8/18/2019 laxmi mam

1/7

First Article

Pleural Effusion

The lungs are covered by a membrane or lining, called the pleura, which has two layers, an inner layerand an outer layer. The outer layer lines the rib cage and diaphragm. The inner layer covers the lungs.The diaphragm is a sheet of muscle which separates the chest from the abdomen. The pleura producesa fluid which acts as a lubricant that helps you to breathe easily, allowing the lungs to move in and outsmoothly. Sometimes too much of this fluid can build up between the two layers of the pleura: this iscalled a pleural effusion.

Pleural effusion is the abnormal accumulation of fluid in the pleural space. 

ormally, only a thin layer of fluid separates the two layers of the pleura. An e!cessive amount of fluid

may accumulate for many reasons, including heart failure, cirrhosis, pneumonia, and cancer. "epending

on the cause, the fluid may be either rich in protein #e!udate$ or watery #transudate$. "octors use this

distinction to help determine the cause.

%lood in the pleural space (hemothorax) usually results from a chest in&ury. 'arely, a blood vessel

ruptures into the pleural space when no in&ury has occurred, or a bulging area in the aorta #aortic

aneurysm$ lea(s blood into the pleural space. %ecause blood in the pleural space does not clot fully, it is

usually easy for a doctor to remove using a large)bore needle or a chest tube.

Pus in the pleural space (empyema) can accumulate when pneumonia or a lung abscess spreads into

the space. A wide range of bacteria as well as certain fungi and mycobacteria #especially the

mycobacterium that causes tuberculosis$ are the most common organisms causing pleural effusion.

Empyema may also complicate an infection from chest wounds, chest surgery, rupture of the esophagus,

or an abscess in the abdomen.

*il(y fluid in the pleural space (chylothorax) is caused by an in&ury to the main lymphatic duct in the

chest #thoracic duct$ or by a bloc(age of the duct by a tumor.

+igh)cholesterol fluid in the pleural space results from a long)standing pleural effusion caused by a

condition such as tuberculosis or rheumatoid arthritis.

Common Causes of Pleural Effusion

 Abscess under the diaphragm

irrhosis

occidioidomycosis and other fungal infections

"rugs such as hydrala-ine, procainamide, isonia-id, phenytoin, chlorproma-ine,

nitrofurantoin, bromocriptine, dantrolene, procarba-ine

+eart failure

8/18/2019 laxmi mam

2/7

+eart surgery

mproper placement of feeding tubes or intravenous catheters

n&ury to the chest

/ow protein levels in the blood

Pancreatitis

Pneumonia

Pulmonary embolus

'heumatoid arthritis

Systemic lupus erythematosus

Tuberculosis

Tumors

Symptoms and DiagnosisThe most common symptoms, regardless of the type of fluid in the pleural space or its cause, are

shortness of breath and chest pain. +owever, many people with pleural effusion have no symptoms at

all.

 A chest !)ray, which shows fluid in the pleural space, is usually the first step in ma(ing the diagnosis.

omputed tomography #T$ more clearly shows the lung and the fluid and may show evidence of

pneumonia, a lung abscess, or a tumor. An ultrasound may help a doctor determine the position of a

small accumulation of fluid.

Pleural Effusion 

http://www.merck.com/mmhe/sf/multimedia/04044ap/t/sec04-ch052-ch052c.htmlhttp://www.merck.com/mmhe/sf/multimedia/04044ap/t/sec04-ch052-ch052c.htmlhttp://www.merck.com/mmhe/sf/multimedia/04044ap/t/sec04-ch052-ch052c.html

8/18/2019 laxmi mam

3/7

 A specimen of the fluid is almost always removed for e!amination using a needle, a procedure called

thoracentesis #see Symptoms and "iagnosis of /ung "isorders: Thoracentesis$. The appearance of the

fluid may help a doctor determine its cause. ertain laboratory tests evaluate the chemical composition

of the fluid and determine the presence of bacteria, including the bacteria that cause tuberculosis. The

fluid specimen is also e!amined for the number and types of cells and for the presence of cancerouscells.

