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Diagnosis and management of
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NS747 Myatt R (2014) Diagnosis and management of patients with pleural effusions.
Nursing Standard. 28, 41, 51-58. Date of submission: February 6 2014; date of acceptance: March 27 2014.
Abstract
Pleural effusions occur when fluid accumulates between the visceral and
parietal pleura in the chest cavity, preventing the lung from expanding
fully during inspiration. The reduction in lung volume, depression of the
diaphragm and reduced chest wall compliance cause dyspnoea, and
occasionally pain or cough. Pleural effusion is a complex problem caused
by a variety of conditions requiring different treatment depending on
the underlying diagnosis. This article discusses the causes and treatment
of pleural effusions, referencing guidelines produced by the British
Thoracic Society.
Author
Rebecca Myatt
Nurse case manager in thoracic surgery, Guy’s Hospital, London.
Correspondence to: [email protected]
Keywords
Dyspnoea, malignant pleural effusion, pleural fluid, pleurodesis,
respiratory disease, respiratory nursing, respiratory symptoms
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Aims and intended learning outcomes
Pleural effusions develop as a result of an
imbalance between fluid formation and
re-absorption in the pleural space (Hooper
et al 2010). This can be a benign indication
of cardiopulmonary disease or may occur
as a result of a malignant process. The most
common causes of pleural effusion in adults
are heart failure, malignancy, pneumonia,
tuberculosis and pulmonary embolism (Light
2002). After reading this article and completing
the time out activities you should be able to:
Describe the anatomy and physiology of the
visceral and parietal membranes, and the
conditions affecting the pleura.
Understand the physiological function of the
pleura and pleural space in health and illness.
Explain the causes, types and symptoms of a
pleural effusion.
Describe the investigations undertaken to
establish a diagnosis of a pleural effusion.
Discuss the nursing care of a patient with a
pleural effusion, considering the physical and
psychological effects on the patient and his
or her family.
List the treatment options for a pleural
effusion and associated complications.
Introduction
To understand the development of a pleural
effusion, a good understanding of the anatomy
and physiology of the lungs and mechanism
of respiration is required. Pleural effusions are
caused by multiple factors, some of which can
be excluded following clinical examination
and history taking, while others require further
investigations which may be invasive. The
june 11 :: vol 28 no 41 :: 2014 51
CPD respiratory nursing
nurse has an important role in assessment and
providing information and reassurance for
patients and their families during what may be
a difficult time.
Complete time out activity 1
Anatomy and physiology of the
respiratory system
The pleura is a thin, double-layered membrane
surrounding the contents of the thoracic cavity
(Figure 1). The parietal pleura lines the inner
surface of the rib cage, superior aspect of the
diaphragm, heart and mediastinum. The
visceral pleura is the inner layer, which covers
the external lung surface and interlobular
fissures (Marieb 2011). The space between the
pleurae is called a potential space because
normally it is so narrow that it is not obviously
a physical space at all (Guyton and Hall 1997).
During inspiration, the muscles of the
diaphragm and external intercostal muscles
actively contract, drawing the lungs upwards
and outwards, increasing the available space
inside the thoracic cavity (interpulmonary
volume) and causing the airways to open.
This causes the interpulmonary pressure to
fall below the atmospheric pressure and air is
drawn into the lungs (Marieb 2011). Separation
of the visceral and parietal pleura is strongly
resisted by a process described as molecular
cohesion pleural coupling. This is similar to the
effect seen when two microscope slides are held
together by a drop of water (Marieb 2011). This
negative intrapleural pressure keeps the lungs
close to the chest wall so that they expand and
recoil passively as the available space inside the
thoracic cavity increases during inspiration and
decreases during expiration (Marieb 2011).
During normal, quiet (resting) inspiration,
the thoracic cavity expands by only a few
millimetres in all directions, yet this is sufficient
to increase the lung volume by almost 500mL of
air (Marieb 2011). The pleural fluid and pleural
space, therefore, have a vital role in ensuring that
the lungs expand fully (Allibone 2006).
Pleural fluid
In health, the pleural space contains
0.1-0.2mL/kg body weight of pleural fluid,
filtered from systemic capillaries down a small
pressure gradient (Rahman et al 2004). Pleural
surface area increases in proportion to body
mass (Zocchi 2002). The pleural fluid prevents
friction occurring between the lungs and the
chest wall during breathing and enables the
52 june 11 :: vol 28 no 41 :: 2014
lungs to accommodate changes in thoracic
configuration (Berne and Levy 1996).
