Pleural effusion is defined as a buildup of excess fluid between the pleura. Recall that the pleura is a serous membrane that essentially folds back on itself to create a pleural sac for each lung. The inner layer is the visceral pleura that covers each lung. The outer layer, which is the parietal pleura, is attached to the chest wall. Pleural fluid between these two layers allow them to slide easily against one another as the lungs move and inflate with respirations.
There are two types of fluids associated with pleural effusion. Exudative fluid is high in protein, and is associated with effusions caused by blockages in the blood or lymphatic vessels, infection, tumors, injury to the lungs, and inflammation.
Transudative fluid is low in protein, and is associated with conditions that allow fluid to leak into the pleural space, such as heart failure.
In a healthy individual, the pleural space holds approximately five to ten milliliters of fluid. A pleural effusion is present with just 25 ml of fluid, though the effusion typically doesn’t show on x-ray until it reaches about 150 ml. What’s more, the patient may not even experience symptoms until the effusion reaches about 300 ml (though, of course, this can vary widely from patient to patient).
Risk factors for pleural effusion
There are a lot of risk factors and disease conditions that put someone at risk for pleural effusion. Common disease conditions that can cause a pleural effusion include pneumonia, heart failure, pulmonary embolism, cirrhosis, pancreatitis and cancer. In fact, pleural effusion is often one of the first noticeable indicators that a patient has cancer. The most common cancers that cause pleural effusion are lung cancer, breast cancer, ovarian cancer, mesothelioma, and lymphoma. When a pleural effusion is associated with cancer, it is called a malignant pleural effusion.
Other risk factors for pleural effusion include smoking, chronic alcohol use, and exposure to asbestos. Even some medications can cause pleural effusion. Examples include:
- Amiodarone – Antiarrhythmic used to treat supraventricular tachycardia and atrial fibrillation
- Methotrexate – DMARD commonly used for rheumatoid arthritis
- Dasatinib – Antineoplastic agent used to treat leukemia
- Hydralazine – Antihypertensive that can cause drug-induced lupus syndrome, which can present as pleural effusion in some patients
Elderly individuals are also at higher risk due to underlying respiratory disease, the presence of other comorbidities, and simply by getting exposed to causative agents for a longer period of time (such as cigarette smoke).
Complications of pleural effusion
Complications of pleural effusion include
- Diminished respiratory function – The excess fluid presses against the lung, preventing full expansion. Further, adhesions and scarring can develop that further impede respiratory function.
- Infection – Infections can be serious and lead to sepsis, which can be life threatening.
- Empyema – Infection can lead to the pus-filled pockets in the pleural space.
- Pneumothorax – Drainage of the fluid can potentially cause a pneumothorax to develop.
Now that you have some background knowledge about pleural effusion, let’s dive into the key nursing implications using the Straight A Nursing LATTE method.
L: How does the patient LOOK?
Depending on the size of the pleural effusion, some patients may have no symptoms. When symptoms are present they could include a nonproductive cough, tachypnea, dyspnea, orthopnea, and persistent hiccups. The patient may also complain of chest pain which is often described as sharp and associated with movement such as respiration, coughing and sneezing.
If infection is present, the patient may have fever, chills, malaise, and an elevated WBC count.
Respiratory assessment may reveal diminished or absent breath sounds over the area of the effusion, shallow respirations, tactile fremitus, egophony, and possibly uneven chest wall expansion with larger effusions.
It’s also important to note that patient presentation can vary widely depending on what is causing the pleural effusion. For example, if cancer is causing the pleural effusion, the patient will display signs and symptoms associated with cancer.
A: How do you ASSESS the patient?
Your key nursing assessments will mainly be centered on respiratory function. This includes assessing respiratory rate and effort, listening to lung sounds, and observing for respiratory distress. Priority vital signs include SpO2, heart rate and temperature.
If the patient is complaining of shortness of breath, ask them to rate it on a 0 to 5 scale (or whatever scale your facility uses). If they are complaining of pain, perform a thorough pain assessment utilizing the OPQRST format.
Some patients with pleural effusion will have a chest tube or pleural catheter (PleurX™) in place. Inspect the drainage system for patency, examine the drain exit site to ensure it is CDI, assess the drainage characteristics, and, of course, assess the chest tube drainage system (if using). Click here to review chest tube management.
T: What TESTS will be conducted for a patient with a pleural effusion?