f these tests cannot identify the cause of the pleural effusion, a biopsy of the pleura may be needed #see

Symptoms and "iagnosis of /ung "isorders: eedle %iopsy of the Pleura or /ung$, which can detect

cancer and tuberculosis. 0sing a biopsy needle, a doctor removes a sample of the outer layer of the

pleura for analysis. f the specimen is too small for an accurate diagnosis, a tissue sample must be ta(en

through a small incision in the chest wall, a procedure called an open pleural biopsy. Sometimes, a

sample is obtained using a thoracoscope #a viewing tube that allows a doctor to e!amine the pleural

space and obtain samples #see Symptoms and "iagnosis of /ung "isorders: Thoracoscopy$.

1ccasionally, bronchoscopy #a direct visual e!amination of the airways through a viewing tube$ helps the

doctor find the cause of the fluid. n about 234 of people with pleural effusion, the cause is not obvious

after initial testing, and in some people a cause is never found, even after e!tensive testing.

Treatment

Small pleural effusions may re5uire treatment of only the underlying cause. /arger pleural effusions,

especially those that cause shortness of breath, may re5uire drainage of the fluid. 0sually, drainage

dramatically relieves shortness of breath. 1ften, fluid can be drained using thoracentesis. An area of s(in

between two lower ribs is anestheti-ed, then a small needle is inserted and gently pushed deeper until it

reaches the fluid. A thin plastic catheter is often guided over the needle into the fluid to lessen thechance of puncturing the lung and causing a pneumothora!. Although thoracentesis is usually performed

for diagnostic purposes, a doctor can safely remove as much as 6.7 liters of fluid at a time using this

procedure.

8hen larger amounts of fluid must be removed, a tube #chest tube$ may be inserted through the chest

wall. After numbing the area by in&ecting a local anesthetic, a doctor inserts a plastic tube into the chest

between two ribs. Then the doctor connects the tube to a water)sealed drainage system that prevents air 

from lea(ing into the pleural space. A chest !)ray is ta(en to chec( the tube9s position. "rainage can be

bloc(ed if the chest tube is incorrectly positioned or becomes (in(ed. f the fluid is very thic( or full of

clots, it may not flow out.

 An accumulation of pus from an infection #empyema$ re5uires intravenous antibiotics and drainage of the

fluid. Tuberculosis or fungal infections such as coccidioidomycosis re5uire prolonged treatment with

antibiotics or antifungal drugs. f the pus is very thic( or if it has formed within fibrous compartments,

drainage is more difficult. Sometimes drugs called fibrinolytics are instilled into the pleura space to help

drainage, which may avoid the need for surgery. f surgery is needed, it can be performed by a

procedure called video)assisted thorascopic debridement or by thoracotomy. "uring surgery, a thic( peel

http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-132http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-137http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-148http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-148http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-132http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-137http://www.merck.com/mmhe/sec04/ch039/ch039c.html#sec04-ch039-ch039c-148

8/18/2019 laxmi mam

4/7

of fibrous material is removed from the lung surface to allow the lung to e!pand normally.

Fluid accumulation caused by tumors of the pleura may be difficult to treat because fluid tends to

reaccumulate rapidly. "raining the fluid and giving antitumor drugs sometimes prevents further fluid

accumulation. %ut if fluid continues to accumulate, sealing the pleural space #pleurodesis$ may be

helpful. All fluid is drained through a tube, which is then used to administer a pleural irritant, such as a

do!ycyclineS1*E T'A"E A*ES 

%'A*;

solution or a talc mi!ture, into the space. The irritant seals the two layers of pleura together, so that no

room remains for additional fluid to accumulate.

f blood has entered the pleural space, usually drainage through a tube is all that is needed

8/18/2019 laxmi mam

5/7

The lungs are covered by a membrane or lining, called the pleura, which has two layers, an inner layer and an outer layer.

The outer layer lines the rib cage and diaphragm. The inner layer covers the lungs. The diaphragm is a sheet of muscle

which separates the chest from the abdomen. The pleura produces a fluid which acts as a lubricant that helps you to

breathe easily, allowing the lungs to move in and out smoothly. Sometimes too much of this fluid can build up between the

two layers of the pleura: this is called a pleural effusion.

