Pleural Effusion

Introduction The lungs are covered by a membrane, or lining, called

the pleura, which has an inner and outer layer. The inner layer covers the lungs. The outer layer lines the

rib cage and diaphragm, which is a sheet of muscle that separates the chest from the abdomen.

Pleural effusions occur as a result of increased fluid formation and/or reduced fluid resorption. The precise pathophysiology of fluid accumulation varies according

to underlying aetiologies

A common cause of pleural disease is cancer. It is estimated that malignant pleural effusion affects

150,000 people per year in the United States

Pathophysiology of Pleural Effusion Pleural effusions may occur in patients with :• increased capillary permeability caused by inflammation,

infection, or pleural metastasis• increased hydrostatic pressure as results from congestive

heart failure• decreased oncotic pressure from hypoalbuminia• increase in the normal negative pressure (more negative

intrathoracic pressure) secondary to atelectasis• impaired or decreased lymphatic drainage secondary to

obstruction of the normal lymphatic channels by tumor, radiation, or chemotherapy induced fibrosis

Causes of Pleural Effusion

1. •Pleural effusions are quite common and are often due to infections such as pneumonia or heart failure, which is when the heart is not pumping the blood efficiently around the body.

2. •A pleural effusion can also be a symptom of several types of cancer. The effusion can develop if cancer cells have spread into the pleura, where they can lead to irritation and cause fluid to build up.

Clinical Feature of Pleural Effusion

• Patients with pleural effusions usually have dyspnea, cough, and occasional sharp nonradiating chest pain that is often pleuritic

• A history of cardiac, renal, or liver impairment can suggest a transudative effusion

• A history of cancer can be suggestive of a malignant pleural effusion.

Algorithm of Pleural Effusion

Treatment Treatment goals for these patients

should focus on relief or elimination of dyspnea, restoration of normal activity

and function, minimization or elimination of hospitalization, and

efficient use of medical care resources

Medical management, with treatment of the underlying

cause, may be effective in some transudates. For exudates, management may be more

difficult

Malignant Pleural Effusion

In a general hospital setting, 25% of all pleural effusions are malignant. In patients with an existing diagnosis of cancer, this increases to 30 to 70% if the fluid is an exudate.

Malignant pleural effusions are a common

oncologic problem resulting from

accumulation of fluid in the pleural space.

Malignant pleural effusions occur commonly in patients with cancer. The malignancies

responsible for more than 75% of all of pleural effusions in order of

frequency are lung, breast, lymphoma, and ovarian cancer.

Currently, lung cancer is the most common

metastatic tumour to the pleura in men and

breast cancer in women

Clinical presentation

• A history of worsening dyspnea, cough, and/or pleuritic chest pain may suggest a pleural effusion.

• Diminished breath sounds, fremitus, and dullness to percussion on physical examination are suggestive.

• Massive pleural effusions, defined as complete or almost complete opacification of a hemithorax on the chest radiograph

Algorithm of MPE

Goals of MPE Management

• Provide rapid symptom relief • Improve Quality of Life• Minimize :• need for repeat procedures • time in hospital • adverse events

Case Report

Identity

• Name : Mr. N• Age : 52 yo• Address : Tajinan, Malang• Job : buruh tani • No. Reg : 11171386

Patient came to ER on Monday night (14th April 2014) on 10.00 pm

Primary Survey

• A : patent• B : symmetrical, regularly, RR 30 tpm• C : blood pressure 150/100 mmHg; pulse

rate 80 bpm, regular; warm acral; CRT > 2’’; Tax 36,2oC

• D : GCS 456

Pasien dikategorikan dalam P2

Initial Treatment

• A : pertahankan patensi jalan nafas• B : O2 4 lpm via nasal canule• C : IVFD NaCl 0,9% maintenence• D : -

• Male, 52 years old, suffered from left chest pain since 7 months ago and non-radiating

• Cough since 1 month ago, blood (+), dahak (-)• Dyspneu since 1 month ago, and became worsening with

activity. Patient usually sleep with 2 pillows and there is no edema in lower extremity

• Epigastric pain since 1 month ago, became worsening since 10 days ago

• Patient also felt decrease of body weight in 3 months, ± 5 kg

Anamnesa

• 3 hari yll, pasien MRS di RS Cakra Husada, Turen karena nyeri dada. Karena tidak ada alat untuk pemeriksaan pasien dirujuk ke RSSA

• 7 months ago, patient hospitalized in Kepanjen Hospital and didiagnosa tumor paru setelah dilakukan pemeriksaan lab, x-ray

• DM (-) HT (-) Riwayat OAT (-)• Pasien merupakan seorang buruh tani dan merokok

12 batang per hari selama 32 tahun, berhenti 7 bulan yll karena nyeri dada

Secondary Survey

• General appearance : looked moderately ill• Head/neck : an-/- ; ict -/- ; JVP R+0cmH20• Thorax : C/ I = ictus invisible

P = ictus palpable at ICS V MCL (S) P = RHM ~ SL (D) LHM ~ Ictus A = S1S2 single, murmur -, gallop -

P/ I = simetris, retraksi (–)Pa= SF N N N

Pe= S D S D S DAu= v Rh - - Wh - -v - - - -v - - - -

• Abdomen : Flat, Soefl, BU (+) N• Ekstremitas: edema - -

- -

Laboratory FindingLAB VALUE (NORMAL)Hb 11,4 13,4-17,7 g/dL

MCV 88,40 80-96 flMCH 30,60 26,5-33,5 pg

Leucocyte 11.580 3.500-10.000/µLEos / Bas / Neu / Limf / Mon2,7 / 0,1 / 74,4 / 14,2 / 8,3 %

SGPT 30 0-41SGOT 22 0-40

Natrium 135 136-145 mmol/LKalium 2,94 3,5-5 mmol/L

Chloride 114 98-106 mmol/LUreum 26,8 10-50 mg/dl

Creatinine 0,53 0,7-1,5 mg/dlRBG 86 <200 mg/dl

Analysis of Pleural Fluid

ECG

Conclusion

Take home message

• Pleural effusions are a significant public health problem. Patients with pleural effusions are frequently symptomatic with dyspnea and loss of function.

• Emergency physician should diagnosed and then treat underlying disease