Pleural fluid secretion is greatest at the
apex of the parietal pleura and absorption
is increased towards the diaphragm and
mediastinum (Negrini et al 1985, Miserocchi
et al 1992). Pleural fluid is removed by an
absorptive pressure gradient through the
visceral pleura, by lymphatic drainage
through the stomas of the parietal pleura
and by cellular mechanisms (Zocchi 2002).
It eventually enters the mediastinal lymph
nodes (Rahman et al 2004).
Development of pleural effusion
If the balance between filtration and
re-absorption of pleural fluid is altered, then fluid
begins to accumulate. A number of mechanisms
may be responsible for this, including pneumonia
causing increased pulmonary capillary
pressure; hypoalbuminaemia causing a decrease
in plasma oncotic pressure, which affects
transcapillary fluid dynamics; areas of collapsed
lung tissue (atelectasis) creating a decreased
(more negative) intrapleural pressure; increased
pleural membrane permeability; and obstructed
lymphatic flow, for example pleural malignancy
or infection. Any disruption or obstruction
by tumour cells along the intricate lymphatic
network results in a build-up of fluid (Miserocchi
1997, Rahman et al 2004) (Figure 1).
Classification of pleural fluid
Pleural effusions are classified into transudates
and exudates according to their biochemical
criteria (Rahman et al 2004). A transudative
pleural effusion occurs when the balance of
forces influencing formation and absorption
alters to favour pleural fluid accumulation,
the most common of which is seen in cardiac
failure (Hooper et al 2010). An exudative
pleural effusion develops when either the pleural
surface or the local capillary permeability
is altered, for example in malignant disease
(Light 1997). Generally, transudates occur in
both pleural cavities simultaneously (bilateral
effusions), have a protein content of less than
30g/L and occur as a result of pressure changes
across the pleural membranes. Exudates occur
on one side (unilateral effusion), have a protein
count of more than 30g/L and arise as a result
of pleural disease or altered lymphatic drainage
(Hooper et al 2010).
Understanding whether an effusion is a
transudate or exudate helps to narrow the
© NURSING STANDARD / RCN PUBLISHING
differential diagnosis (Hooper et al 2010).
Aspiration is not always necessary for patients
with transudative pleural effusions because
the effusion will resolve following treatment
(Maskell et al 2003, Mishra and Davies 2010).
Malignant pleural effusions account for
approximately 40% of all exudative pleural
effusions (Mishra and Davies 2010). Table 1
shows the common causes of transudative and
exudative pleural effusions.
Complete time out activity 2
Diagnosis
It is estimated that there are at least 50
recognised causes of pleural effusion,
including diseases of the pleura and
lung; therefore a systematic approach to
investigations is required (Hooper et al
2010). The British Thoracic Society guideline
on pleural disease (Hooper et al 2010)
emphasises the importance of swift diagnosis
with the minimum number of unnecessary
invasive investigations. Prompt treatment is
essential to reduce the likelihood of repeated
therapeutic aspirations (Hooper et al 2010).
Complete time out activity 3
Presenting symptoms
A patient with a pleural effusion will most
commonly present with dyspnoea, cough, and
often pleuritic pain (pain which increases on
inspiration or coughing) or heaviness in the
chest. He or she may experience shortness
of breath at rest as well as during activity
if the effusion is large (Hooper et al 2010,
Bourke and Burns 2011). Dyspnoea is caused
by a combination of reduced chest wall
compliance, depression of the diaphragm
on the affected (ipsilateral) side, mediastinal
shift and reduction in lung volume (Judson
and Sahn 1995). Small effusions may be
asymptomatic and detected during chest
X-ray (Hooper et al 2010). Other physical
complaints associated with respiratory
symptoms include weight loss, malaise and
anorexia (Roberts et al 2010).
FIGURE 1
1 Using a diagram
from an anatomy and
physiology textbook,
think about how you
would describe to
a patient or junior
member of staff the
role of the pleura in
normal breathing. What
happens if there is an
accumulation of fluid in
the pleural space?
Left pleural effusion
Trachea
Left lung
Visceral pleura
2 List the common
causes of pleural
effusions in patients you
have cared for. Divide
these into transudative
and exudative effusions.