Causes of a pleural effusion

Pleural effusions are 5uite common and are often due to infections, such as pneumonia, or heart failure, when the heart is

not pumping the blood efficiently around the body.

 A pleural effusion can also be a symptom of several types of cancer. A pleural effusion usually develops if cancer cells

have spread into the membrane lining the lungs, where they can lead to irritation and cause fluid to build up. The types of

cancer that are more li(ely to cause a pleural effusion are lung cancer , breast cancer , ovarian cancer , lymphomas and

mesothelioma #cancer of the pleura$.

Signs and symptoms

The build)up of fluid around the lungs presses on the lung, ma(ing it difficult for the lung to e!pand fully. n some

situations part or all of the lung will collapse. This can ma(e you increasingly breathless, not only on e!ertion but at rest as

well. ;ou may also get some chest pain and a cough.

Drainage of a pleural effusion

The treatment of a pleural effusion involves slowing the build)up of the fluid, and draining the fluid to relieve the

symptoms.

The drain is usually inserted by a doctor. ;ou will be as(ed to sit either on a chair or on the edge of the bed and then

helped to lean forward over a table with a pillow to bend on so that your bac( is e!posed. The doctor will decide where to

http://www.cancerbackup.org.uk/Cancertype/Lunghttp://www.cancerbackup.org.uk/Cancertype/Lunghttp://www.cancerbackup.org.uk/Cancertype/Lunghttp://www.cancerbackup.org.uk/Cancertype/Breasthttp://www.cancerbackup.org.uk/Cancertype/Breasthttp://www.cancerbackup.org.uk/Cancertype/Breasthttp://www.cancerbackup.org.uk/Cancertype/Ovaryhttp://www.cancerbackup.org.uk/Cancertype/Ovaryhttp://www.cancerbackup.org.uk/Cancertype/Ovaryhttp://www.cancerbackup.org.uk/Cancertype/Mesotheliomahttp://www.cancerbackup.org.uk/Cancertype/Lunghttp://www.cancerbackup.org.uk/Cancertype/Breasthttp://www.cancerbackup.org.uk/Cancertype/Ovaryhttp://www.cancerbackup.org.uk/Cancertype/Mesothelioma

8/18/2019 laxmi mam

6/7

insert the drain ? usually in the side of the chest. The s(in over the area where the drain is to be inserted is cleaned with

an antiseptic solution to prevent the area from becoming infected. The doctor then gives you an in&ection of local

anaesthetic to prevent the procedure from being painful.

8hen the area has been anaesthetised the doctor ma(es a very small cut in the chest and inserts a needle called a

cannula. The cannula is attached to a tube and drainage bag or bottle. The fluid drains out of the chest and collects inside

the bag or bottle. The fluid that drains may be bloodstained. f there is a large amount of fluid, you will usually need to stay

in hospital for a couple of days. f there is only a small amount of fluid, the cannula is removed immediately after the fluid

has been drained off and the area is covered with a dressing. 1therwise, the cannula will be held in place with a small

stitch.

8hen the local anaesthetic wears off, you may have some pain or discomfort. /et the doctor or nurse (now if you have

any pain, as pain(illers can be prescribed to help.

1nce the drainage has slowed down and the doctors thin( that most of the fluid has drained, you will have a chest !)ray to

see how well your lung has re)e!panded. f it has, the drain will be removed.

n some situations it may be possible to have your pleural effusion drained while you are at home using a catheter that is

very similar to a chest drain. The catheter will be put in while you are in the hospital, where it will be attached to a suction

bottle that will gently suc( out some of the fluid. t is then clamped off and covered with a dressing. ;ou can then go home.

 A district nurse will visit to re)attach the suction bottle to your catheter and drain off some more fluid. This is repeated over 

the ne!t few days, as many times as necessary to drain off all the fluid. "raining the fluid from time to time in this way

helps to encourage the lung to re)inflate and the layers of the pleura to seal together.

