1. 1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 23 Effusion and Empyema Chapter 23 Pleural Effusion and Empyema

2. 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 23-1. Right-sided pleural effusion. FA, Fluid accumulation; DD, depressed diaphragm; CL, collapsed lung (partially collapsed). Inset, Atelectasis, a common secondary anatomic alteration of the lungs. DD FA CL

3. 3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.   Lung compression   Atelectasis   Compression of the great veins and decreased cardiac venous return Anatomic Alterations of the Lungs

4. 4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Etiology Common Causes of a Transudative Pleural Effusion   Congestive heart failure   Hepatic hydrothorax   Peritoneal dialysis   Nephrotic syndrome   Pulmonary embolus

5. 5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Common Causes of An Exudative Pleural Effusion   Malignant pleural effusions   Malignant mesotheliomas   Bacterial pneumonias   Tuberculosis   Fungal disease   Pleural effusion resulting from diseases of the gastrointestinal tract   Pleural effusion resulting from collagen vascular diseases Etiology (Cont’d)

6. 6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Other Pathologic Fluids that Separate the Parietal from the Visceral Pleura  Empyema  Chylothorax  Hemothorax Etiology (Cont’d)

7. 7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with Pleural Effusion The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by  Atelectasis

8. 8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

9. 9 Clinical Data Obtained at the Patient’s Bedside

10. 10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination  Vital signs  Increased Respiratory rate (tachypnea) Heart rate (pulse) Blood pressure  Chest pain/decreased chest expansion

11. 11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination (Cont’d)  Cyanosis  Cough (dry, nonproductive)

12. 12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination (Cont’d)  Chest Assessment Findings  Tracheal shift  Decreased tactile and vocal fremitus  Dull percussion note  Diminished breath sounds  Displaced heart sounds  Pleural friction rub (occasionally)

13. 13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

14. 14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or      IC FRC TLC RV/TLC ratio    N

15. 15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Small Pleural Effusion) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2    (slightly)     (slightly) 

16. 16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

17. 17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Large Pleural) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) pH PaCO 2 HCO 3 PaO 2 pH PaCO 2 HCO 3 PaO 2    (Slightly)     (Slightly) 

18. 18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

19. 19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices (Large Pleural Effusion) Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2 Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2   N  (Severe)     N  (Severe)  

20. 20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Large Pleural Effusion CVP RAP PA PCWP CO SV CVP RAP PA PCWP CO SV             SVI CI RVSWI LVSWI PVR SVR SVI CI RVSWI LVSWI PVR SVR            

21. 21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest Radiograph  Blunting of the costophrenic angle  Fluid level on the affected side  Depressed diaphragm  Mediastinal shift (possibly) to unaffected side  Atelectasis  Meniscus sign

22. 22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 23-2. Right-sided pleural effusion (small black arrow) complicated by a pneumothorax (large white arrow).

23. 23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure 23-3. Subpulmonic pleural effusion. Right lateral decubitus view. Subdiaphragmatic fluid has run up the lateral chest wall, producing a band of soft tissue of water density (meniscus sign). The medial curvilinear shadow (arrow) indicates fluid in the major fissure.

24. 24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of Pleural Effusion   The management of each patient with pleural effusion must be individualized   Should a thoracentesis be performed?   Can the underlying cause be treated?   What is the appropriate antibiotic   Should a chest tube be inserted?   Examination of pleural fluid may be needed to assess: Transudate Exudate

25. 25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PLEURODESIS   Chemical or medication injected into the chest cavity   Talc   Tetracycline   Bleomycin sulfate   Produces inflammatory reaction between lungs and inner chest cavity   Causes lung to stick to chest cavity General Management of Pleural Effusion (Cont’d)

26. 26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Oxygen Therapy Protocol  Lung Expansion Therapy Protocol  Mechanical Ventilation Protocol Respiratory Care Treatment Protocols