Parietal
pleura
Pleural space
(slight negative
pressure -4mmHg
less than atmospheric
pressure)
Diaphragm
© NURSING STANDARD / RCN PUBLISHING
Pleural effusion (accumulation
of excessive fluid, blood or pus
in the pleural space)
PETER LAMB
Right and left
main bronchi
3 Think of a patient
you have cared for with
a pleural effusion. Did
he or she present with
typical symptoms? If
so what were these?
If not, what further
investigations were
required to establish
a diagnosis?
june 11 :: vol 28 no 41 :: 2014 53
CPD respiratory nursing
Clinical assessment
Accurate clinical assessment incorporating
detailed history taking, including details
of medications, combined with a thorough
physical examination can identify the cause
of some pleural effusions, thus eliminating
the need for pleural fluid sampling, unless the
patient fails to respond to treatment (Hooper
et al 2010). This may be the case in left
ventricular failure, pulmonary embolism
and effusions caused by medication (Box 1).
Discussion of the patient’s medical history
should include other health conditions, smoking
habits and employment. Details of known or
suspected asbestos exposure is important, as is
information regarding possible exposure from
parents or spouses, who may have brought
asbestos dust home on their clothes because
mesothelioma can develop following secondary
exposure (Hooper et al 2010, Macmillan
2013). Physical examination of the chest shows
decreased breath sounds on auscultation on
the affected side, reduced transmission of the
voice to the chest wall (vocal fremitus) and stony
dullness on percussion, rather than the resonant
note expected in a normal air-filled lung. Chest
expansion may also be reduced (Bourke and
Burns 2011).
Complete time out activity 4
Diagnostic imaging
Following clinical assessment and physical
examination, a chest X-ray is required to
confirm the diagnosis. Initially, fluid will
accumulate between the diaphragm and
the lower lobe resulting in blunting of the
costophrenic angle at the base of the lung.
A posterior-anterior chest X-ray will provide
a clearer picture of the pleural effusion than
the anterior-posterior approach because an
anterior-posterior chest X-ray allows any free
fluid to lie posteriorly in the dependent portion
of the chest (Hooper et al 2010). Conversely,
the posterior-anterior chest X-ray will appear
abnormal with approximately 200mL of fluid
present (Rahman et al 2004).
Large effusions show almost complete
opacification of the entire hemithorax,
sometimes with shift of the mediastinum
to the opposite side. A lateral chest X-ray
can show posterior costophrenic angle
blunting with as little as 50mL of pleural fluid
(Blackmore et al 1996). A contrast enhanced
thoracic computed tomography (CT) scan
is recommended before full drainage of the
fluid because pleural abnormalities will
BOX 1
Commonly prescribed drugs which can cause
pleural effusions
 Amiodarone.
 Beta blockers.
 Methotrexate.
 Nitrofurantoin.
 Phenytoin.
(Hooper et al 2010)
TABLE 1
Common causes of transudative and exudative pleural effusions
Transudates
Exudates
Left ventricular failure, causing increased
pulmonary capillary pressure.
Malignancy, causing increased pleural membrane permeability with
obstructed lymphatic flow (5% are transudates).
Liver cirrhosis.
Parapneumonic effusions (pneumonia causes increased pulmonary capillary
permeability).
Hypoalbuminaemia, causing decreased plasma
oncotic pressure.
Tuberculosis.
Peritoneal dialysis.
Pulmonary embolism (10-20% are transudates).
Hypothyroidism.
Rheumatoid arthritis, autoimmune pleuritis and systemic lupus erythematosus.
Atelectasis, causing decreased intrapleural
pressure.
Other connective tissue disorder.
Nephrotic syndrome.
Pancreatitis.
Mitral stenosis.
Post-myocardial infarction.
Constrictive pericarditis.
Post coronary artery bypass graft.
Urinothorax.
Drugs, such as amiodarone and methotrexate.
(Light 2002, Rahman et al 2004, Hooper et al 2010)
54 june 11 :: vol 28 no 41 :: 2014
© NURSING STANDARD / RCN PUBLISHING
be visualised, and empyema or underlying
malignancy detected (Hooper et al 2010).
Complete time out activity 5
Management
Following confirmation of a pleural effusion by
history, clinical examination and chest X-ray,
fluid is aspirated to relieve the symptoms and
establish the cause. Current recommendations
are that aspiration is performed under
ultrasound guidance because this increases
the chances of identifying a suitable site for
aspiration, particularly if the effusion is small
(Rahman et al 2007, Hooper et al 2010). This
minimises the need for repeated aspiration and
reduces the risk of organ puncture (Diacon et al
2003, Hooper et al 2010). Ultrasound can also
assist in diagnosis since malignant features can
be distinguished (Qureshi et al 2009).
