Pleural Disorders: 5/29/2018 1 by Shegaw Z (MSC in Ahn)

Pleural disorders
5/29/2018 BY Shegaw Z(MSc in AHN) 1

Pleural Conditions
• Pleural conditions are disorders that involve the

membranes covering the lungs (visceral pleura) and
the surface of the chest wall (parietal pleura) or disorders
affecting the pleural space.

PLEURISY
• Pleurisy (pleuritis) refers to inflammation of both layers of the
pleurae (parietal and visceral).
• Pleurisy may develop in conjunction with pneumonia or an upper
respiratory tract infection, TB, after trauma to the chest,
pulmonary infarction, or pulmonary embolism; in patients with
primary and metastatic cancer; and after thoracotomy.
• The parietal pleura has nerve endings; the visceral pleura does not.
• When the inflamed pleural membranes rub together during
respiration (intensified on inspiration), the result is severe, sharp,
knifelike pain.

PLEURISY….
Clinical Manifestations
• The key characteristic of pleuritic pain is its relationship to

respiratory movement.
• Taking a deep breath, coughing, or sneezing worsens the pain.
• Pleuritic pain is restricted in distribution rather than diffuse; it

usually occurs only on one side.
• The pain may become minimal or absent when the breath is

held, or it may be localized or radiate to the shoulder or abdomen.
• Later, as pleural fluid develops, the pain decreases.

PLEURISY….
Assessment and Diagnostic Findings
• In the early period, when little fluid has accumulated, a pleural

friction rub can be heard with the stethoscope, only to disappear
later as more fluid accumulates and separates the inflamed pleural
surfaces.
• Diagnostic tests may include chest x-rays, sputum examinations,

thoracentesis to obtain a specimen of pleural fluid for
examination, and less commonly a pleural biopsy.

PLEURISY….
Medical Management
• The objectives of treatment are to discover the underlying
condition causing the pleurisy and to relieve the pain.
• As the underlying disease (pneumonia, infection) is treated,
the pleuritic inflammation usually resolves.
• At the same time, it is necessary to monitor for signs and
symptoms of pleural effusion, such as shortness of breath,
pain, assumption of a position that decreases pain, and
decreased
5/29/2018 chest wall excursion.
BY Shegaw Z(MSc in AHN) 6
PLEURISY….
• Prescribed analgesics.
– Indomethacin (Indocin), a non-steroidal anti-inflammatory
drug (NSAID), may provide pain relief while allowing the
patient to take deep breaths and cough more effectively.
• If the pain is severe, an intercostal nerve block may be

required.

PLEURISY….
Nursing Management
• Because the patient has considerable pain on

inspiration, the nurse can offer suggestions to enhance
comfort, such as turning frequently onto the affected
side to splint the chest wall and reduce the stretching of
the pleurae.
• The nurse also can teach the patient to use the hands or a
pillow to splint the rib cage while coughing.
PLEURAL EFFUSION
• Pleural effusion, a collection of fluid in the pleural
space, is rarely a primary disease process but is usually
secondary to other diseases.
• Normally, the pleural space contains a small amount of

fluid (5 to 15 mL), which acts as a lubricant that allows
the pleural surfaces to move without friction

PLEURAL EFFUSION….
• Pleural effusion may be a complication of heart failure,
TB, pneumonia, pulmonary infections, nephrotic
syndrome, pulmonary embolism, and neoplastic tumors.
• Bronchogenic carcinoma is the most common malignancy

associated with a pleural effusion.

PLEURAL EFFUSION…

Clinical Manifestations
• Usually the clinical manifestations are those caused by
the underlying disease.
• Pneumonia causes fever, chills, and pleuritic chest pain,
whereas a malignant effusion may result in dyspnea and
coughing.
• The size of the effusion and the patient’s underlying lung
disease determine the severity of symptoms.

• A large pleural effusion causes shortness of breath.
• When a small to moderate pleural effusion is present,

dyspnea may be absent or only minimal.
• The severity of the symptoms assessed depends on

the time course of the development of the pleural
effusion and the patient’s underlying disease

