated with certain drug such as Dantrolenesodium(lomg acting skeletal muscle relaxant), Methysergide, Ergot alkaloids, Procarbazine, Amiodarone, Interleukin 2. k) MISCELLANEOUS CONDITIONS Uremic pleurisy, a rare complication of chronic renal failure that describes an exudative inflammatory blood stained effusion may insidiously progress to fibrosis. Other causes are related to AIDS and organ transplantation especially lung transplantation.

CLINICAL FEATURES
Pleural fluid more than 30 50 ml Progressive dyspnoea with decreased chest wall movement on the affected side. Dullness to percussion , attetenuated or abolished breath sounds and fremitus .(classical sign of cresent or typical pleural effusion) Decreased vocal resonance and fremitus Pleural friction rub. In large effusion there may be tracheal deviation away from the effusion Bulging of intercoastal space Unilaterraly lagging breath excursions. Dyspnoea of varying degrees. Mediastinal shift

 Orthopnea Dry non productive cough Snowball crunching sign on auscultation

DIAGNOSTIC PROCEDURES
CHEST RADIOGRAPHY It is better to obtain a chest radiograph with the patient in upright position to show a pleural meniscus at the pleural fluid meniscus at the costophrenic angles. In supine position the radiograph shows a generalized haze, which interfers with the detection of pulmonary infilterates. In lateral position the presence of 1 cm meniscus from the lung to the rib margin suggest that the effusion is large. ULTRASOUND Pleural fluid and loculli can be used to locate the presence of pleural effusion. It describes the charectersistics of effusion (exudative/transudative), diaphragm motility etc. helps to identify the site for thoracentesis. COMPUTED TOMOGRAPHY It helps to delineate the pleural membrane and differentiate peripheral lung consolidation from pleural fluid formation. In addition to show the size and location of pleural effusion, the chest CT gives information about the underlying lung parenchyma and the primary process causing the effusion. MRI & PET MRI can be used to identify the thin layer of extrapleural fat, which is an indication of chest wall tumor. PET identifies malignant effusion with a sensitivity of 91 % and specificity of 100 %.

ANALYSIS OF PLEURAL FLUID In thoracentesis the pleural fluid is collected percutaneously. A sample of more than 20 ml is needed for basic macroscopic, biochemical, cytological and microbiological assessment. The general appearance including color, viscosity and smell leads to the primary categorization into serous, suppurative, sanginous or chylous effusion. The amount of protein, LDH, cholesterol etc. are used for analysis. Serum albumin level of more than 1.2 gm/dl suggest the presence of transudate. Glucose and pH level helps to identify the etiology. Low level(glucose <0.5, ph<7.3) are charecteristics of empyema, tuberculosis and rheumatic effusion. Measurement of pleural amylase helps in the identification of pancreatic disease.it may be hemmorhagic (tumor),

chylorous (in lymphatic obstruction or trauma to thoracic duct), rich in cholesterol (recurrent effusion as in TB), if there is high WBC count and fluid is purulent , it indicates empyema. Transudate VS Exudate: Light's criteria An accurate diagnosis of the cause of the effusion, transudate versus exudate, relies on a comparison of the chemistries in the pleural fluid to those in the blood, using Light's criteria. According to Light's criteria (Light, et al. 1972), a pleural effusion is likely exudative if at least one of the following exist. 1. The ratio of pleural fluid protein to serum protein is greater than 0.5 2. The ratio of pleural fluid LDH and serum LDH is greater than 0.6 3. Pleural fluid LDH is greater than 0.6 or times the normal upper limit for serum. TRANSUDATIVE Appearance Clear Specific gravity < 1.012 Protein content < 2 g/dl Cholesterol content < 45 mg/dl PLEURAL BIOPSY Any unexplained exudative effusion is the indication for pleural biopsy. a) Needle biopsy of pleura: small specimen of parietal pleura is obtained. The needles that are used commonly are the Cope needle and Abrams needle. It is mainly used in the diagnosis of tuberculus or malignant pleural effusion. b) Open biopsy of pleura: thoracotomy with direct biopsy of the pleura provides the best visualization of the pleura and best biopsy. The main indication is undiagnosed progressive pleural disease that cannot be approached by thoracotomy. EXUDATIVE Cloudy > 1.020 > 2.9 g/dl > 45 mg/dl