Pleural effusions are identified via chest x-ray, chest CT scan and ultrasound. Once identified, a sample of the fluid is sent for analysis where it is tested for things like protein count, cell count, cancer, and infection.
Other important diagnostic tests will be aimed at identifying the underlying cause for the pleural effusion. For example, if it is suspected the patient has heart failure, an echocardiogram may be conducted. If infection is the cause, then following the WBC will be important.
T: What TREATMENTS are provided to address pleural effusion?
Goals of therapy in pleural effusion are to remove the fluid (which usually causes an immediate improvement in respiratory status), prevent recurrences, and treat the underlying cause.
Pleural fluid is most often removed through a procedure called a thoracentesis. For a thoracentesis, the patient is often positioned upright to ensure the diaphragm is in its lowest position and fluid is at the base. A commonly used position is sitting on the edge of the bed with arms over the bedside table. If the patient is unable to hold this position, they may be positioned on their unaffected side with HOB raised to about 45 degrees. The practitioner then sterilizes and numbs the skin, inserts the needle and removes the pleural fluid into a collection container.
This fluid will be sent to the lab for analysis, and how this is done can vary from one facility to the next. If you are sending the entire collection to the lab, be sure to affix a patient label to the container(s) that includes the date, time and your initials.
Throughout the procedure, monitor the patient for signs of discomfort and respiratory distress, which could indicate a pneumothorax.
In the EMR, record the patient’s vital signs throughout the procedure, the amount of fluid removed, the fluid characteristics such as color and viscosity, and the patient’s overall response to the procedure.
Once the thoracentesis is complete, apply a dressing to the site (often a bandaid or small gauze bandage) and monitor it for excessive leaking or bleeding. It’s also important to observe the patient for any signs of respiratory compromise, especially pneumothorax. Signs of pneumothorax include dropping SpO2, absent breath sounds on the affected side, considerable respiratory distress, unequal chest wall expansion, and a deviated trachea in severe cases. If this serious complication is suspected, alert the MD so they can decide if a STAT chest x-ray needs to be obtained.
Chest tubes and drains
In some cases, thoracentesis may not be enough to remove the accumulated fluid, or the MD may choose to remove the fluid more slowly. In other cases, patients may have recurrent buildup of fluid and require long-term drainage. In these cases a chest tube or pleural drain may be placed. While a patient will need to stay in the hospital with a chest tube, they can be discharged to home with a pleural drain.
In patients with recurrent pleural effusion (which is common in cancer), a procedure called pleurodesis may be performed. The goal of pleurodesis is to eliminate the pleural space so fluid cannot accumulate. There are two main ways this is performed. One is through direct manual injury to the pleura during a surgical procedure called VATS (video-assisted thoracoscopic surgery). The other, more common method, is through administration of a sclerosing agent into the pleural space. These chemical sclerosants can be instilled via a pleural catheter or during a VATS procedure. A common sclerosing agent used is talc.
Address the underlying cause
Treatments will also include specific interventions aimed at treating the underlying cause when applicable. For example, if the pleural effusion is a result of infection, antibiotics will be prescribed. If the patient has pleural effusions due to heart failure, then they may be prescribed diuretics and other medications utilized to manage their cardiac condition. If pleural adhesions are causing the accumulation of fluid, they can be lysed during a VATS procedure and may involve the installation of a thrombolytic to break up the adhesions.
General treatments for pleural effusion
General treatments and nursing interventions for a patient with pleural effusion include:
- Pain medication as needed
- Supplemental oxygen as needed
- Maintain an upright position, which can help facilitate breathing
E: How do you EDUCATE the patient/family?
In addition to explaining all medications and nursing interventions, education about pleural effusion should include:
- Since there are many underlying causes, explain what is causing the patient’s pleural effusion. If it’s related to malignancy, ensure the patient understands they could have recurrent pleural effusions.
- Educate the patient/family about signs and symptoms of worsening pleural effusion and when to seek medical care (increased dyspnea and pain).
- Provide smoking cessation resources to help reduce pleural effusion risk.
- Teach the patient how to splint with a pillow when coughing to help reduce pain.
- If a pleurodesis is done, the MD may want the patient to change position frequently for the first two hours after the procedure. Ensure the patient understands the importance of this and that it is done to distribute the sclerosing agent evenly.
- Teach drain care for patients going home with a pleural catheter (PleurX) and ensure they know to watch for signs of infection at the insertion site and in the drainage.
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