Pleural Effusion cont’d
Medical Management
• objectives of treatment are to discover the underlying cause, to
prevent re-accumulation of fluid, and to relieve discomfort, dyspnea,
and respiratory compromise
• Specific treatment is directed at the underlying cause (e.g., heart failure,

pneumonia, lung cancer, cirrhosis).
• If the pleural fluid is an exudate, more extensive diagnostic procedures

are performed to determine the cause.
• Thoracentesis is performed to remove fluid, to obtain a specimen for

analysis, and to relieve dyspnea and respiratory compromise

Pneumothorax
A pneumothorax occurs if air enters the pleural space, producing partial
or complete lung collapse.
Pathophysiology
• During spontaneous breathing, the pleural pressure remains negative in
both inspiration and expiration but increased negativity with inspiration.
• Therefore, airway pressure remains higher than pleural pressure
throughout the respiratory cycle.
• Sudden communication of the pleural space with either alveolar or
external air allows gas to enter, changing the pressure from negative to
positive
• When the pleural pressure increases, the elasticity of the lung causes it to
collapse.
Pneumothorax…
There are two types of pneumothorax:
1. Spontaneous pneumothorax is any pneumothorax that

results from the introduction of air into the pleural space
Primary spontaneous pneumothorax occurs in the absence of

underlying lung disease
• Family history and cigarette smoking are risk factors.
Secondary spontaneous pneumothorax occurs as a

complication of underlying lung disease (eg, COPD, asthma,
Pneumocystis cariniipneumonia, necrotizing pneumonia)

Pneumothorax…
2. Traumatic pneumothorax occurs when the pressure of air in
the pleural space exceeds the atmospheric pressure.
• As pressures in the thorax increase, the mediastinum shifts to the

contralateral side, placing torsion on the inferior vena cava and
decreasing venous return to the right side of the heart
• The most common causes of a traumatic pneumothorax is invasive

procedures and trauma associated with mechanical ventilation

Pneumothorax…
• open pneumothorax, air enters the chest during inspiration and
exits during expiration.
• There may be slight inflation of the affected lung due to a decrease

in pressure as air moves out of the chest.
• In tension pneumothorax, air can enter but not leave the chest.
• As the pressure in the chest increases, the heart and great vessels
are compressed, and the mediastinal structures are shifted toward the
opposite side of the chest.
• The trachea is pushed from its normal midline position toward the
opposite side of the chest, and the unaffected lung is compressed

Clinical manifestation
• Sudden onset of acute pleuritic chest pain localized to the affected
lung.
• shortness of breath,
• increased work of breathing, and dyspnea.
• Chest wall movement may be uneven because the affected side

does not expand as much as the normal (unaffected) side.
• Breath sounds are diminished or absent on affected side.
• Tachycardia and tachypnea

Diagnosis
• A chest radiograph is obtained with the patient in the upright
position.
• In a patient with a tension pneumothorax, the chest film shows

mediastinal shift, ipsilateral(same side) diaphragmatic depression.
• Chest CT may be used to confirm the size of the pneumothorax.
• ABGs are used to assess for hypoxemia and hypercapnia

Management
• Supplemental oxygen is administered to all patients with
pneumothorax because oxygen accelerates the rate of air
resorption from the pleural space.
• If the pneumothorax is 15% to 20%, no intervention is

required, and the patient is placed on bed rest or limited
activity.
• If the pneumothorax is greater than 20%, then a chest tube is

placed in the pleural space, located at the midaxilary line to
assist air removal.
Thoracentesis
• Thoracentesis also known as pleural tap,
– Is an invasive procedure to remove fluid or air from
the pleural space for diagnostic or therapeutic
purposes.
• A cannula, or hollow needle, is carefully introduced into
the thorax, generally after administration of local
anesthesia.
• Recommend site the midaxillary line, in the sixth,
seventh, or eighth intercostal space
Thoracentesis
• Indications
– The most common causes of pleural effusions
• Congestive heart failure
• Cancer
• Pneumonia
• Recent surgery
– Pneumothorax
– Hemothorax

Thoracentesis
• Left-sided Pleural Effusion

Thoracentesis
• Thoracenthesis usually takes 10-15 min but if there is a lot of fluid, it may
take up to 45 minute.
• After thoracentesis, the client may need a chest x-ray to check for any lung
problems.
Complications
– Pneumothorax (3-30%),
– Hemopneumothorax
– Hemorrhage
– Pulmonary edema
– infection

Performing Thoracentesis
• Equipments
– Sterile set containing
• Galipots
• Pair of artery forceps
• Swabs and gauze an a receiver
• Towel with a hole fun striated towel
• Hand towel
• Gloves
• Syringe and needle for local anesthesia
• Glass tube for specimen
• Receiver to collect fluid

• Equipments…
– Clean
• Rubber sheet and towel
• Receiver for used instrument
• Local anesthesia
• Plaster and scissor

