Can Draining the Pleura Too Fast Cause the Pleura to Fill Again Quickly?

Nursing. Author manuscript; available in PMC 2009 Dec 21.

Published in final edited form as:

PMCID: PMC2796548

NIHMSID: NIHMS147485

Caring for a Patient with Cancerous Pleural Effusion

Introduction and Case Study

Mrs. Peters is a 65-twelvemonth erstwhile married adult female with a known history of right breast cancer, diagnosed and treated x years ago. In the past several weeks, she has a new nonproductive coughing and is a scrap fatigued and short of breath with physical activity. Her married man finally convinces her to come across her health care provider who obtains her history and completes a physical exam. On listening to her lungs, an absence of breath sounds is constitute in the lower half of the correct lung. When percussed, at that place is dullness in the areas of absent breath sounds. Middle sounds are normal. In that location is no pedal edema. An in office pulse oximetry is 91% on room air. A chest x-ray including lateral, anterioposterior and decubitus films demonstrate a correct-sided pleural effusion. Mrs. Peters is admitted for a piece of work upward of a presumptive diagnosis of metastatic chest cancer with malignant pleural effusion (MPE). This article will discuss the clinical presentation, diagnosis, treatment and nursing management of the patient with a MPE.

What is MPE?

A pleural effusion is a collection of fluid between the parietal and visceral pleural layers of the lung. Pleural effusions are oftentimes associated with avant-garde malignancies such as carcinoma of the lung or breast. However, many other malignancies are known to produce MPE, such as mesothelioma, renal, ovarian, and sarcomas (Porcel & Vives, 2003). Relatively common, over 150,000 new cases of MPE are diagnosed each year (Neragi-Miandoab, 2006).

The pleural space lies between the 2 layers of the pleura. The visceral layer covers the lungs and the parietal layer lines the chest wall cavity. Nether normal circumstances, a maximum of fifty mLs of pleural fluid is present in the pleural infinite. The fluid allows the lung layers to motion easily during respiration. The capillaries contained in the parietal pleura manufacture pleural fluid and the visceral pleura reabsorb the fluid (Taubert, 2001). Anything that disturbs this balance can result in the development of a pleural effusion, such every bit a reduction in or obstruction of lymphatic drainage, increased or decreased oncotic pressure in the capillaries, increased capillary permeability, or increased negative pressure in the lungs from atelectasis (Putman, 2002; Taubert). A mutual etiology of pleural effusion in patients with a malignancy is lymphatic obstacle (Shuey & Payne, 2005). Effusions may be unilateral or bilateral.

Several types of pleural effusions occur including transudative and exudative, but most MPE are exudative (Taubert) characterized past high protein and high LDH levels, and a high white blood cell count (Goldman, 2004). The fluid is yellowish, cloudy or blood-tinged (Goldman). Fluid obtained during a diagnostic procedure is ever sent for these diagnostic studies. In addition, other diagnostic studies useful in pleural fluid cess are Gram stain, civilization and sensitivity, cytology, glucose, amylase, and albumin (Calorie-free, 1999). Even so, the fluid LDH and the fluid to serum ratio of total protein are the about accurate tests available to distinguish a transudative effusion from an exudative effusion with the pleural fluid LDH; more than 2-thirds of the upper limit of normal of the serum LDH is diagnostic for an exudative effusion (Tassi, Cardillo, Marchetti, Carleo, Martelli, 2006). Transudative effusions are seen in patients with lymphoma but about oft are associated with nonmalignant atmospheric condition (Taubert). Characterized by low levels of protein and a watery fluid, transudative effusions are associated with cirrhosis or congestive centre failure.

