Pleural Effusion: Cause, Management,ICD

 Pleural Effusion 

This is a collection of fluid in the pleural space. It is the result of excessive fluid accumulating between the thin layers of tissue that line the lungs and thorax. Pleural fluid is normally a clear pale yellow colour.  A large amount of purulent drainage indicates an empyema. 

Causes 

Transudate may be caused by cardiac failure, kidney disease, hypoalbuminaemia due to chronic liver disease,  hypothyroidism.  The fluid has similar protein level to those found in normal pleural fluid, with no evidence of blood, inflammation, or infection. 

Exudate may develop as a result of pneumonia, neoplasm, tuberculosis, or pulmonary infarction. The fluid contains increased levels of protein, blood, or evidence of inflammation or infection. 

Empyema is pus in the plural space, and it may be developed as a result of pneumonia, lung abscess, bronchiectasis, or tuberculosis. 

Assessment findings 

• Trachea displaced away from a massive effusion 
• Expansion reduced on the affected side
• Percussion dullness over the area of fluid
• Breath sounds reduced or absent 
• Added sounds bronchial above the effusion due to compression of overlying lung. 
• Tachypnoea and central cyanosis 
• Fever 
• Cough
• Pleuritic pain

Management 

• Chest X-ray
• Ultrasound examination 
• ABG and pulse oximetry 
• CBC, serum creatinine and LFTs
• Treatment for pleural effusions will require management of the underlying cause (e. g. antimicrobial therapy for pneumonia, diuretics for cardiac failure ). 
• Monitor haemodynamics
• Monitor electrolytes and treat imbalance 
• Monitor fluid status and treat imbalance 
• Oxygen therapy 
• Adherence to infection prevention and control 

Large, infected, or inflamed pleural effusion often requires drainage to improve symptoms and prevent complications. Various procedures may be used to treat pleural effusion, including the following :

• Thoracentesis- to remove large amounts of pleural effusion or effusion or for diagnostic purposes.
• Pleurodesis - an irritant ( e.g talc, doxycycline) is injected through a chest tube into the pleural space. The irritant creates an inflammatory response that cause the surface of the pleura and chest wall to adhere, sealing the space and thus preventing further fluid collection. 
• Tube thoracotomy (chest drain) -a plastic tube is inserted into the pleural space via small incision made in the chest wall. The tube is attached to suction and may remain in site for several days.

Nursing care of chest drain 

A chest drain has three functions:

• To drain fluid or air
• To prevent additional air from entering chest.
• To facilitate lung-expansion using suction. 

Monitor the appearance of drained fluid and record measurements hourly. If a chest drain was indicated for a pneumothorax, drainage of fluid is less likely. 

Use of water seal prevents air from entering chest tube and the patient's lungs. Fluctuation of the water in the tubing on inspiration and expiration is normal, and if not present this could indicate kinked, blocked tubing or a fully reinflated lung. Bubbling of the water indicates that air is escaping from the pleural cavity ( e.g. in the case of pneumothorax ). New bubbling could indicate a new undiagnosed pneumothorax or disconnection of the tubing. It is possible to distinguish between an air leak and a pneumothorax by clamping the tubing close to the chest wall, which will stop the bubbling if the air is caused by pneumothorax, but the bubbling will continue if it is due too a loose connection or disconnection

Clamping of a chest tube should only by performed to identify the cause of an air leak and one medical orders.

Removal of a chest tube can be undertaken at the bedside with the patient in bed, using an aseptic non-touch technique. Two sutures are usually inserted -the first to assist later closure of the wound after drain removal, and the second(a stay suture) to secure the drain which needs to be removed.  Care must be taken to avoid air entering the pleural cavity. Clamping prior to removal is not recommended on the basis of the latest evidence.  The patient should be instructed to exhale while the tube is being removed. Once the tube has been removed the closure suture should be tied and an occlusive dressing applied.  The patient should be monitored for signs of respiratory distress. Disposal of the chest drain must include safe disposal of the fluid.