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منتدى العناية المركزة والقلب قسم يضم جميع الأمراض والمشاكل التي تندرج تحت تخصص ICCU,CCU




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قديم 11-29-2010, 12:09 AM رقم المشاركة : 1
معلومات العضو
مشرفة منتدى الباطنة والجراحة

الصورة الرمزية همس العيون
-||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
افتراضي Pleural Effusion

Pleural Effusion


Definition

an abnormal accumulation of fluid in the pleural space
Excess fluid results from the disruption of the equilibrium that exists across pleural membranes


Pathophysiology
Pleural effusion is an indicator of a pathologic process that may be of primary pulmonary origin or of an origin related to another organ system or to systemic disease. It may occur in the setting of acute or chronic disease and is not a diagnosis in itself.
Normal pleural fluid has the following characteristics
Clear ultrafiltrate of plasma, pH 7.60-7.64, protein content less than 2% (1-2 g/dL), fewer than 1000 WBCs per cubic millimeter, glucose content similar to that of plasma, lactate dehydrogenase (LDH) level less than 50% of plasma and sodium, and potassium and calcium concentration similar to that of the interstitial fluid.
The principal function of pleural fluid is to provide a frictionless surface between the two pleurae in response to changes in lung volume with respiration
The following mechanisms play a role in the formation of pleural effusion:
Altered permeability of the pleural membranes as inflammatory process, neoplastic disease, pulmonary embolus
Reduction in intravascular oncotic pressure as hypoalbuminemia, hepatic cirrhosis
Increased capillary permeability or vascular disruption as, trauma, neoplastic disease, inflammatory process, infection, pulmonary infarction, drug hypersensitivity, uremia, pancreatitis
Increased capillary hydrostatic pressure in the systemic and/or pulmonary circulation as congestive heart failure, superior vena caval syndrome
Reduction of pressure in pleural space; lung unable to expand as extensive atelectasis, mesothelioma
Inability of the lung to expand as extensive atelectasis, mesothelioma
Decreased lymphatic drainage or complete blockage, including thoracic duct obstruction or rupture as malignancy, trauma
Increased fluid in peritoneal cavity, with migration across the diaphragm via the lymphatics hepatic cirrhosis, peritoneal dialysis
Movement of fluid from pulmonary edema across the visceral pleura
Persistent increase in pleural fluid oncotic pressure from an existing pleural effusion, causing accumulation of further fluid
Iatrogenic causes as central line misplacement

Causes
Your body produces pleural fluid in small amounts to lubricate the surfaces of the pleura, the thin tissue that lines the chest cavity and surrounds the lungs
A pleural effusion is an abnormal, excessive collection of this fluid
Two different types of effusions can develop
Transudative pleural effusions are caused by fluid leaking into the pleural space. This is caused by elevated pressure in, or low protein content in, the blood vessels. Congestive heart failure is the most common cause.
Exudative effusions usually result from leaky blood vessels caused by inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions, and asbestosis

SymptomsChest pain, usually a sharp pain that is worse with cough or deep breaths
Cough
Fever
Hiccups
Rapid breathing
Shortness of breath
Sometimes there are no symptoms


Signs and tests
During a physical examination, the doctor will listen to the sound of your breathing with a stethoscope and may tap on your chest to listen for dullness
The following tests may help to confirm a diagnosis
Chest x-ray
Pleural fluid analysis (examining the fluid under a microscope to look for bacteria, amount of protein, and presence of cancerous cells)
Thoracentesis (a sample of fluid is removed with a needle inserted between the ribs)
Thoracic CT
Ultrasound of the chest


Medical management



Prehospital CareMost commonly, a pleural effusion is an incidental finding in a stable patient
Emergency medical services are required more often be patients with a toxic condition, respiratory distress, or cardiovascular instability
As with any other life-threatening condition, direct initial management toward stabilization of the airway to ensure adequate oxygenation and ventilation
Administer supplemental oxygen to all unstable patients
After airway stabilization, address and support the patient's circulatory status
For any unstable patient, time is a critical factor
Patients in unstable condition require prompt evaluation by an emergency physician because ultimate treatments required for stabilization are not available in the prehospital setting
Upon arrival in the ED, disclosure of physical findings as deviation of the trachea, distended neck veins, absence of breath sounds, muffled heart sounds, peripheral edema, ascites, subcutaneous emphysema is important