Signs and symptoms/patient cess

Patients such as Mrs. Peters complain of feeling curt of breath with activity or fifty-fifty at rest [dependent on the size of the effusion], fatigue, a dry cough, and chest pain or pleuritic pain or chest heaviness. These symptoms oftentimes cause the patient to seek wellness care from the physician or CRNP. Baseline vital signs and weight are washed. A nursing history should include the onset and exacerbating factors for the shortness of jiff (SOB) or dyspnea on exertion, its outcome on the patient'due south performance status and quality of life. Ask about the cough and whether or not information technology is productive and if chest pain is present. Have the patient explain the severity of the breast pain, any accompanying symptoms, and if the hurting is worse with a deep breath which would be a sign of pleuritic hurting. Discover the trachea and await for deviation from the midline. Auscultation of the lungs reveals absent breath sounds in the area of the effusion and percussion over the expanse of interest is dull. Using percussion, a line can often be fatigued between the fluid level and aerated lung showing the size of the effusion. Pulse oximetry may be normal or low dependent on the size of the effusion and the amount of normal lung tissue nowadays. If the pleural effusion is associated with cardiac disease, other signs of excess fluid should be present such as lower extremity edema or tachycardia. If associated with liver illness, in that location should be other signs of disease such equally ascites or varicies (telangectasia).

Symptomatic Management of MPE

Supplemental oxygen therapy will often amend the patient'south symptoms past improving blood oxygen levels. The respiratory and middle rates will decrease and the pulse oximetry readings increment. Medications such as oral morphine may also provide comfort and pain relief. Fatigue is mutual in patients with MPE. The patient needs to take care planned so that as fiddling effort on the role of the patient is required until the MPE is drained and lung function improves. The nurse assists the patient with bones care needs such as bathing and toileting to conserve energy. The patient should consume a loftier calorie diet to meet their respiratory caloric needs by consuming small amounts of calorie concentrated foods that are easy to consume. Anxiety needs to be managed as information technology will increase the respiratory rate and lead to more anxiety (Taubert, 2001) and morphine is often useful for this purpose. MPE in patients with solid tumors is often associated with end-of-life and patients benefit from consultation with a social worker and referral to hospice. The nurse needs to take the time to heed to the patient'due south needs and anticipate physical intendance needs to reduce the burden on the patient. Education of the patient and family volition help reduce anxiety and permit them to exist active participants in their care.

Diagnostic Studies

A chest x-ray with anterior-posterior, lateral and decubitus films, will demonstrate a pleural effusion. Other diagnostic studies include ultrasound and chest CT scan which will assist the physician with obtaining a sample of pleural fluid for diagnosis. A thoracentesis is done to obtain non merely fluid for diagnosis only to be therapeutic and remove the fluid filling the pleural infinite and crowding the lung preventing expansion and is the test and procedure of choice in the evaluation of pleural effusion (DeCamp, Mentzer, Swanson, Sugarbaker, 1997). Nether local anesthesia, and ultrasound if the effusion is modest, a needle in placed in the pleural space to remove a fluid sample for assay. Additional fluid is removed to improve the patient's breathing and reduce the feeling of shortness of jiff and if possible, all the fluid is removed however, excess fluid removal may crusade hypotension from fluid shifting from the intravascular space and pulmonary edema (Taubert, 2001). A pleural biopsy may also be done. After a thoracentesis, a chest 10-ray is done to make sure that a pneumothorax or hemothorax did non occur during the process. The fluid from a showtime time thoracentesis may not be diagnostic and a second i may be needed to obtain a diagnosis. Patient didactics later a thoracentesis includes the need to report the acute onset of shortness of breath which may be associated with a pneumothorax or hemoptysis from bleeding and changes in heart rate. The nurse monitors the patient for hypoxia, cyanosis, tachycardia, respiratory changes, hemoptysis, and changes in breath sounds indicating the reaccumulation of the pleural effusion and checks the vital signs. Repeated thoracenteses tin cause fluid loculations, infection or the implantation of tumor forth the needle tracts (Genc, Petrou, Ladas, Goldstraw, 2000). Thoracentesis and fluid removal is helpful in the curt term relief of shortness of breath for 1-3 days afterwards which reaccumulation is possible with the majority recurring within thirty days (Anderson, Philpott, Ferguson, 1974). So if MPE is recurrent, additional therapeutic measures are necessary.

