Chapter 23 Pleural Effusion and Empyema Mosby items

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 Ø Ø Ø 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 Ø Pleural effusion resulting from collagen vascular diseases Ø Ø Ø 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 Ø Ø Ø 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 Ø Atelectasis Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

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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 Ø 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 Ø Ø Ø 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 N or IC FRC TLC RV VC 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) p. H Pa. CO 2 HCO 3 (slightly) Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. Pa. O 2 15

Pa. O 2 and Pa. CO 2 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) p. H Pa. CO 2 HCO 3 (Slightly) Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. Pa. O 2 17

Pa. O 2 and Pa. CO 2 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 DO 2 VO 2 N C(a-v)O 2 (Severe) O 2 ER Sv. O 2 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 Ø Ø Ø 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 Ø Ø Ø 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 Ø Ø Ø Talc Tetracycline Bleomycin sulfate Produces inflammatory reaction between lungs and inner chest cavity Ø 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