Pleural fluid aspiration can be uncomfortable
and anxiety provoking for the patient. The nurse
has a significant role in explaining, educating
and reassuring the patient and his or her family.
Current recommendations are that large
pleural effusions are drained gradually with a
maximum of 1.5L being removed at two-hourly
intervals (Roberts et al 2010). This is to prevent
complications associated with the procedure
such as pain, cough or vaso-vagal symptoms
such as tachycardia, hypotension or fainting.
If the patient is diagnosed with a malignant
pleural effusion, treatment options will depend
on several factors, including the symptoms
and performance status of the individual,
the primary tumour and its response to
systemic therapy and most importantly, lung
re-expansion following fluid evacuation
(Roberts et al 2010). The fluid may resolve as
the underlying disease is treated, for example
following chemotherapy for lymphoma
(Tan 2004). Management options include
observation, pleural aspiration, instillation of a
sclerosing agent such as sterile talc to promote
adhesion of the pleurae (pleurodesis) either by a
medical or surgical approach, or insertion of an
indwelling pleural catheter (Roberts et al 2010).
Thoracoscopy
Thoracoscopy is the recommended approach
for patients with symptomatic exudative pleural
effusions without a diagnosis – this procedure is
relatively uncomplicated and pleurodesis is likely
to be required (Hooper et al 2010). During this
procedure, the inside of the chest and pleural
surfaces are visualised using a thoracoscope.
Medical thoracoscopy and therapeutic pleural
© NURSING STANDARD / RCN PUBLISHING
aspiration is performed by chest physicians
with the patient under conscious sedation and
local anaesthesia. Thoracoscopy is a safe and
well-tolerated procedure and complications
are estimated to occur in only 2.3% of cases
(Hooper et al 2010). It is a useful intervention
for patients who have poor respiratory function
or who are high risk for general anaesthesia.
For patients able to tolerate surgical
intervention and general anaesthesia,
video-assisted thoracoscopy is the recommended
intervention (Hooper et al 2010). This procedure
allows visual examination of the hemithorax,
biopsies to be taken, mechanical or chemical
pleurodesis with improved distribution of the
sclerosing agent, as well as assessment of the
potential for full lung re-expansion under
positive pressure ventilation (Tan et al 2006,
Efthymiou et al 2009). Video-assisted
thoracoscopy is generally only performed
in specialist cardiothoracic centres, which
may mean extended travel and hospital
admission. This may be difficult for a
symptomatic patient with a limited life
expectancy (Arber et al 2013).
Pleurodesis
Pleurodesis is the artificial synthesis of the
visceral and parietal pleural surfaces (Mishra
and Davies 2010). Various sclerosing agents
have been used to produce pleural adhesions,
including tetracycline (Fentiman et al 1986),
bleomycin (Zimmer et al 1997) and sterile
iodised talc (Heffner and Klein 2008, Roberts
et al 2010). Current evidence suggests that
talc pleurodesis is the most effective method
of preventing fluid from accumulating again
(Kennedy et al 1994, Roberts et al 2010,
Zahid et al 2011).
The sclerosing agent has an irreversible
physiological effect on the pleura. Following
instillation, an inflammatory reaction occurs
causing local activation of the coagulation
system with fibrin deposition. This creates
adhesions between the visceral and parietal
pleural membranes, which obliterate the
potential space (Antony 1999). This negates the
need for fluid for lubrication, and so the
production and re-absorption of pleural fluid is
prevented and re-accumulation does not occur.
In clinical practice, this process manifests as
pain and pyrexia, which can be uncomfortable
for the patient (Roberts et al 2010). Fever usually
occurs four to 12 hours after instillation of the
sclerosing agent and temperatures of up to
39.8°C have been reported (Kennedy et al 1994).
The nurse has an important role in reassuring
4 What common
investigations are used
to diagnose pleural
effusion? Brainstorm all
the needs and concerns
of patients and relatives
associated with this
diagnostic process, and
rate the needs in terms
of complexity. Prepare a
spider diagram placing
the word diagnosis in
the centre of the page.
Referring to these
needs, discuss with
colleagues what you
could do to help both
the patient and family
during the diagnostic
period.