PREPROCEDURE CARE
• Verify a signed informed consent for the procedure.
• Pre procedure fasting or sedation is not required.
• Only local anesthesia is used in this procedure, and the gag
and cough reflexes remain intact.
• Administer a cough suppressant if indicated. Movement and
coughing during the procedure may cause deliberating damage
to the lung or pleura.
• Inform the client that although local anesthesia prevents pain as
the needle is inserted, a sensation of pressure may be felt.
• Procedure
– Explain the procedure to the patient
– Bring the equipment to the bedside and screen
– Position the patient
• Sitting up position with the arm on the affected side above the
head in order to extend the inter costal space is preferred.
• He/she may also leaning forward on a pillow on over-bed table,

or can lie on unaffected side with the arm above the head if the
patient can not sit up, in the sitting up position.
• Procedure
– Place rubber sheet and towel behind and

expose the back of the patient
– Open the sterile set and pour the cleansing

solution into the galipot
– Scrub your hand , put glove and clean the area
– Anesthetize the area

During the Procedure
• Vital signs (heart rate, blood pressure, breathing rate, and
oxygen level) are to be monitored during the procedure.
• The patient may receive supplemental oxygen as needed,
through a face mask or nasal cannula (tube).
• Observe the client for signs of distress, such as dyspnea,
pallor, and coughing
• The skin at the puncture site will be cleansed with an
antiseptic solution.
• Don’t remove more than 1000 ml of fluid from the pleural
cavity within first 30 minutes.
Thoracentesis
• Thoracentesis

Nursing Actions after the procedure
• Apply a dressing over the puncture site and position the client
on the unaffected side for 1 hr by elevating the bed 30 degree.
because this position facilitates expansion of the affected lung
and eases respirations
• Record the color, amount and viscosity of the aspirated fluid
• Monitor the client’s vital signs and respiratory status

(respiratory rate and rhythm, breath sounds, oxygenation status)
hourly for the first several hours after the thoracentesis.

Nursing Actions after the procedure
• Encourage the client to deep breathe to assist with lung

expansion.
• The client can usually resume normal activity after 1

hr if no signs of complications are present.
• Obtain a post procedure chest x-ray (check resolution

of effusions, rule out pneumothorax) usually with in 24
hrs.

Complications
Pneumothorax
• It can occur due to injury to the lung during the procedure.
Nursing Actions
– Monitor the client for signs and symptoms of pneumothorax, such as
diminished breath sounds.
– Monitor post procedure chest x-ray results.
Bleeding:
• Bleeding can occur if the client is moved during the procedure

or is at an increased risk for bleeding.
Nursing Actions
• Monitor the client for coughing and/or hemoptysis.
• Monitor the client’s vital signs and laboratory results for
evidence of bleeding (hypotension, reduced Hgb level).
Infection
Nursing Actions:
• Insure that sterile technique is maintained, the client’s
temperature following the procedure.

Water seal drainage system

• Underwater-seal chest drainage is a closed
(airtight) system for drainage of air and fluid
from the chest cavity.

• A chest tube
– Is a flexible plastic tube that is inserted through

the chest wall and into the pleural space or
mediastinum
– It is used to remove air or fluid, or pus from

the intrathoracic space.
– The site of insertion is 5th intercostals space

slightly anterior to mid axilary line
• Chest tube

Cont…….d
• The underwater-seal system is established by
connecting a catheter (chest tube) that has been
placed in the patient's pleural cavity to drainage
tubing that leads to a sealed drainage bottle.
• Air and fluid drain into the bottle, but water acts
as a seal to keep the air from being drawn back
into the pleural space.

Cont……….d
• By keeping the drainage bottle at floor level,
fluid will be prevented from being siphoned
back.
• As air and fluid are drained, pressure on the

lungs is relieved and re-expansion of the lung is
facilitated.

Indications for Chest tube drainage
• To evacuate air or fluid from pleural space
• Pneumothorax > 20 %
• Hemothorax > 500cc
• Pneumohemothorax
• Pleural Effusion
• Fluid collections
• Mechanically ventilated patients with any size pneumothorax or
hemothorax
• Respiratory distress or ventilator dependence that does not permit
thoracentesis
• To Monitor ongoing air leak or blood loss
Contraindications
• Coagulopathy or platelet dysfunction warrants
/caution
• Known or suspected mesothelioma
• Pure tuberculosis effusion
• Mesothelioma is a rare form of cancer that
develops from the protective lining that covers
many of the body's internal organs Its most
common site is the pleura
Underwater Seal
Chest drainage
•Provides means for air