Mrs. Peters underwent a thoracentesis which drained 500 ml of fluid of which a sample sent to the lab revealed that the fluid was exudative. The cytology of the specimen was positive for breast cancer. While awaiting the results of the diagnostic studies, her effusion reaccumulated. Since her prior cancer therapy consisted of surgery, radiations therapy and adjuvant chemotherapy, the health care providers recommended single amanuensis chemotherapy to palliate her MPE afterwards receiving additional local therapy for the effusion.

Management of Recurrent MPE

When managing a MPE the clinician should take into consideration the overall wellbeing of the patient. The general treatment for MPE is palliative in nature. Those patients who take developed MPE associated with a main chest tumor equally Mrs. Peters has may have a survival of ane-two more years, whereas patients with a lung cancer main have a much shorter time span such as iv-half-dozen months. The prognosis may influence the handling that the patient can tolerate (Burrows, Mathews, Colt, 2000).

If the effusion is pocket-sized, systemic handling may not be required, however if the main tumor can be treated, clinicians may decide to care for it every bit mentioned above in our case study with chemotherapy later treating the effusion get-go.

The objective in treatment is assisting the patient to exhale without difficulty past administering supplemental oxygen if required, and removal of the fluid that has built upward between the parietal and visceral pleural layers of the lung which can help with both symptom management and diagnosis of the cause of the fluid build up (Tyson, 2004).

Mrs. Peters has already had fluid removed past thoracentesis for diagnosis which was positive for chest cancer and now the methods of more permanent fluid removal need to exist explored.

Thoracentesis

This is a process in which a catheter is placed under sterile atmospheric condition into the pleural space for drainage of the fluid. The procedure can either be performed at the bedside, using local anesthesia and anatomical landmarks to guide catheter insertion, or radiologically, using fluoroscopy to direct catheter location. No thing which method is used there are some common potential complications to appraise for. Having the patient awake and able to report symptoms that they are experiencing is valuable. Complaints of shortness of breath, coughing or hurting could be an indication of a problem.

Fluid should exist removed slowly so every bit to forbid some complications and care should exist given not to remove besides much fluid at in one case, by and large no more than 1000ml despite the fact that some inquiry shows removal of more fluid may exist tolerated (Feller-Kopman, 2007). Removal of likewise much fluid also quickly along with hurting or coughing could result in reexpansion pulmonary edema, hypotension and circulatory collapse from the rapid reexpansion of the lung. Another difficulty from removing too much fluid rapidly is that it may allow for fluid to reaccumulate rapidly again.

Other complications from thoracentesis, especially if they are being performed repeatedly, are infection, pneumothorax, bleeding and fluid loculations from scar tissue formation from repeated catheter insertions. Post process chest ten-ray ever needs to be completed to determine if the procedure and the manipulation acquired a pneumothorax. Thoracentesis is also considered only a temporary mensurate for symptomatic relief, and with the diagnosis of cancer cell shedding, will cause fluid reaccumulation over and over.

Tube Thoracoscopy

Placement of a chest tube for drainage and management of a MPE is another method which could be utilized. Chest tubes could come in two bones forms the first beingness poly vinyl chloride (PVC) type catheters which are big and rigid, usually used after surgery because of the thick, bloody drainage. These tubes can be placed at the bedside by blunt dissection in the area of the fifth intercostal space using anatomical landmarks to guide placement (Jain, Deoskar, Barthwal & Rajan, 2006). However, since the PVC tubes are usually large (26 to 36 French sized), a peachy bargain of hurting is unremarkably involved and the patients seem to do better with moderate sedation or if the tube is placed under anesthesia. These are tubes that are normally used equally chest tubes after surgery in the thoracic cavity. Patients will rarely get dwelling house with a larger chest drainage organization as in that location is not always the support needed at dwelling for this blazon of system.

The second type of tube for tube thoracoscopy is a pigtail catheter which can be placed at the bedside also, merely is mostly placed in Interventional Radiology under fluoroscopy. This catheter is much smaller in size (8-12 French sized), and is made of silicone, so it is much more flexible and comfy for the patient. Once the proper placement is determined in the pleural space and the catheter is placed accurately, the tip of the catheter is curled to lock it into place and to prevent a penetrating injury (Gammie, et al., 1999; Tsai, et al. 2006)- thus the name "pigtail".