5 What are the
options for managing a
patient with a pleural
effusion? How does the
care of a patient with a
malignant effusion differ
from that of a patient
with a benign effusion?
june 11 :: vol 28 no 41 :: 2014 55
CPD respiratory nursing
the patient and his or her family that this is
normal and ensuring adequate analgesia is
available. Both the patient and chest drain are
monitored according to local policy. Rotating
the position of the patient following pleurodesis
is not necessary (Roberts et al 2010).
Complications of pleurodesis Both inhalation and
injection of sterile talc are occasionally associated
with the development of adult respiratory distress
syndrome, a form of acute respiratory failure
caused by pulmonary oedema resulting from
endothelial damage as a result of a cascade of
inflammatory events or acute pneumonitis,
inflammation caused by physical, chemical or
allergic processes (Rinaldo et al 1983, Kennedy
et al 1994, Yim et al 1996, Roberts et al 2010,
Bourke and Burns 2011). It has been speculated
that a systemic inflammatory response, talc
impurity or talc emboli may be responsible
for this (Rinaldo et al 1983, Bouchama et al
1984, Kennedy et al 1994, Roberts et al 2010).
Current evidence suggests that talc composed of
larger particles is associated with increased lung
inflammation, therefore the use of graded sterile
talc, with uniform particle size, is recommended
(Maskell et al 2004, Janssen et al 2007).
Malignant pleural effusions
A malignant pleural effusion is associated
with a poor prognosis for patients with cancer,
with a median survival of three to 12 months
(Roberts et al 2010). Recurrence rates following
aspiration is high because the disease affects
the normal mechanism responsible for the
re-absorption to production of pleural fluid
ratio, and consequently the patient may require
repeated pleural aspiration to relieve symptoms
(McAlpine et al 1990). Re-accumulation
of pleural fluid following drainage occurs in
70-100% of patients (Mishra and Davies 2010).
Repeating pleural aspiration is recommended
only for symptomatic patients with a short life
expectancy (Arber et al 2013). Management
of these patients requires close team working
between surgical, medical and palliative
specialists and close collaboration with the
patient and his or her family.
Insertion of an indwelling pleural catheter
In some patients, the use of talc to achieve
pleurodesis may not result in the required
outcome. This is especially true of a lung that
will not inflate sufficiently to allow the pleural
surfaces to adhere to each other (trapped lung)
(Rahman et al 2004). Other patients may
56 june 11 :: vol 28 no 41 :: 2014
have a large effusion, which requires frequent
admission to hospital and repeated drainage.
For these patients, the insertion of an indwelling
pleural catheter is an alternative method of
controlling recurrent, symptomatic effusions
(Roberts et al 2010). This device can be inserted
on a day case basis, as a medical procedure or
surgically during video-assisted thoracoscopy
under general anaesthesia. Video-assisted
thoracoscopy allows clear examination of the
lung, biopsies to be taken and assessment of
the potential for full lung re-expansion under
positive pressure ventilation (Efthymiou et al
2009). The procedure involves use of a 15.5
French silastic catheter, with a one-way airtight
valve in the hub. Once tunnelled beneath the
skin and into the pleural cavity, it can be left in
place indefinitely.
Intermittent drainage into a vacuum
drainage bottle is carried out by a nurse in
either the ward or community. With adequate
training and supervised practice, the patient
or a relative can also learn how to operate
the system. The frequency with which this is
undertaken depends on the amount of fluid
accumulation. Before discharge, the patient
is taught how to connect the sealed vacuum
bottle to the catheter and given an information
pack supplied by the company containing a
record book to document volumes drained,
information leaflets with relevant telephone
numbers and educational support material.
The effect on the pleural space of the foreign
material (silastic catheter) is to stimulate an
inflammatory response. This, combined with
the connection of the vacuum drainage bottle
encourages re-expansion and obliteration of the
pleural space (Roberts et al 2010). Systematic
reviews of the literature have found that the use
of a long-term ambulatory indwelling pleural
catheter provides symptomatic improvement
(Van Meter et al 2010), improved mobility
(Efthymiou et al 2009) and improved quality
of life (Putnam et al 2000, van den Toorn et
al 2005) and causes spontaneous pleurodesis
(Van Meter et al 2010). There is also a shorter
hospital stay and reduction in the proportion of
patients requiring further interventions (Davies
et al 2012). Assisting faster discharge is an
important consideration in a terminally ill
patient because it allows him or her to spend
more time at home (Arber et al 2013).
