Hello and thank you for watching Nursing School Explained. Today's topic is pleural
effusion. So let's look at how this happens. so
remember that normally we have about 5 to 15 milliliters of lubricating fluid
between the visceral and the parietal pleura.
so these are the different layers that surround the lungs
that allow for expansion of the chest and the lungs with inhalation and
exhalation. so that there is no there is no rubbing
against those two cavities and everything happens smoothly. so that's
just like oil in a car allows for lubrication and
smooth movement. now in an effusion basically means an
increased fluid in that space and an effusion can apply to anything for
example you can have a joint diffusion in your knee
if you have an injury and that fluid escapes the joint capsule. so an effusion
is always an abnormally high amount of fluid in a
specific place where it doesn't belong and so a
pleural effusion means an abnormal amount of fluid in the
pleural cavity. so normally the way that this fluid
is regulated is a nice balance of hydrostatic
pressure, oncotic pressure as well as capillary
membrane permeability. so what that means is the hydrostatic pressure remember is
the pressure that's exerted against the blood vessels by a fluid
as well as the oncotic pressure which helps
to draw fluid into the blood vessels and that's usually done with the
help of plasma proteins such as albumin and then capillary membrane permeability
basically meaning how likely is the capillary bed
to let things seep through this the membrane and regulate the fluid that
way. so now when this regulation is out of
balance then we'll have a pleural effusion.
so this abnormal regulation usually happens because of
increased pulmonary capillary pressure, decreased
oncotic pressure or increased pulmonary pleural membrane permeability or
obstruction of lymphatic flow that can be another reason.
and pleural effusions there are two different types. one of them is
exudative and the other one is transudative. so exudative
think about exudate as in pus and that usually is because of
inflammation so some sort of inflammation is happening
which makes all the inflammatory cells attracted to that
site and increases the pleural cavity permeability
and that is usually because of infection or malignancy.
and that fluid is then usually cloudy and yellow, thick kind of pus-looking
exudative type of fluid; where in transudative pleural
effusion those are non-inflammatory conditions
that cause that. and so when the hydrostatic pressure
increases, the blood pressure increases, the heart works
harder, it causes heart failure and therefore
all that fluid is backing up into the lungs causing the plural effusion
as well as with when we have decreased oncoticc pressure
so decreased blood albumin usually because of
liver and renal disorders we will have transudative pleural effusions and that
fluid is usually clear and very pale yellow.
not so inflamed, infected-looking as in the exudative. And that's just kind
of a background so that you understand how these mechanisms happen
and mostly the most common um causes for profusions that i've seen in
my practice was heart failure, liver failure
as well as malignancy so tumors can cause that.
So now let's look over here signs and symptoms. Sso now if we have
increased fluid in the pleural cavity
where there should be gas exchange the patient is going to be feeling short of
breath. They might have a cough remember in a
pleural effusion, pulmonary edema that cough can be pink and frothy that's kind of a
telltale sign. The patient a lot of times will have
sharp, non-radiating chest pain that increases with inhalation so every
time the lungs expand in that pleural cavity it puts more
pressure because now that fluid is being displaced and causes
pain. The patient will have decreased breast sounds because now we have fluid
and not air in that pleural cavity that we can also hear by dullness on
percussion so usually lung percussion should be resonant, nice
hollow sounds, but now if we have fluid in that cavity
where it doesn't belong it's going to be sounding more dull such
as if you're percussing over an organ like the liver. Now diagnostic
tests will be chest x-ray or chest cat scan to really see the extent of the
pleural effusion and the location specifically and we'll
get into that when we talk about treatment.
So treatment here is always treating the underlying cause.
so if this is due because of heart failure
we want to treat the heart failure by getting rid of some of that fluid with
administering diuretics as well as placing the patients on a low sodium
diet. And if it's cancer then we certainly
want to treat that cancer in whatever way would be recommended.
And then in order to get rid of this pleural effusion
we a lot of times a procedure called a thoracentesis
is recommended. And think about centesis means removal of fluid, in this
case it's from the thorax, so it's a
thoracentesis. If we have an effusion in the knee that
we talked about before, so increased fluid in the knee, that would
be an arthrocentesis so an removal of fluid
from the joint. So centesis meaning removal of fluid. And so we want
this is usually something that the physician, the provider will do
sometimes it's done in the interventional radiology department.
And the best position is the patient dangling at the edge of the bed
usually supporting themselves over a bedside table
so that the intercostal spaces here opened up giving the physician
or the provider easier access to that area and certainly they are going to
check the results of the radiology studies to see the
location and where they need to put this tube. So it
is much like the insertion of an IV catheter
remember an IV catheter has a needle as well as this plastic cannula.
So in order to get the needle in the right
spot first of all they'll numb the patient up with some local lidocaine
and then they will insert the needle into the intercostal space,
again usually it's on the lower lungs because fluid will usually settle down
with gravity. And then there's a tube so basically
they'll use that needle to guide that tube just into the right space and then
they withdraw that needle just like in an IV insertion
and the tube will remain in that pleural space
and that's usually a pretty long tube that is connected to usually a one
liter of kind of a vacutainer so that's a similar mechanism as when you get your
blood drawn. so that this vacutainer just draws the
fluid out by creating this negative pressure.
And sometimes more than one of these vacutainers will be needing depending on
the size of that pleural effusion. Now when it's
all drained we will have to remove that tube and
that will again be the physician or the provider
and we'll have to put a sterile occlusive dressing there
because it's a direct line into the pleural cavity so we want to make sure
that we don't cause any infection there from the procedure.
Now keep in mind usually about 1 liter to 1200 milliliters of fluid are removed
it is not really recommended to remove more volume than that
because removal of large volumes or rapid removal of fluids remember
whenever you lose fluid your overall blood pressure can drop
and that is mostly if we're talking about hydrostatic and oncotic pressures
here so we're removing some of the fluid we have low albumin already now we're
not having enough fluid in the intravascular space causing
hypotension. Patient can also become hypoxemic as
well as that pulmonary edema can expand. So
again it'll be up to the provider or the physician
to determine how much fluid they want to drain from that patient's pleural space
but whenever there's more than this volume keep in mind
that you have to stay with the patient and really observe them for these things.
And nursing care here involves monitoring vital signs after the
procedure. Every vital sign all the five vital
signs including pain and for sure the O2 sat
and also monitoring the patient for signs and symptoms of respiratory
distress. And usually because this is considered a
semi-surgical it's not really an OR-type procedure but like i mentioned
it can be done in the interventional radiology
department so a lot of times nursing care and monitoring of vital
signs involves maybe monitoring the vital
signs Q five minutes for the first 15 minutes
and then Q 15 minutes for an hour and then Q 30 minutes for the next two to
four hours so depending on how the patient is
doing. now this can be done as an inpatient as
well as an outpatient basis so some patients who might have
this chronically from a lung tumor for
example they might come into the interventional radiology department
and have this done on a semi regular schedule.
Ao thank you for watching this video on pleural effusion
and the mechanisms and pathophysiology. If
you need to review these topics of hydrostatic and oncotic pressure
i would recommend that you watch my other videos on fluid volume excess and
deficit as well as the basic IV
fluid videos that explain these principles
Thank you for watching Nursing School Explained and i look forward to seeing
you again next time.