PLEURAL EFFUSION

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PLEURAL EFFUSION
DEFINITION: Pleural effusion is defined as the collection or accumulation of fluid in the pleural space (cavity) which is secondary to other disease process. It results from excess fluid production or decreased absorption of abnormal collection of fluid in the pleural space of the lungs. When this happens it limits the expansion of the lungs and hence the patient experiences difficulty in breathing. The accumulated fluid is referred to as the PLEURAL FLUID.
The pleural effusion is the most common manifestation of pleural disease. The pleural space is bordered by the parietal and visceral pleurae. The parietal pleural covers the inner surface of the thoracic cavity including the mediastinum, diaphragm and ribs. The visceral pleura envelop all lungs surfaces, including the interlobar fissures. The right and left pleural spaces are separated by the mediastinum.

TYPES OF PLEURAL EFFUSION: There are 2 types of pleural effusions.
1• TRANSUDATIVE PLEURAL EFFUSION : This is the type that is caused by fluid leaking into the pleural space. This is from increased pressure in the blood vessels or a low blood protein count. Heart failure is the most common cause. Chemically, transudate pleural effusions contain less protein and LDH (lactate dehydrogenase) than exudate pleural effusions. Examples of transudate pleural effusions include;
• Congestive heart failure 
• Liver failure or cirrhosis 
• Kidney failure or nephrotic syndrome 
• Peritoneal dialysis
• Extravascular migration of central venous catheter
• Myxedema (advanced hypothyroidism)
• Cerebrospinal fluid leaked into the pleural.
2• EXUDATIVE/ EXUDATE PLEURAL EFFUSION : This is the type that is caused by inflammation of the pleural itself and are often due to disease of the lung. EXUDATIVE effusions are caused by blocked blood vessels, inflammation, lungs injury, and drugs reactions. Examples of exudate causes includes....
• Lung or breast cancer

• Lymphoma

• Pneumonia 

• Tuberculosis 

• Post Pericardotomy syndrome

• Systemic Lupus Erythematous

• Uremia or Kidney failure

• Meigs Syndrome ( Meigs syndrome is defined as the triad of benign ovarian tumor with ascites and pleural effusion that resolves after resection of the tumor)

• Pancreatic pseudocyst

• Ascites

• Intra-abdominal abscess

• Asbestosis ( a lung disease resulting from the inhalation of asbestos particles, marked by severe fibrosis and a high risk of mesothelioma (cancer of the pleura)   and   mesothelioma (Mesothelioma is a malignant tumor that is caused by inhaled asbestos fibers and forms in the lining of the lungs).

 Causes/ predisposing factors of pleural effusion are...
• Pulmonary embolism
• Tuberculosis
• Pneumonia
• Pulmonary infection
• Heart failure
• Smoking and drinking alcohol
• Any previous complaint of hig blood pressure
• History of any contact with asbestos

PATHOPHYSIOLOGY OF Pleural EFFUSION 
Pleural effusion is defined as accumulation of fluid in the pleural space. It is could be caused by TB, pneumonia, witches and wizards, village people, etc 

When there is an accumulation of fluid in the pleural cavity, it leads to increase in the volume of fluid within the pleural space. This increased volume will lead to  compression of nerves manifesting as CHEST PAIN and DIFFICULTY IN LYING FLAT. Chest pain will lead to SHORTNESS OF BREATH (bradypnea) and RAPID BREATHING (tachypnoea) . If the fluids formed within the pleural cavity becomes infected, the microorganisms could find its way into the systemic circulation which brings about FEVER and CHILLS. DYSPNEA and COUGH occur due to the compression of the lung by the effusion.

SIGNS AND SYMPTOMS OF PLEURAL EFFUSION....
1• Dyspnea 
2. Cough
3. Hiccups
4. Shortness of breath
5. Rapid breathing
6. Fever
7. Chest pain
8. Difficulty in lying flat
9. Chills
Shortness of breath when lying flat (orthopnea)
10. Paroxysmal nocturnal dyspnea
11. Hemoptysis (especially when the pleural effusion is caused by tuberculosis).

DIAGNOSTIC EVALUATIONS
1. Physical examination - this is done by listening to the sound of the lungs with a stethoscope (auscultation) and percussion (tapping) the chest and the upper back . 
2. CHEST CT SCAN OR CHEST X-RAY: This May be enough for your health care provider to decide on the line of treatment to follow as it is able to reveal the structures involved. 
3. FLUID ASPIRATION FOR CULTURE AND SENSITIVITY : Needle aspiration may be done by inserting a needle between the intercoastal spaces of the ribs. Tests on the fluid will be done to look for infection, cancer cells and protein levels.
4. Blood tests that may be down include: Complete blood count to check for signs of infection or anaemia, also kidney and liver function blood tests.
5. Echocardiography to look for heart failure 
6. Urine protein testing
7. Lung biopsy to look for cancer.

Other diagnostic evaluation includes; 
1. Pleural fluid analysis
2. Thoracocentesis   
3. Thoracic CT

MANAGEMENT OF PLEURAL EFFUSION.
The goal of treatment is to: 
1. Remove the fluid
2. Prevent fluid from building up again
3. Determine and treat the cause of the fluid buildup
 Since pleural effusion May compromise breathing, the ABC (Airway, Breathing , and Circulation) of resuscitation are often the first consideration to make certain that there is enough oxygen available for the body to function. 
 The treatment of pleural effusion usually requires that the underlying illness or disease is treated and controlled to prevent accumulation of the pleural fluid. For patients with pleural-effusion-related breathing problems, this may include the following;
1. THORACENTESIS: Therapeutic thoracentesis May be fine if the fluid collection is large and causing chest pressure, shortness of breath, or other breathing problems such as low level oxygen . Removing the fluid allows the lungs to expand, making breathing easier. 
2. CHEMICAL PLEURODESIS: This procedure involves the insertion of agents such as talc or bleomycin to eliminate the pleural space altogether so that fluid can no longer build up.
3. PLEURAL DECORTICATION: Also called pleurectomy, this surgery removes the pleural, like chemical plerodesis, pleural decortication eliminates the pleural space thereby preventing pleural fluid from building up.
4. PLEURECTOMY: This is an operation to remove the pleural. It is sometimes used in people with effusions due to cancer when other treatment options have failed.
5. If it is due to heart failure, you may receive diuretics (water pills) and other medications to treat heart failure.
6. If it is due to infection, antibiotics will be given.

POSSIBLE COMPLICATIONS OF PLEURAL EFFUSION....
1. Lung damage
2. Infection that turns into an abscess called an EMPYEMA
3. Air in the chest cavity (pneumothorax) after drainage of the effusion.
4. Pleural thickening ( scarring of the lining of the lungs).

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