As with all palliative interventions, the
patient should be informed that the drain
has time-limited benefits. Pleurodesis may be
achieved and the malignant effusion resolved,
however for the patient nearing the end of
© NURSING STANDARD / RCN PUBLISHING
life, knowing which symptoms are related to
approaching death rather than the accumulation
of pleural fluid is a factor which requires
pre-emptive discussion (Arber et al 2013).
Malignant pleural mesothelioma
Those diagnosed with malignant pleural
mesothelioma caused by asbestos exposure
are entitled to compensation from either the
government through the Pneumoconiosis
etc. (Workers’ Compensation) Act 1979 or
the insurance of the company who they were
employed by when exposure to asbestos
occurred (Department for Work and Pensions
2011, Macmillan 2013). There are numerous
local and regional support groups as well as a
national helpline for the charity Mesothelioma
UK providing information in this area.
For those where exposure to asbestos is
not as a result of their work as an employee,
the 2008 Diffuse Mesothelioma Scheme
(Department for Work and Pensions 2011,
Macmillan 2013) allows a one-off lump sum
payment. These individuals include those who
came into contact with asbestos from a relative,
for example when washing work clothes, those
whose exposure cannot be traced but occurred
in the UK, those who lived near an asbestos
factory and have been affected and those who
were self-employed. Patients are recommended
to seek specialist advice as soon after diagnosis
as possible to ensure appropriate recompense.
Currently, claims must be made within three
years of the date of diagnosis of an illness
related to asbestos (Macmillan 2013).
Up to 40% of patients with malignant pleural
mesothelioma may develop malignant seeding,
whereby the tumour grows through the chest
wall at the entry site of surgical instrumentation
or the intercostal tube site (Roberts et al 2010).
Current recommendations to prevent this are
prophylactic radiotherapy for patients who have
undergone a significant breach of the chest wall
such as thoracoscopy, surgery or a large-bore
chest drain (Roberts et al 2010).
References
Allibone L (2006) Assessment
and management of patients with
pleural effusions. Nursing Standard.
20, 22, 55-64.
Antony VB (1999) Pathogenesis of
malignant pleural effusions and talc
pleurodesis. Pneumologie. 53, 10,
493-498.
Arber A, Clackson C, Dargan S
(2013) Malignant pleural effusion
in the palliative care setting.
International Journal of Palliative
Nursing. 19, 7, 320-325.
Berne RM, Levy MN (1996)
Principles of Physiology. Second
edition. Mosby, St Louis, MO.
Blackmore CC, Black WC, Dallas RV,
Crow HC (1996) Pleural fluid volume
estimation: a chest radiograph
prediction rule. Academic Radiology.
3, 2, 103-109.
Bouchama A, Chastre J, Gaudichet A,
Soler P, Gibert C (1984) Acute
pneumonitis with bilateral pleural
effusion after talc pleurodesis. Chest.
86, 5, 795-797.
Bourke SJ, Burns GP (2011)
Respiratory Medicine Lecture Notes.
Eighth edition. Blackwell Publishing,
Oxford.
Cambridge University Hospitals
NHS Foundation Trust (2014)
Breathlessness Intervention Service
(BIS). www.cuh.org.uk/cms/
addenbrookes-hospital/services/
breathlessness-intervention-servicebis (Last accessed: May 22 2014.)
Davies HE, Mishra EK, Kahan BC
et al (2012) Effect of an indwelling
pleural catheter vs chest tube and
talc pleurodesis for relieving
dyspnea in patients with malignant
pleural effusion: the TIME2
randomized controlled trial. Journal
of the American Medical
Association. 307, 22, 2383-2389.
Department for Work and Pensions
(2011) Pneumoconiosis etc. (Workers
Compensation) Act 1979 and 2008
Diffuse Mesothelioma Scheme.
www.gov.uk/government/uploads/
system/uploads/attachment_data/
file/223188/meso_april_2011.pdf
(Last accessed: May 22 2014.)
Diacon AH, Brutsche MH, Solèr M
(2003) Accuracy of pleural puncture
sites: a prospective comparison of
clinical examination with ultrasound.
Chest. 123, 2, 435-441.
Efthymiou CA, Masudi T, Thorpe JA,
Papagiannopoulos K (2009)
Malignant pleural effusion in the
© NURSING STANDARD / RCN PUBLISHING
presence of trapped lung. Five-year
experience of PleurX tunnelled
catheters. Interactive Cardiovascular
and Thoracic Surgery. 9, 6, 961-964.