MANAGEMENT OF PLEURAL EFFUSION

TRANSUDATIVE EFFUSION It usually responds to the correction or elimination of the underlying systemic pathology such as decreased myocardial contractility, fluid overload and protein deficiency. Diuretics and albumin replacement in severe hypoproteinemic conditions are effective approach. Frusemide and combination of thiazide and spirinolactone are usually used diuretics. Other treatment methods are chest tube insertion, pleurodesis, pleural-peritoneal shunt. TUBERCULOSIS PLEURISY

It can be diagnosed effectively by endoscopic biopsy techniques. Systemic steroid therapy is often suggested as it mitigate the acute exudative symptoms and to prevent fibrothorax. The therapeutic benefit of thoracoscopicdebridement with peeling of massive fibrin memberanes and loculations has not been validated but it was proved effective in clinical trials. OTHER NON BACTERIAL INFLAMMATORY DISEASES The main drug of choice are the corticosteroids, non-steroidal anti-inflammatory drugs and group of drug called disease modifying anti-rheumatic drugs (dmards) that includes azathioprine, cyclophosphamide, d-penicillamine, methotrexate, chloroquine, ciclosporin etc. MALIGNANT EFFUSION Percutaneous irradiation in pleural malignancy is used almost exclusively as an adjunct to palliative therapy to the tuimor that obstructing the pleuropulmonary lymphatic clearance system.whole lung irradiation for the management of malignant lymphoma. A radical surgery is considered in advance stages of carcinoma which includes the resection of extrapleuralpneumectomy, resection of diaphragm etc.

LOCAL INTERVENTIONS
CHEST TUBE DRAINAGE In cases where there is large exudates, the chest tube draining is the best method. The insertion of chest tube is conventionally performed in the lateral decubitus position. In patients with severe breathing difficulty it is carried out in upright position. Premedication with atropine is indicated to avoid vaso-vagal syncope. Large bore transparent silicon or pvc tubes (>24 fr) about 60-70 cm in length and distal perforations over 18-20 cm are optimum specifications for thoracic drainage therapy. In monolocular effusions the safe and reliable standard entry point for these instruments would be the fifth and sixth intercoastal space in the mid or anterior axillary line, keeping a 3-4 cm safety distance from the diaphragm.fix the drain with a transparent dressing which allows the inspection of drain site for leaking or kinking. For routine use, suction level of 10-20 cm H2o is used, but in thick exudates or malexpansion of lungs a suction level of 40 cm H2O is used. Drainage should not exceed 1l/h. It is wise to administer intravasal volume by isotonic volume replacement to prevent hypovoluemic circulatory syncope. LONG TERM CONTROL (PLEURODESIS) It is the process of fusing the parietal and visceral pleurae wiyh fibrotic reaction that prevents further pleural fluid formation. Methods to produce pleural symphysis includes surgical abrasion and the application of intrapleural chemicals such ac doxycycline, minocycline and talk. Topical analgesia-200 to 250 mg lidocaine is useful in the reduction of pain during pleurodesis. It is most commonly used in the management of symptomatic pleural effusion caused by cancer. The factors that influences the efficacy of the treatment are:

 Complete removal of pleural fluid Full lung expansion Equal pleural distribution of the agent and continous drainage after instillation until the fluid production ceases. Ultrasound follow up is essential to confirm the efficacy of the treatment. PLEURO -- PERITONEAL SHUNTING In refractory chronic transudative and exudative effusions a pleuroperitoneal Denver shunt can be used. It may be inserted using local anesthesia without important complications. Indications are failure of pleurdesis (trapped lungs and chylothorax). The device consists of a double valved pump with an afferent (pleural) and efferent (peritoneal) tube.fluid moves from the pleural space to the pump chamber and then to peritoneal cavity. the patient manually pumps on the reservoir daily to move fluid from the pleural space to the peritoneal space. PLEURECTOMY (PLEURAL STRIPPING) Surgical stripping of the parietal pleura away from visceral pleura, which produces an intense inflammatory reaction that promotes adhesion formation between the two layers .