Emergency Department Care
On the basis of presentation in the ED, patients with pleural effusions may be stable, requiring hospital admission; stable, not requiring hospital admission; or unstable
Generally, any patient who requires thoracentesis in the ED is admitted to the hospital. When a patient is stable hemodynamically, time may be available to investigate the patient's past medical history
Previous hospitalization and outpatient records and radiographs can be invaluable
Stable patients who do not require admission include those in whom the clinical circumstances clearly explain the effusion and/or prior investigations of the cause were performed, effusions are typical of the disease or asymptomatic, and diagnostic or therapeutic thoracentesis is not required. Such patients include the following
Patients with effusions due to viral pleurisy, with a free pleural fluid level thinner than 10 mm on a lateral decubitus radiograph; asymptomatic patients with pleural effusions associated with systemic diseases such as congestive heart failure, renal disease, and hepatic cirrhosis; patients with small free pleural fluid level <10 mm on the lateral decubitus radiograph pleural effusions after recent (<3 d) thoracic or abdominal surgery; and patients with asymptomatic effusions immediately postpartum
In such patients, thoracentesis is not indicated and can be deferred
Therapy for the specific cause, if indicated, should be initiated, and no improvement occurs after a few days, diagnostic thoracentesis should be performed
Consultation with the patient's primary physician or pulmonologist may be appropriate
Consider the patient's financial circumstances and ability to follow up on an outpatient basis
If early follow-up seems unlikely at an outpatient clinic or with a specialist, clearly instruct the patient to return to the ED for reevaluation in 2-3 days or sooner, if necessary
Document that the patient understands the importance of compliance with the treatment regimen and follow-up
Stable patients requiring admission include most patients with pleural effusion thicker than 10 mm on the lateral decubitus radiograph. Such patients include the following
Patients with no prior history of pleural effusions, patients with parapneumonic effusions who do not appear to have a toxic condition, and patients with a prior history of pleural effusions who have a change in their usual symptoms or effusion
Often, these patients do not require a monitored bed and can be admitted to a regular floor
Although these patients are not in acute respiratory distress, diagnostic thoracentesis is imperative
Thoracentesis need not be performed in the ED if the accepting physician will perform it soon. When the cause of pleural effusion is obvious, initiate appropriate medical therapy (diuretics, antibiotics) in the ED
Simple parapneumonic effusions have a great potential to become complicated effusions or empyemas
Antimicrobial therapy alone is not sufficient for complicated parapneumonic effusions or empyemas; they require tube thoracostomy and antibiotics
The distinction of simple and complicated parapneumonic effusion can be made only after the pleural fluid characteristics are assessed
For parapneumonic effusions, if possible, antibiotics should be instituted after diagnostic thoracentesis during which pleural fluid is analyzed with appropriate microbiologic studies. However, if a delay in thoracentesis is anticipated, antibiotic treatment takes precedence and is preferred to be initiated in the ED
Unstable patients include those in severe sepsis/septic shock, respiratory distress, or cardiovascular compromise due to the effusion
The initial treatment focus should be stabilizing the airway and circulation. Patients with dyspnea or severe respiratory distress should sit, because the seated position increases tidal volume, decreases the work of breathing, and may improve symptoms of congestive heart failure and/or pulmonary edema
Life-threatening traumatic or medical conditions as tension hydropneumothorax, massive effusion with contralateral mediastinal shift, pulmonary embolism, esophageal perforation, traumatic rupture of the thoracic duct, strangulated diaphragmatic hernia must be ruled out
These patients require immediate diagnostic and therapeutic thoracentesis.
Chest tube placement is an appropriate initial diagnostic and therapeutic modality when a hemothoracic mechanism exists
Hemothorax, pneumothorax, and drainage of thick pus at initial diagnostic thoracentesis are the only clear indications for chest tube placement in the ED
Direct the chest tube tip posteroinferiorly with draining blood or pus and superiorly with draining air.
Other conditions, such as complicated parapneumonic effusion, chylothorax, or malignant pleural effusion, may require chest tube placement for definitive treatment; however, a pulmonologist should make this decision after reviewing radiographic and diagnostic findings
The criteria to place a chest tube when pleural fluid has a pH less than 7.00 and/or when the glucose level is less than 40 m/dL applies only to parapneumonic effusions
Pleural fluid in conditions such as rheumatoid effusions, malignant effusions, and TB may have similar characteristics, but these conditions do not require tube thoracostomy
The decision to place a chest tube in a patient with positive Gram staining results, a pleural fluid pH less than 7.0, or a glucose level less than 40 m/dL should be made after consulting a pulmonologist
Infected pleural fluid with bronchopleural fistula is considered a medical emergency. Suspect bronchopleural fistula when a patient with pleural effusion produces a larger amount of sputum especially when lying in one position than that expected from associated pulmonary disease
The presence of an air-fluid level in the pleural space on upright radiographs suggests bronchopleural fistula. Patients with this require immediate diagnostic thoracentesis, antibiotics, and pulmonary consultation
For suspected parapneumonic effusions, initiate antibiotics in the ED
The choice of antibiotics should be based on clinical factors and consistent with guidelines for the treatment of pneumonia
In any patient with chest trauma penetrating or nonpenetrating hemothorax should be suspected. Maintain a high index of suspicion for concomitant pneumothorax with blunt or penetrating traumatic hemothorax
Traumatic hemothorax is an indication for the insertion of a large-bore (36-40F) chest tube
If initial radiographic findings are negative for pneumothorax or hemothorax, a follow-up chest radiograph should be obtained 3-6 hours after the accident
These patients require admission for monitoring
Early consultation with the ICU or surgical teams is an essential part of treatment
All patients with pleural effusions require thorough evaluation in the ED
Ascites should be excluded in patients with pleural effusion
A history of chronic alcohol or drug use, hepatitis, or pelvic neoplasm should heighten suspicion for ascites
In women with undiagnosed pleural effusion and ascites, a pelvic examination is required to exclude large ovarian or uterine masses
When ascites is present, paracentesis with thoracentesis is important for diagnosis similarity of pleural and peritoneal fluid characteristics indicates a common diagnosis of hydrothorax, which almost always is an extension of peritoneal fluid and treatment
Management of pleural effusions associated with ascites is directed primarily toward control of ascites
Maintain a high index of suspicion for concomitant infection. Certain conditions, such as rheumatoid arthritis, congestive heart failure, hepatic cirrhosis, esophageal rupture, and immunocompromise, have a predilection for infection
When patients with these conditions require thoracentesis, Gram staining and culturing of the pleural fluid is important. Gram staining always should be performed by using the sediment of the centrifuged pleural fluid; this method increases sensitivity
With Gram staining, positive findings can provide useful information for initial antibiotic selection in the ED
Negative results do not rule out infection; the ultimate diagnosis depends on culture findings