Fentiman IS, Rubens FD,
Hayward JL (1986) A comparison
of intracavitary talc and tetracycline
for the control of pleural effusions
secondary to breast cancer.
European Journal of Cancer and
Clinical Oncology. 22, 9, 1079-1081.
Guyton A, Hall J (1997) Human
Physiology and Mechanisms of
Disease. Sixth edition. WB Saunders
Company, Philadelphia PA.
Heffner JE, Klein JS (2008) Recent
advances in the diagnosis and
management of malignant pleural
effusions. Mayo Clinic Proceedings.
83, 2, 235-250.
Hooper C, Lee GYC, Maskell N (2010)
Investigation of a unilateral pleural
effusion in adults: British Thoracic
Society pleural disease guideline
2010. Thorax. 65, Suppl 2, ii4-ii17.
Janssen JP, Colier G, Astoul P
et al (2007) Safety of pleurodesis
with talc poudrage in malignant
pleural effusion: a prospective
cohort study. The Lancet.
369, 9572, 1535-1539.
Judson M, Sahn S (1995) Pulmonary
physiologic abnormalities caused
by pleural disease. Seminars in
Respiratory and Critical Care
Medicine. 16, 4, 346-353.
Kennedy L, Rusch VW, Strange C,
Ginsberg RJ, Sahn SA (1994)
Pleurodesis using talc slurry. Chest.
106, 2, 342-346.
Light RW (1997) Diagnostic
principles in pleural disease. European
Respiratory Journal. 10, 2, 476-481.
Light RW (2002) Pleural effusion.
New England Journal of Medicine.
346, 25, 1971-1978.
Macmillan (2013) Financial
Help and Compensation for
Mesothelioma. www.macmillan.
org.uk/Cancerinformation/
Cancertypes/Mesothelioma/
Livingwithmesothelioma/
Financialhelpcompensation.aspx
(Last accessed: May 22 2014.)
Marieb EN (2011) Essentials of
Human Anatomy and Physiology.
Tenth edition. Pearson Education,
San Francisco CA.
Maskell NA, Gleeson FV, Davies RJ
(2003) Standard pleural biopsy
versus CT-guided cutting-needle
june 11 :: vol 28 no 41 :: 2014 57
CPD respiratory nursing
Role of the nurse
6 Now that you have
completed the article,
you might like to write
a practice profile.
Guidelines to help you
are on page 62.
The nurse has an important role in the
investigation, diagnosis and treatment of
a patient with a pleural effusion. Pain and
dyspnoea are frightening, especially when the
cause is unknown. Both the patient and family
require support, education and reassurance,
as well as practical assistance with managing
symptoms. In the case of malignant pleural
effusion, the patient requires additional
help and advice from a respiratory or lung
clinical nurse specialist. Interventions such as
breathing exercises, the use of hand-held fans
on the side of the face, as well as education on
relaxation techniques combined with advice
on diet and managing fatigue can have a
considerable effect on those whose dyspnoea
is affecting their everyday life (Cambridge
University Hospitals NHS Foundation Trust
2014). The patient with a mesotheliomarelated pleural effusion requires specific advice
regarding specialist help for compensation
claims, benefit claims, and information on
local and national support groups.
biopsy for diagnosis of malignant
disease in pleural effusions: a
randomised controlled trial. The
Lancet. 361, 9366, 1326-1330.
Maskell NA, Lee YC, Gleeson FV,
Hedley EL, Pengelly G, Davies RJ
(2004) Randomized trials
describing lung inflammation after
pleurodesis with talc of varying
particle size. American Journal of
Respiratory and Critical Care
Medicine. 170, 4, 377-382.
McAlpine LG, Hulks G, Thomson NC
(1990) Management of recurrent
malignant pleural effusion in the
United Kingdom: survey of clinical
practice. Thorax. 45, 9, 699-701.
Miserocchi G (1997) Physiology
and pathophysiology of pleural fluid
turnover. European Respiratory
Journal. 10, 1, 219-225.
Miserocchi G, Ventuoli D, Negirini D,
Gilardi MC, Bellina R (1992)
Intrapleural fluid movements
described by a porous flow model.
Journal of Applied Physiology.
73, 6, 2511-2516.
Mishra EK, Davies RJ (2010)
Advances in the investigation and
treatment of pleural effusions.
Expert Review of Respiratory
Medicine. 4, 1, 123-133.