NURSING MANAGEMENT
1) Ineffective airway clearance related to retained secretions and excessive mucous as evidenced by ineffective cough, adventitious breath sounds and dyspnoea. Patient outcome: Demonstrates effective coughing and increased air exchange. Experiences normal breath sounds Interventions Auscultate breath sounds and note the area of decreased or absent breath sound and for the presence of adventitious sounds for evaluating the effectiveness to treatment. Remove secretions by encouraging coughing or by suctioning Regulate the fluid intake to optimize the fluid balance and liquefy the secretions. Assist the patient to a sitting position with head slightly flexed, shoulders relaxed and knees flexed to improve the respiratory status. 2) Impaired gas exchange related to fluid collection in lungs and pleural space as evidenced by drainage chest from chest tube, decreased breath sounds and abnormal pulse oximetry.

Outcome: Demonstrates full lung expansion with normal oxygen saturation. Interventions Monitor respiratory and oxygenation status to allow early recognition of significant changes in respiratory status. Initite and maintain supplemental oxygen to treat hypoxemia. Position to alleviate dyspnoea to increase the comfort of the patient. Monitor for bubbling of the suction chamber of the chest tube drainage system. Ensure that all tubing connections are securely attached and taped to prevent air leaks. Keep the drainage container below the chest level to prevent tension pneumothorax. 3) Acute pain, pleuritc related to inflammatory process Outcome: Verbalize reduction in pain Interventions monitor the respiratory rate, depth and rhyrhm of respiration. auscultate breath sounds and note the area of decreased or absent breath sound and for the presence of adventitious sounds. provide the patient optimal pain relief with prescribed analgesics. institute and modify the pain control measures on the basis of patients response. position the patient to alleviate the symptoms of dyspnoea.

PROGNOSIS:
The diagnosis of a malignant pleural effusion signals a poor prognosis. Patients with carcinoma of lungs, stomach and ovary tend to have survival time of only a few months from the time pleral effusion has diagnosed: patients with breast cancer may survive longer. Benign asbestos pleural effusion generally resolves leaving behind some residual on the chest radiograph.

REHABILITATION AND FOLLOW-UP

The rehabilitation of the patients with pleural effusion mainly depends on the underlying cause of the disorder. In patients with non-malignant pleural effusion, the symptoms will be relieved after the treatment of underlying disorder and patient can resume the actions of daily living once he is asymptomatic. But in patients with malignant pleural effusion, the health professionals should attend to their needs and treatment methods is focused on the symptomatic relief and

palliative aspect. Follow-up is essential for both the cases and the family members should be educated regarding the adherence to medical regimen.

CONCLUSION
Pleural effusion is a common clinical finding in patients with underlying disease of the neighbouring lung or the pleural space itself. It is also a manifestation of extrapulmonary disorders such as heart, kidney or abdominal organs. Treatment varies considerably and depends on the specific cause. Cure is possible in many instances and symptomatic relief can be provided for nearly all patients with pleural effusion.