Nursing management
keep bed rest
Encouraged highly nutritious food
Prepare patient mentally and physically for thoracentesis
Assist physician for the procedure
Implementing the medical regimen.
The nurse prepares and position the patient for thoracentesis and offers support throughout the procedure.
Pain management is a priority, and the nurse assists the patient to assume positions that are the least painful
Frequent turning and ambulation are important to facilitate drainage the nurse administers analgesics as prescribed and as needed
If a chest tube drainage and a water-seal system is used, the nurse is responsible for monitoring the system’s function and recording the amount of drainage at prescribed intervals
If a patient is to be managed as an outpatient with a pleural catheter for drainage, the nurse is responsible for educating the patient and family regarding management and care of the catheter and drainage system.



Expectations prognosis

The expected outcome depends upon the underlying disease

Complications

A lung surrounded by excess fluid for a long time may collapse
Pleural fluid that becomes infected may turn into an abscess, called an empyema, which requires prolonged drainage with a chest tube placed into the fluid
Pneumothorax (air within the chest cavity) can be a complication of the thoracentesis procedure
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قديم 11-29-2010, 10:49 AM رقم المشاركة : 2
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الصورة الرمزية الزعيم احمد
كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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همس العيون

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الزعيم احمد
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قديم 11-29-2010, 02:47 PM رقم المشاركة : 3
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كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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همس العيون


مشكوره على الموضوع الراقي

دمتي ودام قلمك

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قديم 11-29-2010, 02:56 PM رقم المشاركة : 4
معلومات العضو
مشرفة منتدى الباطنة والجراحة

الصورة الرمزية همس العيون
كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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همس العيون

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استمري بالعطاء الجميل والراقي

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قديم 11-29-2010, 02:57 PM رقم المشاركة : 5
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مشرفة منتدى الباطنة والجراحة

الصورة الرمزية همس العيون
كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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المشاركة الأصلية كتبت بواسطة مزيد شحاده مشاهدة المشاركة
همس العيون


مشكوره على الموضوع الراقي

دمتي ودام قلمك

تحياتــــــــــــي
مشكور اخي ع المرور

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قديم 11-29-2010, 03:25 PM رقم المشاركة : 6
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كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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همس العيون

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بارك الله في جهودك ,,


 






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قديم 11-29-2010, 05:08 PM رقم المشاركة : 7
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كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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قديم 11-29-2010, 06:43 PM رقم المشاركة : 8
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مشرفة منتدى الباطنة والجراحة

الصورة الرمزية همس العيون
كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
افتراضي

المشاركة الأصلية كتبت بواسطة غزاوية حرة مشاهدة المشاركة

همس العيون

يسلمووو علي الطرح القيم

بارك الله في جهودك ,,
غزاوية حرة

مرورك انار متصفحي

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قديم 11-29-2010, 06:45 PM رقم المشاركة : 9
معلومات العضو
مشرفة منتدى الباطنة والجراحة

الصورة الرمزية همس العيون
كاتب الموضوع : همس العيون -||- المنتدى : منتدى العناية المركزة والقلب -||- الموضوع : Pleural Effusion
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effusion, pleural
 

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ملف بعنوان ....Pleural Effusion سامر مبارك منتدى العناية المركزة والقلب 34 06-08-2011 11:56 AM
A pleural Effusion ممرض غزاوي منـتـدى البـاطـنـة والـجراحة والحروق 16 02-02-2010 04:59 PM
Pericardial effusion بنت نابلس منتدى العناية المركزة والقلب 18 11-15-2009 02:05 PM


   
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