and fluid to escape the
chest cavity
To the drainage
system •Prevents air from re-
entering the pleural
space
•Re-establishes
intrapleural negative
pressure
5/29/2018 •Re-expands the lungs45
BY Shegaw Z(MSc in AHN)
One bottle system
From patient Air out
For small pneumothorax
use only !
Risk of progressive resis-

tance building by
haemothorax.
Water seal
Cont…….d
– Connecting or drainage tubing joins the patient's chest tube
with a drainage tube (glass rod) that enters the drainage
bottle.
– The end of the glass rod is submerged in water, extending

about 2.5 cm (1 inch) below the water level.
– The water seal permits drainage of air and fluid from the
pleural space but does not allow air to reenter the chest.
– Drainage depends upon gravity, the mechanics of

respiration, and, if ordered, the addition of controlled
suction.
Cont…….d.
• The water level in the bottle fluctuates as the patient

breathes. It rises when the patient inhales and lowers
when the patient exhales.
• Since fluid drains into this bottle, be certain to mark the

water level prior to opening the system to the patient.
This will allow correct measurement of patient
drainage.
Two bottle system
From patient
Separation of water seal
Air out and collection in 2 bottles
elliminates the risk of
progressive resistance
building.
No active suction co-

nection recommended.
Collection
bottle
5/29/2018
Water seal
• The Two-Bottle Water-Seal System………ctd
– The two-bottle system consists of the same water-seal bottle
plus a fluid collection bottle.
– Pleural fluid accumulates in the collection bottle, and not in
the water-seal bottle (as in the single-bottle system).
– Drainage depends upon gravity or the amount of suction
added to the system.
– When suction is added, it is connected at the vent tube in the
water-seal bottle.

Three bottle system
Active suction
From patient
Suction control
bottle
Collection
bottle
5/29/2018
Water seal
Three bottle system
• Separated collection, underwater seal and suction
control bottle
• No risk of progressive resistance building
• Exact active suction control

Cont……..d
The Three-Bottle Water-Seal System.

– This system consists of the water-seal bottle, the
fluid collection bottle, and a third bottle which
controls the amount of suction applied.
– The third bottle, called the manometer bottle, has
three tubes.
– One short tube above the water level comes from
the water-seal bottle.
Cont…..d
• The Three-Bottle Water-Seal System.
– A second short tube leads to the suction.
– The third tube extends below the water level and opens to the
atmosphere outside the bottle.
– It is this tube that regulates the suction, depending upon the

depth the tube is submerged.
– It is normally submerged 20 cm (7.6 inches).
– The suction pressure causes outside air to be sucked into the

system through the tube, creating a constant pressure.
– Bubbling in the manometer bottle indicates the system is

functioning properly.
Four bottle system
From patient
Active
suction
Patient
assesment Collection Water seal Suction control
bottleBY Shegaw Z(MSc
bottle bottle
bottle
5/29/2018 in AHN) 55
Four bottle system
From patient
Active
suction
Patient
assesment Collection Water seal Suction control
bottleBY Shegaw Z(MSc
bottle bottle
bottle
5/29/2018 in AHN) 56
Four bottle system
• Separated collection, underwater seal, suction control and
patient assesment bottles
• No risk of progressive resistance building
• Exact active suction control
• Exact information about the situation inside the chest

cavity

Nursing management
• It is important to evaluate the patient’s physical condition, skin
colour, breathing and discomfort.
• The underwater seal chest drain must always be kept below the
patient’s chest level to ensure gravity flow and to prevent a
pneumothorax.
• Ensure you educate your patient to keep their drain below chest
level when mobilizing .
• Asses for subcutaneous emphysema

• A lack of drainage may indicate a clot obstructing the
tube.
• If that occurs, try milking the tube: Starting at the
proximal end, gently squeeze and release it between your
fingers along the length of the tubing.
• However, don't “strip” the chest tube, which means
squeezing the length of the tube without releasing it.
• Once a common practice, stripping the tube causes
dangerous increase in intrathoracic pressure and
doesn't lead to any significant increase in output.
Cont…..d
• Regular pain assessments are required to maintain adequate analgesic relief
from the discomfort and pain caused by chest drains.
 Remember pain is subjective and patients will have individual experiences.
 Inadequate pain relief will delay your patient’s recovery if not treated properly.
 Because Pain prevents coughing, deep inspiration and early mobilization and
will affect pulmonary function.
Mobilization
• It is important to encourage the patient to mobilse, this can be in the form of;
– deep breathing exercises if the patient is bed bound,
– short walks if the patient is more active.
• The movement will help with fluid and air drainage.

