Chapter 23
Pleural Effusion and Empyema
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
1
CL
FA
DD
Figure 23-1. Right-sided pleural effusion. FA, Fluid accumulation; DD, depressed diaphragm; CL,
collapsed lung (partially collapsed). Inset, Atelectasis, a common secondary anatomic alteration
of the lungs.
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
2
Anatomic Alterations of the Lungs



Lung compression
Atelectasis
Compression of the great veins and
decreased cardiac venous return
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
3
Etiology
Common Causes of a Transudative
Pleural Effusion





Congestive heart failure
Hepatic hydrothorax
Peritoneal dialysis
Nephrotic syndrome
Pulmonary embolus
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
4
Etiology (Cont’d)
Common Causes of An Exudative Pleural
Effusion







Malignant pleural effusions
Malignant mesotheliomas
Bacterial pneumonias
Tuberculosis
Fungal disease
Pleural effusion resulting from diseases
of the gastrointestinal tract
Pleural effusion resulting from collagen vascular
diseases
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
5
Etiology (Cont’d)
Other Pathologic Fluids that Separate the
Parietal from the Visceral Pleura



Empyema
Chylothorax
Hemothorax
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
6
Overview
of the Cardiopulmonary Clinical Manifestations
Associated with
Pleural Effusion
The following clinical manifestations result from the
pathophysiologic mechanisms caused (or activated)
by

Atelectasis
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
7
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
8
Clinical Data Obtained at the
Patient’s Bedside
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
9
The Physical Examination

Vital signs


Increased
• Respiratory rate (tachypnea)
• Heart rate (pulse)
• Blood pressure
Chest pain/decreased chest expansion
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
10
The Physical Examination (Cont’d)


Cyanosis
Cough (dry, nonproductive)
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
11
The Physical Examination (Cont’d)

Chest Assessment Findings


Tracheal shift
Decreased tactile and vocal fremitus
 Dull percussion note
 Diminished breath sounds
 Displaced heart sounds
 Pleural friction rub (occasionally)
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
12
Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
13
Pulmonary Function Test Findings
Moderate to Severe
(Restrictive Lung Pathophysiology)
Lung Volume & Capacity Findings
VT
IRV
ERV
RV
VC
N or 




IC
FRC
TLC



RV/TLC ratio
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
N
14
Arterial Blood Gases
(Small Pleural Effusion)
Acute Alveolar Hyperventilation with Hypoxemia
(Acute Respiratory Alkalosis)
pH
PaCO2


HCO3
 (slightly)
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
PaO2

15
PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
16
Arterial Blood Gases
(Large Pleural)
Acute Ventilatory Failure with Hypoxemia
(Acute Respiratory Acidosis)
pH
PaCO2


HCO3
 (Slightly)
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
PaO2

17
PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
18
Oxygenation Indices
(Large Pleural Effusion)
QS/QT
DO2
VO2


N
C(a-v)O2
 (Severe)
O2ER
SvO2


Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
19
Hemodynamic Indices
Large Pleural Effusion
CVP
RAP
PA
PCWP
CO
SV






SVI
CI
RVSWI
LVSWI
PVR
SVR






Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
20
Radiologic Findings

Chest Radiograph






Blunting of the costophrenic angle
Fluid level on the affected side
Depressed diaphragm
Mediastinal shift (possibly) to unaffected side
Atelectasis
Meniscus sign
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
21
Figure 23-2. Right-sided pleural effusion (small black arrow) complicated by a pneumothorax
(large white arrow).
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
22
Figure 23-3. Subpulmonic pleural effusion. Right lateral decubitus view. Subdiaphragmatic fluid has run up
the lateral chest wall, producing a band of soft tissue of water density (meniscus sign). The medial
curvilinear shadow (arrow) indicates fluid in the major fissure.
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
23
General Management of Pleural
Effusion

The management of each patient with pleural
effusion must be individualized





Should a thoracentesis be performed?
Can the underlying cause be treated?
What is the appropriate antibiotic
Should a chest tube be inserted?
Examination of pleural fluid may be needed to
assess:
• Transudate
• Exudate
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
24
General Management of Pleural
Effusion (Cont’d)
PLEURODESIS
 Chemical or medication injected into the
chest cavity




Talc
Tetracycline
Bleomycin sulfate
Produces inflammatory reaction between
lungs and inner chest cavity

Causes lung to stick to chest cavity
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
25
Respiratory Care Treatment
Protocols



Oxygen Therapy Protocol
Lung Expansion Therapy Protocol
Mechanical Ventilation Protocol
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.
26