In either example, once the preferred tube is placed information technology tin be connected to a chest drainage system or a drainage bag with a one mode valve at the discretion of the clinician. In this way fluid can be drained and measured appropriately. Complications associated with this procedure are again infection, pneumothorax, haemorrhage, and reexpansion pulmonary edema if a large corporeality of fluid is removed too quickly. A post procedure chest 10-ray is needed later this procedure to rule out a pneumothorax. If patients are very near to the stop of their lives management of the MPE with a pigtail catheter to a gravity bag with a one style valve is a reasonable choice to control the patient'southward fluid build up and SOB for their remaining days.

There has been a recent push for more portable chest drains that allow patients to manage chest drainage bug at dwelling house. In having a more than mobile or portable approach patients tin can go home sooner and care for their tubes equally outpatients, costs will exist deceased and the patients may have an improved quality of life (Carroll, 2005). Several of these tubes are geared toward patients with a pneumothorax and concord very little volume of drainage, then they would not be good options for a patient with a MPE. One of these mobile types of drains is made by Atrium and is called the Express Mini 500®. This drain can actually exist connected to suction if required and holds up to 500 ml of fluid which can be emptied if needed with a Luer-Lok syringe. This drainage system could be utilized for patients if the drainage in not too large in book, they desire to be more than mobile, and accept good dexterity for emptying the container, and the patient's clinician has no further plans for handling of the MPE (Carroll, 2005).

Tube Thoracostomy with Assistants of a Sclerosing Agent

Generally, placement of a breast tube alone is bereft to completely treat the effusion. If a patient's life expectancy is longer than simply a few weeks, and then attempting to relieve the effusion more permanently is considered necessary. This can be tin can be accomplished by placement of any chest tube of a desired size and instillation of a substance to causes a chemical sclerosing. The basic principle to sclerosing is that the chest tube itself will work to completely drain the pleural space, and the placement of a sclerosing amanuensis into the tube causes a chemical pleuritis with scar tissue formation or adhesions which causes the visceral and parietal pleura to "stick together" and allows no space for reaccumulation of fluid (Taubert, 2004). The process works best if the pleural space is empty in lodge in society not to decrease the authorisation of the sclerosing agent.

A number of substances take been used equally a sclerosing amanuensis namely antibiotics, talc, and some chemotherapeutic agents. Tetracycline used to be the agent used most commonly, merely is only available in oral form since the mid 1990'southward so is no longer used and was effective about 80% of the time. Bleomycin Sulfate is 1 of the more common chemotherapeutic agents used and is effective nigh lx-80% of the time. These substances would be administered direct into the pleural space via the chest tube and the tube clamped to keep the amanuensis in place. The patient would exist asked to change positions to permit the agent to come in contact with all surfaces if possible, then the chest tube is unclamped. Monitoring chest x-rays and the volume of drainage will account for the effectiveness of the item sclerosing agent for that patient.

Side effects with this method of elimination of the MPE are similar to full general tube placement, and in addition fever and pain from the irritation of the agent to the pleural surface. Infection is always of business concern merely with the initial tube placement, tube manipulation (opening and closing the system) and because of the addition of a strange substance. Once it is adamant that the pleurodesis is successful, the breast tube is removed, and breast x-ray determines that at that place is not a pneumothorax, and the patient is sent domicile allowing for the chest tube site to heal in a few days.

Video Assisted Thorascopic Surgery with Talc Sclerosing

Video Assisted Thorascopic Surgery (VATS) is a procedure using a thoracoscope through a small incision in the chest, allowing viewing of the pleural space and a way to administrate the talc directly by insufflation (aerosolized) directly onto the pleural surface (Heffner, 2008). With this method it ensures that all surfaces are covered and therefore ameliorate results with the irritation and adhesion formation, close to 100% (Taubert, 2004). This process is considered surgical and performed under general anesthesia. Side furnishings to monitor for are those with chest tube placement and fever and hurting. The patient will probably have to stay in the infirmary a few days recovering from the surgical procedure. Talc may exist mixed into a slurry or suspension and administered directly through the breast tube. Similar to sclerosing with tetracycline or bleomycin the patient would accept to plough to effort to get all surfaces covered and there is a great deal of pain involved in the irritation component. Patients would have to exist monitored but every bit any other mail service operative patient would for haemorrhage and infection.

