Chapter 23 Pleural Effusion and Empyema Mosby items

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,

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 ©

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

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

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.

Oxygenation Indices (Large Pleural Effusion) QS/QT DO 2 VO 2 N C(a-v)O 2 (Severe)

Hemodynamic Indices Large Pleural Effusion CVP RAP PA PCWP CO SV SVI CI RVSWI

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