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Pleural Disorders - Coggle Diagram
Pleural Disorders
Anatomy & Physiology of Pleural
Pleurisy/Pleuritis
Inflammation of both layers of the pleurae (parietal & visceral)
Etiology
Hyperacute onset (minutes to hours)
Emergencies such as pneumothorax, acute coronary syndromes, pulmonary emboli, acute pericarditis, and chest wall trauma
Acute (hours to days)
Viral and bacterial pneumonia
Subacute (days to weeks)
Rheumatoid arthritis, malignancy, or tuberculosis
Pathophysiology
Inflammation
(Caused by infections, autoimmune conditions, or irritants, leading to roughening of the pleural surfaces)
Pain
(The parietal pleura has sensory nerves, and inflammation triggers sharp, localized chest pain that worsens with breathing, coughing, or movement)
Pleural Friction Rub
(The inflamed surfaces may produce a "pleural friction rub" sound during respiration, detected through auscultation)
Pleural Effusion
(Inflammation can cause excess pleural fluid accumulation, leading to pleural effusion, which may cause discomfort, dyspnea, and reduced lung expansion)
Release of Inflammatory Mediators
(Cytokines, prostaglandins, and leukotrienes contribute to the inflammation, pain, and potential fluid build-up)
Clinical Manifestation
Exacerbated by respiratory movements, coughing, sneezing, or chest wall/trunk movement
Pain also can be dull aching, burning, or simply as a “catch"
Sharp and localized thoracic or shoulder pa
Diagnostic Evaluation
History
Underlying medical history
Social history: travel history, tobacco/electronic cigarette use, alcohol use history, illicit (specifically intravenous) drug
Onset, duration, and progression of symptoms
Physical Examination
Diminished breath sounds
Percussion: Dullness
Auscultation: Pleural rub can be heard during inspiration
Palpation: may also be palpable
Investigation
CXR
Cytology for pleural fluid: TRO malignant
Complications
Parapnuemonic effusions and empyemas
→ pleural thickening → trapped lung
Recurrent pneumonia
→ bloodstream infections
Malignant effusions
→ pleural thickening and fibrosis → restrictive lung disease
Pulmonary emboli
→ pulmonary hypertension → chronic dyspnea, exertional intolerance, or hypoxemia
Medical Management
Monitor for signs and symptoms of pleural effusion/pneumothorax
Analgesic: NSAID
Treat the underlying condition causing the pleurisy
Nursing Management
Turning frequently onto the affected side to splint the chest wall and reduce the stretching of the pleurae
Teach the patient to use the hands or a pillow to splint the ribcage while coughing
Pain on inspiration: offer suggestions to enhance comfort
Aminah, 22-year-old patient admitted to ward due to pleuritis. Her vital signs: T: 37.6 C, P: 110/min, R: 32/min, BP: 158/78mmHg, Pain score: 8/10. Form nursing care plan for Aminah
Pleural Effusion
Collection of fluid in the pleural space/cavity (between parietal & visceral pleura)
General Etiology
Parenchymal disease (e.g., infection, malignancy, or inflammatory conditions)
Rare: pulmonary embolism, drug-induced
Idiopathy
Types of Effusion
Transudates
Alter the hydrostatic or oncotic pressures in the pleural space
E.g., congestive left heart, failure, nephrotic syndrome, liver cirrhosis, hypoalbuminemia, and initiation of peritoneal dialysis
Exudates
Pulmonary infections, malignancy, inflammatory disorders (e.g., pancreatitis, lupus, rheumatoid arthritis), post-cardiac injury syndrome, chylothorax (due to lymphatic obstruction), hemothorax and benign asbestos pleural effusion
Pathophysiology
Imbalance of Fluid Dynamics
(a small amount of fluid lubricates the pleura, but an imbalance leads to excess accumulation)
Decreased Oncotic Pressure
Low blood protein levels (e.g., in liver cirrhosis, nephrotic syndrome) reduce fluid retention, leading to leakage
Increased Capillary Permeability
Infections, inflammation, and malignancies make capillaries more permeable, allowing fluid and proteins to escape
Increased Hydrostatic Pressure
Conditions like congestive heart failure cause fluid to leak into the pleural space
Obstructed Lymphatic Drainage
Tumors or other conditions can block lymphatic channels, preventing normal fluid removal
Types of Pleural Effusion
Transudative
Due to systemic issues like heart failure, liver cirrhosis, or renal conditions, leading to a fluid that is low in protein
Exudative
Caused by local factors like infections (pneumonia, tuberculosis), malignancies, or autoimmune diseases, resulting in a fluid that is rich in proteins and cells
Fluid Accumulation
Excess fluid compresses the lung, reducing its expansion
Can lead to symptoms like dyspnea (shortness of breath), chest pain, and reduced gas exchange, causing hypoxemia
Clinical Manifestation
Exertional breathlessness
Cough, fever, and systemic symptoms (depending of the cause)
Asymptomatic
Diagnostic Evaluation
History
Underlying pulmonary or systemic cause of the effusion
Physical Examination
Percussion: Fullness of intercostal spaces and dullness on percussion on that side
Auscultation: Decreased breath sounds, egophony
Radiography
CXR
Ultrasound-aided in thoracentesis
Laboratory Investigation (Pleural Fluid)
pH, fluid protein, albumin and LDH, fluid glucose, fluid triglyceride, fluid cell count differential, fluid gram stain and culture, and fluid cytology
hprotein, hLDH, and iglucose: Exudates
LDH > 1000 U/L: ?tuberculosis, lymphoma, and empyema
pH < 7.2: complex pleural, esophageal rupture, rheumatoid arthritis
Medical Management
Chest tube drainage/thoracentesis – not more than 1500mls/attempt to avoid re-expansion pulmonary edema
CXR post thoracentesis - residual fluid, pneumothorax
Treat underlying cause
Surgery
Thoracentesis
Pre-Procedure
Prepare equipment, medication, laboratory form/CXR (wet films), ultrasound machine
Emotional support
Consented doctor/patient – explained the procedure and risk
Vital signs
Position patient – sit up
Remove any clothing, jewelry, or other objects that may interfere with the procedure
During Procedure
Emphasized patient NOT to cough during insertion of needle
Provide supplemental oxygen as per Dr’s ordered
Vital signs
Observe the client for signs of distress, such as dyspnea, pallor, and coughing
Emotional support
Post-Procedure
Position patient
Observe changes in the patient’s cough, sputum, respiratory depth, and breath sounds, and note complaints of chest pain
Pressure dressing
Observe puncture site for bleeding and others drainage
Vital signs