National Institute for Health
and Care Excellence (2004)
Guidance on Cancer Services:
Improving Supportive and Palliative
Care for Adults with Cancer.
www.nice.org.uk/nicemedia/
live/10893/28816/28816.pdf (Last
accessed: May 22 2014.)
Negrini D, Pistolesi M, Miniati M,
Bellina R, Giuntini C, Miserocchi G
(1985) Regional protein absorption
rates from the pleural cavity in
dogs. Journal of Applied Physiology.
58, 6, 2062-2067.
Putnam JB Jr, Walsh GL, Swisher SG
et al (2000) Outpatient
management of malignant pleural
effusion by a chronic indwelling
pleural catheter. Annals of Thoracic
Surgery. 69, 2, 369-375.
Qureshi NR, Rahman NM,
Gleeson FV (2009) Thoracic
ultrasound in the diagnosis of
malignant pleural effusion.
Thorax. 64, 2, 139-143.
Rahman NM, Chapman SJ, Davies
RJ (2004) Pleural effusion: a
structured approach to care.
British Medical Bulletin. 72, 1,
31-47.
Rahman NM, Davies RJO, Gleeson FV
(2007) Investigating suspected
58 june 11 :: vol 28 no 41 :: 2014
As well as practical support, the patient and
his or her family require emotional support.
Repeated hospital admissions and movement
between teams may be required, which can be
made easier if the patient has a named contact
or key worker to co-ordinate care, promote
continuity, and provide a point of contact for
help and advice during what can be a difficult
time (National Institute for Health and Care
Excellence 2004).
Conclusion
Pleural effusions have many causes and
some resolve spontaneously while others are
portentous of serious malignant disease. For
the patient, it is a debilitating condition causing
pain, dyspnoea and anxiety. Appropriate
and timely management is essential to ensure
optimum patient outcomes. The nurse is ideally
placed to improve the care and quality of life
for both the patient and his or her family by
providing support and education NS
Complete time out activity 6
malignant pleural effusion. British
Medical Journal. 334, 7586, 206-207.
chronic indwelling pleural catheter.
Lung Cancer. 50, 1, 123-127.
Rinaldo JE, Owens GR, Rogers RM
(1983) Adult respiratory distress
syndrome following intrapleural
instillation of talc. Journal of
Thoracic and Cardiovascular
Surgery. 85, 4, 523-526.
Van Meter ME, McKee KY,
Kohlwes RJ (2010) Efficacy and
safety of tunneled pleural catheters
in adults with malignant pleural
effusions: a systematic review.
Journal of General Internal Medicine.
26, 1, 70-76.
Roberts ME, Neville E, Berrisford RG,
Antunes G, Ali NJ (2010)
Management of a malignant pleural
effusion: British Thoracic Society
pleural disease guideline 2010.
Thorax. 65 Suppl 2, ii32-ii40.
Tan C (2004) Pleurodesis for
malignant effusion. In Treasure T,
Hunt I, Keogh B, Pagano D (Eds)
The Evidence for Cardiothoracic
Surgery. TfM Publishing,
Shrewsbury, 119-129.
Tan C, Sedrakyan A, Browne J,
Swift S, Treasure T (2006) The
evidence on the effectiveness of
management for malignant pleural
effusion: a systematic review.
European Journal of Cardio-Thoracic
Surgery. 29, 5, 829-838.
van den Toorn LM, Schaap E,
Surmonta VF, Pouwa EM,
van der Rijt KC, van Klaverena RJ
(2005) Management of recurrent
malignant pleural effusions with a
Yim AP, Chan AT, Lee TW, Wan IY,
Ho JK (1996) Thoracoscopic talc
insufflation versus talc slurry for
symptomatic malignant pleural
effusion. Annals of Thoracic
Surgery. 62, 6, 1655-1658.
Zahid I, Routledge T, Billiè A,
Scarci M (2011) What is the
best treatment for malignant
pleural effusions? Interactive
Cardiovascular and Thoracic
Surgery. 12, 5, 818-823.
Zimmer PW, Hill M, Casey K,
Harvey E, Low DE (1997)
Prospective randomized trial
of talc slurry vs bleomycin in
pleurodesis for symptomatic
malignant pleural effusions.
Chest. 112, 2, 430-434.
Zocchi L (2002) Physiology and
pathophysiology of pleural fluid
turnover. European Respiratory
Journal. 20, 6, 1545-1558.
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