• It is important to check the chest tube connections for;
– signs of air leaks, such as “hissing” sounds (sound like letter S)
– Also check the chest tube dressings and
condition of the tube itself, such as position or clotting in
the tube.
– If a tube accidentally pulls out, the insertion site should be quickly
sealed with a petroleum gauze dressing to prevent air from entering
the pleural cavity.
– In order to confirm that your patient’s chest catheter(s) are patent,
temporarily turn suction off and check for oscillation of the patient
pressure float ball in the water seal column coinciding with patient
respiration.

Pleural Disorders: 5/29/2018 1 by Shegaw Z (MSC in Ahn)

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Pleural Disorders: 5/29/2018 1 by Shegaw Z (MSC in Ahn)

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Pleural disorders

5/29/2018 BY Shegaw Z(MSc in AHN) 1

• Pleural conditions are disorders that involve the

5/29/2018 BY Shegaw Z(MSc in AHN) 2

5/29/2018 BY Shegaw Z(MSc in AHN) 3

• The key characteristic of pleuritic pain is its relationship to

• Taking a deep breath, coughing, or sneezing worsens the pain.

• Pleuritic pain is restricted in distribution rather than diffuse; it

• The pain may become minimal or absent when the breath is

• Later, as pleural fluid develops, the pain decreases.

5/29/2018 BY Shegaw Z(MSc in AHN) 4

• In the early period, when little fluid has accumulated, a pleural

• Diagnostic tests may include chest x-rays, sputum examinations,

5/29/2018 BY Shegaw Z(MSc in AHN) 5

• If the pain is severe, an intercostal nerve block may be

5/29/2018 BY Shegaw Z(MSc in AHN) 7

• Because the patient has considerable pain on

• Normally, the pleural space contains a small amount of

5/29/2018 BY Shegaw Z(MSc in AHN) 9

• Bronchogenic carcinoma is the most common malignancy

5/29/2018 BY Shegaw Z(MSc in AHN) 10

5/29/2018 BY Shegaw Z(MSc in AHN) 11

5/29/2018 BY Shegaw Z(MSc in AHN) 12

• When a small to moderate pleural effusion is present,

• The severity of the symptoms assessed depends on

5/29/2018 BY Shegaw Z(MSc in AHN) 13

• Specific treatment is directed at the underlying cause (e.g., heart failure,

• If the pleural fluid is an exudate, more extensive diagnostic procedures

• Thoracentesis is performed to remove fluid, to obtain a specimen for

5/29/2018 BY Shegaw Z(MSc in AHN) 14

1. Spontaneous pneumothorax is any pneumothorax that

Primary spontaneous pneumothorax occurs in the absence of

• Family history and cigarette smoking are risk factors.

Secondary spontaneous pneumothorax occurs as a

5/29/2018 BY Shegaw Z(MSc in AHN) 16

• As pressures in the thorax increase, the mediastinum shifts to the

• The most common causes of a traumatic pneumothorax is invasive

5/29/2018 BY Shegaw Z(MSc in AHN) 17

• There may be slight inflation of the affected lung due to a decrease

5/29/2018 BY Shegaw Z(MSc in AHN) 18

• increased work of breathing, and dyspnea.

• Chest wall movement may be uneven because the affected side

• Breath sounds are diminished or absent on affected side.

• Tachycardia and tachypnea

5/29/2018 BY Shegaw Z(MSc in AHN) 19

• In a patient with a tension pneumothorax, the chest film shows

• Chest CT may be used to confirm the size of the pneumothorax.

• ABGs are used to assess for hypoxemia and hypercapnia

5/29/2018 BY Shegaw Z(MSc in AHN) 20

• If the pneumothorax is 15% to 20%, no intervention is

• If the pneumothorax is greater than 20%, then a chest tube is

– The most common causes of pleural effusions

• Congestive heart failure

5/29/2018 BY Shegaw Z(MSc in AHN) 23

5/29/2018 BY Shegaw Z(MSc in AHN) 24

5/29/2018 BY Shegaw Z(MSc in AHN) 25

5/29/2018 BY Shegaw Z(MSc in AHN) 26

• Rubber sheet and towel

• Receiver for used instrument

• Plaster and scissor

5/29/2018 BY Shegaw Z(MSc in AHN) 27

– Explain the procedure to the patient

– Bring the equipment to the bedside and screen