PLEURAL EFFUSION

A pleural effusion is a collection of fluid in the pleural cavity. The fluid may be transudate (as in heart failure), exudate, blood or chyle (lymphatic fluid leaking from the thoracic duct). It occurs most commonly with malignancies of bronchus, breast, lymphoma, ovary and mesothelioma.

Mechanism In normal individuals there is 10ml to 20ml of pleural fluid acting as a lubricant between the parietal pleura (lining the chest wall) and the visceral pleura (covering the lungs). There is a daily flow of about 500ml of pleural fluid. Malignant effusions are mainly due to direct infiltration of the pleura causing capillary damage and leakage of protein, or reduced absorption of fluid due to damaged pulmonary lymphatics. Ascitic fluid can also spread into the pleural space via lymphatic connections crossing the diaphragm.

Prognosis A pleural effusion does not necessarily imply a short prognosis. Median survivals of 6 to 16 months have been reported depending on the primary tumor (bronchus 6 months, breast 14 months, mesothelioma 16 months).

Assessment A pleural effusion may be silent if the fluid accumulates slowly. The usual history is increasing dyspnea over a number of days, sometimes with a dry cough or pleuritic pains (which resolve as fluids separate the pleural surfaces). The typical signs are stony dullness and absent breath sounds. Chest x-ray shows a basal opacity.

Management options:

  1. Leave untreated

  2. Aspiration

  3. Intra-cavity instillations

  4. Talc pleurodesis or pleurectomy

  5. Radiotherapy or chemotherapy

1. A pleural effusion should be left untreated in a patient with advanced metastatic disease (and a known diagnosis) if it is not causing breathlessness.

2. Aspiration of 500ml or more of fluid will often relieve dyspnea but the fluid tends to re accumulate over 1 to 7 days. A simple aspiration under local anesthetic is a useful technique for a patient with advanced disease. It takes 20 to 30 minutes and can safely be performed in the home.

Technique:

  • Stop or reverse any anti-coagulants!

  • Use bupivacaine 0.25%, 5ml to 10ml.

  • Use a small-bore needle or wide gauge IV catheter.

  • Use a 3-way tap and large syringe.

  • Pass on top of a rib (avoid neurovascular bundle).

  • Do not remove more than 1 to 1.5 liters (pulmonary edema).

  • Stop if there is pain, coughing, or dizziness (mediastinal shift).

The procedure is much easier if the needle is preattached to the 3- way tap by a long, flexible plastic tube. This allows the operator to move the 3-way tap without moving the needle in the chest wall.

Sudden removal of fluid can cause pulmonary edema in the rapidly expanded lung.

  Simple aspirations should be performed first in patients with advanced disease, before using instillations.

Aspiration is quick and painless and may relieve dyspnea for several days or until the patient dies. Simple procedures such as aspiration of fluid should be painless. By using plenty of local anesthetic and waiting a few minutes for it to take effect, patients rarely experience discomfort. Some patients dread these simple procedures because they have needlessly experienced a lot of pain when these were previously performed.

3. Aspiration of fluid can be followed by the instillation of either cytotoxics or sclerosants in an attempt to stop the fluid re-accumulating. Intracavity cytotoxics have little effect on tumor cell counts and act as irritants to cause pleural inflammation. Sclerosant agents are inserted via an intercostal drain, which is clamped for 3 to 4 hours and the patient placed in various positions to promote a diffuse pleural response. A variety of agents have been used.

Agent % Control of Effusion
Quinacrine 75
Doxorubicin 73
Tetracycline 71
Bleomycin 55

Thiotepa

27

Instillations can be painful and should only be considered for rapidly recurring effusions in a relatively fit patient. Instillations cause an intended pleurisy with pain and fever for 24 hours. A tetracycline instillation is very painful, and must therefore be mixed with lidocaine.

4. Talc pleurodesis has a 90% success rate and should be considered in patients with a prognosis of 2 to 3 months or more. Large effusions in malignant disease tend to recur rapidly. For patients in good general condition talc pleurodesis or pleurectomy can give a better quality of life than repeated aspirations. It requires general anesthetic and skilled operators. 10g of sterilized talc is insufflated. It is painful for 24 hours and opioid analgesics are required. Two chest drains have to remain in place for at least 4 days post-operatively to allow the pleural surfaces to remain in opposition.

5. Chemotherapy (for breast cancer, small (oat) cell cancer of the bronchus, or lymphoma) may effectively prevent recurrence of a pleural effusion.


The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.


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