Other Surgical Methods for Treating MPE

Two surgical procedures which could be considered by the medico when a patient has a MPE are a pleurectomy or placement of a pleuroperitoneal shunt. The shunt is placed surgically and consists of a tube or passage allowing the fluid from the effusion to move from the pleural space to the peritoneal space where it is hoped the fluid volition be slowly absorbed. Many times this procedure is done if the patient failed chemic pleurodesis. It requires manual pumping of the shunt and could have complications from blockage of the shunt (Taubert, 2004; Heffner, 2008).

The other surgical procedure considered merely in patients who tin can withstand a long surgical procedure and with a good life expectancy is a pleurectomy. A pleurectomy involves removal of the parietal pleura and manual irritation of the visceral pleura causing formation of adhesions and scar tissue and therefore no more fluid build upwards in the space (Taubert, 2004; Heffner, 2008). This is a major surgical process done under general anesthesia as an open breast instance. A partial pleurectomy could be washed via a thoracoscope. Patients having this process would need to be monitored and cared for as whatever thoracotomy patient would with loftier risk for pneumonia and deep vein thrombosis.

Tunnelled Indwelling Pleural Catheter with Intermittent Drainage

The final method for managing a MPE is use of an indwelling pleural catheter. These silicone catheters are generally placed in Interventional Radiology using fluoroscopy and tunnelled directly into the pleural space. The catheters of which there are several on the market take a 1 way valve that prevents air from inbound the chest cavity and fluid from coming out without accessing the valve (Taubert, 2004). One time the catheter is placed and chest x-ray has confirmed that there is no pneumothorax, patients can go domicile and manage their effusion as an outpatient by draining the catheter using the appropriate supplies 2-three times a week or as ordered past the md. The nurse monitors the patient for all the usual side furnishings of placement of a chest tube, and teaches the patient and their family how to drain, manage bug and care for the patient with this type of catheter. Patients feel a sense of control with this catheter, allowing them to be at home and not connected to a drainage organisation all of the time for the remaining fourth dimension that they have.

Overall nursing care for whatsoever of these methods of managing a MPE is to monitor patients for signs of bleeding, increased SOB and infection. Care for whatever of the post surgical patients by monitoring for respiratory bug, infection and administering pain medications. Patients having their pleural effusion tuckered will often have some pain with the procedure and the nurse needs to adequately medicate the patient to control that hurting.

Mrs. Peters had an indwelling pleural catheter placed and her husband was taught how to empty the drain three times a week. This lasted for about 10 weeks before the effusion was only producing 75ml at a time. The catheter was pulled. Mrs. Peters went on hospice well-nigh half dozen months subsequently and died peacefully at dwelling house.

Quality of Life and Terminate-of-Life Issues

MPE has a significant impact on the patient's quality of life every bit it is oft mutual in the last iv-6 months of life (Burrows, Mathews, Colt, 2000; von Gruenigen, Frasure, Reidy, Gil, 2003). A patient's concrete condition with MPE helps predict how well they volition do and their survival after MPE treatment. In patients who underwent a thorascopic pleurodesis for the management of MPE, the patients who had the all-time performance condition (functional status) were the ones that had ameliorate post-operative survival (Burrows, et al). In this study, the patients who were able to perform cocky care lived 395 days and the patients who required hospitalization simply survived 34 days (Burrows). Management of dyspnea at this point is paramount and nurses play a major part in symptom management. Besides morphine, oxygen therapy is useful along with a fan which helps reduce the feeling of breathlessness. Positioning the patient for maximal lung expansion by sitting them upward in bed and educational activity them how to use the diaphragm for maximal lung expansion is helpful. Pursed lip animate helps reduce the feeling of breathlessness and controls the respiratory rate. When activeness is required, the patient needs to be taught how to pace himself to not become short of breath. Referral to hospice and social work is appropriate to maximize the quality of the patient's remaining life span.

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