;our specialist nurse will teach you, or your helpers, how to loo( after the catheter and suction bottle when you are at

home. 1nce the fluid has stopped draining, you will go bac( to the hospital to have the catheter removed.

Pleurodesis

f the lung re)inflates after the fluid has been drained it may be possible to seal the two layers of the pleura together to

prevent the fluid from building up again. This is (nown as pleurodesis. t can usually be done using drugs called bleomcyin

or tetracycline, or sometimes talcum powder, which are in&ected through the drain.

The doctor in&ects the drug #or talc$ through the drain and then leaves the drain clamped for appro!imately one hour. ;ou

will be as(ed to lie in various positions in the bed, e.g. on your bac(, your front, your left side and your right side, to help

the drug circulate around the covering=lining of the lungs. The drain may then be attached to a suction machine to apply a

small amount of pressure, which encourages the pleura to become sealed together.

8hen the drain is removed, if there was a stitch holding the drain in, it can be pulled together, sealing the hole which is

then covered with a dressing. The stitch is usually removed about a wee( later. Sometimes &ust a dressing is used to

cover the area where the drain has been.

t is possible for the pleural effusion to collect again, and drainage may need to be carried out more than once.

;our doctor may also prescribe chemotherapy or  hormonal therapy to treat the cancer and help prevent the fluid from

building up again.

Additional information

• #sually the fluid will $e drained off fairly slowly% as a sudden release of pressure

in the chest can cause a drop in $lood pressure. ! litre of fluid may $e drained

http://www.cancerbackup.org.uk/Treatments/Chemotherapyhttp://www.cancerbackup.org.uk/Treatments/Chemotherapyhttp://www.cancerbackup.org.uk/Treatments/Hormonaltherapieshttp://www.cancerbackup.org.uk/Treatments/Hormonaltherapieshttp://www.cancerbackup.org.uk/Treatments/Chemotherapyhttp://www.cancerbackup.org.uk/Treatments/Hormonaltherapies

8/18/2019 laxmi mam

7/7

safely as soon as the drain has $een inserted. &ollowing this% drainage should $e

done more slowly. 'our $lood pressure will $e checked during the procedure. 'ou

should let your doctor or nurse know if you feel di((y% sick or light)headed.

• *he chest drain can $ecome $locked although this is rare. *his can sometimes $e

cleared $y changing your position or sitting upright. +ccasionally the drain may

need to $e replaced.• *he drain can $ecome infected. 'ou will ha,e your temperature checked for any

sign that you are de,eloping an infection.

• -f a pleurodesis is necessary this can sometimes cause chest pain for a day or so

after the treatment and you may need to take painkillers.

• -f your drainage tu$e is attached to a $ottle% you will $e a$le to walk a$out with it.

-t is important to $e careful with the $ottle% and it should not $e raised a$o,e the

le,el of the chest% as the fluid could go $ack into your lungs.

References

This section has been compiled using information from a number of reliable sources including@

• +ford *et$ook of +ncology 2nd edition. Souhami et al. +ford #ni,ersity

Press% 2002.

• Cancer and -ts 1anagement 4th edition. Souhami and *o$ias. +ford lackwell

Scientific Pu$lications% 2003.

• Symptom 1anagement in !d,anced Cancer 3rd edition. *wycross and ilcock.

"adcliffe 1edical Press% 200.

http://www.cancer$ackup.org.uk/"esourcessupport/Symptomssideeffects/+thersymptoms

sideeffects/Pleuraleffusion

http://www.cancerbackup.org.uk/Resourcessupport/Symptomssideeffects/Othersymptomssideeffects/Pleuraleffusionhttp://www.cancerbackup.org.uk/Resourcessupport/Symptomssideeffects/Othersymptomssideeffects/Pleuraleffusionhttp://www.cancerbackup.org.uk/Resourcessupport/Symptomssideeffects/Othersymptomssideeffects/Pleuraleffusionhttp://www.cancerbackup.org.uk/Resourcessupport/Symptomssideeffects/Othersymptomssideeffects/Pleuraleffusion