RECENT ADVANCES:
Pleural effusion VEGF levels as a prognostic factor of malignant pleural mesothelioma. Malignant pleural mesothelioma (MPM) is an aggressive malignant tumor of mesothelial origin associated with asbestos exposure. MPM has a limited response to conventional chemotherapy and radiotherapy so early diagnosis of MPM is very important. Vascular endothelial growth factor (VEGF), a potent mitogen for the vascular endothelium, is also known to be an autocrine growth factor for MPM. Patients with MPM had significantly higher pleural effusion VEGF levels than a population with non-malignant pleuritis or lung cancer involving malignant pleural effusion, and the patients with advanced stage MPM showed higher levels of VEGF than the early stage MPM patients. Pleural effusion VEGF concentration could be useful as an aid for the diagnosis of MPM and as a prognostic factor. Pleurovenous shunting in the treatment of nonmalignant pleural effusion The goals of treatment of chronic nonmalignant pleural effusionare relief of dyspnea and improved quality of life..Pleurovenous shunting (PVS) representsan alternative, minimally invasive method.All patients received Denver shuntsystems from the pleural cavity to either the subclavian orjugular vein. RESULTS: Shunt occlusion was observed in one case (chylothorax) 4 weeksafter implantation. There was one early death, which was notrelated to the procedure (hepatic failure). No air embolismor infection was observed. All systems were patent throughoutthe observation period of 1 to 40 months (mean = 13.3 months),and none of the patients required further treatment for pleuraleffusion. CONCLUSIONS: Pleurovenous shunting offers an efficient, minimally invasivealternative to other surgical methods for treatment of recurrentnonmalignant pleural effusion. Alteplaseinthetreatmentof complicated parapneumoniceffusion Thetreatmentof complex parapneumoniceffusions in childrenremains controversial, with some advocating less invasive, strictlymedical management and others supporting a more aggressive

approachof thoracotomy with or without decortication. Recentadvances,including video-assisted thoracoscopic surgery and intrapleuralfibrinolytictherapy, offer new options for effective treatment.We report the first case of successful resolution of a complexparapneumoniceffusionin a 16-month-old girl with the use oftissue plasminogen activator (alteplase), infused via a catheterinthepleural space. Autofluorescence video thoracoscopy in exudative pleural effusions: Videothoracoscopy has been proven to be a safe tool to establish the diagnosis in >90% of patients with exudative pleural effusions of unknown origin. In the majority of patients with malignant pleural diseases, the endoscopic appearance of pleural lesions during white light thoracoscopy is suggestive of malignancy. Areas with fat on the pleural layer appeared yellow under the conventional mode, but orange under the autofluorescence mode.in all cases of histologically proven malignant pleural disease the colour of the affected area of the pleura changed from white/pink to red in a darker or slighter attenuation .Therefore, the sensitivity of AFT for detecting malignant lesions on the pleural surface was 100%.

BIBLIOGRAPHY
1. Mason RJ, Murray FJ, Nadel AJ. Textbook of respiratory medicine. 4th edition. Philadelphia: Elsevier publications; 2005 2. Fishman AP, Elias AJ, Grippi AM, Kaiser LR,Senior RM. Fishmans pulmonary disease and disorders. 3rd edition. London:McGraw publications; 1998 3. Fauci AS, Kasper DL, Lomgo DL.et al. Principles of Harrisons internal medicine. 17th Edition.London: McGraw Hill Publications; 2008 4. Davidson S. Davidsons principles and practices of medicine. 21st Edition. London:Churchil Livingstone; 2010 5. Black MJ,HawksHJ.Medical surgical n nursing.8th Edition.New Delhi: Saunders Elsevier;2005. 6. Linton AD. Introduction to Medical surgical nursing.4th Edition. Missouri: Saunders Publications;2007. 7. Vargas SF, Novaes PN, Marchi E, Teixireae LR. Influence of parecoxib in experimental pleurodesis. Journal of respiratory medicine. 2009 (103) 595-600 8. Genofre ED, Vargas FS, Acenico MP, Marchi E. Talc pleurodesis: evidence of systemic inflammatory response to small size talc particles. Journal of respiratory medicine. 2009 (103) 91-97 9. Jayalakshmi TK, Lobo I, Nair G, Swami S. JAPI. 2010 Apr; (58) 251-52

ASSIGNMENT ON MEDICAL SURGICAL NURSING PLEURAL EFFUSION

Submitted To,
Mrs. Jyothi Chakraborthy Assistant Professor Dept. Medical Surgical Nursing Manipal College Of Nursing

Submitted By,
Ms. Roona Jayan Roll no: 100503001 1st Year MSc Nursing MCON, Manipal