Pleural effusion diagnosis and treatment

So if somebody has a pleural effusion, and this is what we're looking at right here, we're looking at a set of lungs with a pleural effusion, we're going to know that something is wrong based off of a couple of signs and symptoms that we'll collect from the patient. So just to kind of revisit what a pleural effusion is, remember that we have our lung, right? Our lung sits in this sac, this is called our visceral pleura which is this darker color pink that we have. And then on the outside of that, we have a lighter pink color and that sac or that membrane is actually called the parietal pleura. The effusion is the buildup of fluid in between, and that's our pleural space. And imagine what the problem would be with this. What do you think a patient would complain about if they had a buildup of fluid in their pleural space? So we can see it's really cramping up the available room of the lung. So some of the things that they're going to complain about is going to be some chest pain, right? Certainly chest pain. Especially as they are trying to breathe in, as they're trying to inhale, because there's not enough space for the lung to expand. And we call that pleurisy. And that's when you have that chest pain when you're trying to inhale. They might be having some difficulty breathing. So that would be our dyspnea. We could even see that this person has a dry cough. And I make a point to say dry cough, because the fluid that we have accumulating in this space is really on the outside of the lung. It's not on the inside where our air space is, it's on the outside. So that dry cough, we're not bringing up anything, essentially because there's nothing to bring up. There's nothing that we can clear. However our lungs are still going to try to compensate to make room by coughing, as if it could clear out something. So our first thing would be the clues, right? Would be our clue. So I'm going to just actually come over here and I'm going to write our clues and the clues really are our signs and symptoms. So S-S. And that's going to lead us to believe that there is something going on with this patient. So if we suspect, you know what, there's something going on in this guy's lungs, we've really got to check this out. There's a couple things that we can do. One of the early things that we can do is actually to do a chest x-ray. So we could do a chest x-ray and that really is just looking at the lungs. So I'm drawing a box around the lungs. So you can imagine that this is a picture. And that would be a chest x-ray. And that's going to give us a visualization so we can see if there's fluid in there. And here's what a picture of a chest x-ray might look like of a patient that had a pleural effusion. Now imagine this patient is lying down on their side. So this would be a side view of this chest x-ray. And what we can see is that we're able to see the ribs, and I kind of draw this out, and we can see that this is their heart or cardiac segment here, and then this would be part of their arm, this is their diaphragm, so on this side what you're looking at here, and let me just kind of highlight this in a better color, on this side, this would be our normal lung. This is a normal space. So we see the darker color because that represents air space. But on this side, you see that there's less air space. And we have a lot more of what looks like to be a more solid type of dense area and this dense area is actually the effusion. So when you're looking at a chest x-ray, you see that this is the effusion that's happening here. The reason why you see it on the side is because the patient is lying on their side. So that's gravity. If this patient were sitting straight up, then you would see the fluid at the bottom. Just like if they were perhaps lying on their other side, you would see the fluid lying along the sternal border. So that's something to look out for in a chest x-ray. Another thing that we could do is we can do a CT scan. And both a chest x-ray and a CT scan will give us an image of the lungs. A CT scan is just going to give us a little bit more of a detailed image. So we would do some diagnostics. Diagnostics, that's what these fall under. Now in addition to that chest x-ray and that CT scan, we could do some further tests. Perhaps we think that this person has an infection, so we want to do like a blood culture and the blood culture really is just taking a sample of the blood, so let's say that this is my blood drop here, taking a sample of the blood to figure out if there is any type of infection that's happening inside that blood and what we need to do to kill that infection. But really, based off of that chest x-ray and based off of that CT scan, we should be able to see if there is, in fact, fluid in the lung. So if there is now, well what do we do? So our first choice of a treatment, and let me get back my color here, would be to do a thoracentesis. And I'm writing these words down because they're pretty big words, and they're not something that we use every day. So a thoracentesis, and what a thoracentesis is, is really going in to this space. So going in to this pleural space, and I'm going to pick a color that we can see brightly. So let's go with yellow. What we do is we take a needle and we insert the needle into the pleural space and we can actually aspirate or withdraw the fluid from that needle. And how that works is we'll insert the needle, so here's my yellow needle going into the pleural space, and we're going to withdraw the fluid and the needle is attached to tubing and that tubing is either going to be connected to some kind of collection bag, so a collection bag to collect the fluid, or it could be connected to a glass container. And that just really depends on the facility and whoever is doing the procedure. So we can actually collect the fluid, so the fluid is going to collect into the bag. And we want to make sure that we collect it because we want to test it later to figure out what type of fluid it is. Is it transudative or is it exudative. And that's going to give us an idea of kind of where it came from. Now what we do with thoracentesis, we actually are going to have the patient sit upright. So this patient is going to be sitting upright on the edge of their bed, so it's done in their room, and they're going to be kind of draped over the bedside table. So that's what I'm drawing here is the table. They're going to have their hands draped over the bedside table, and their arm, and we're actually going to enter into that pleural space from behind the patient. So the patient's awake for this, right? We're definitely going to give them something so they feel comfortable, so they're not going to experience pain. And we also do this ultrasound guided. So I'm writing US guided. And that's important, that way we can see exactly where we're going because we don't want to hurt the patient or any of the tissue. And so what we'll do with the thoracentesis, just extract all that fluid, collect it and test it. Other things that we can do, these would be more invasive procedures, but other things we can do, we can do something called a pleurodesis. Pleurodesis. Now if somebody has recurrent pleural effusions, meaning it's happening over and over and over again, we can do something called a pleurodesis. And what that is, is that we're going to go into that same pleural space, and let's use this lung, and what we're going to do is we're going to introduce some type of medication or some type of irritant. And that's really going to cause irritation inside of there. And the goal is, is that irritation is going to cause some sort of tissue damage essentially. And as the tissue heals, and you see me scribbling in the space, as the tissue heals, scar tissue is going to develop, and these two membranes, these two pleuras, right? We have our visceral and we have our parietal, they're going to adhere together, they're going to stick together, and what that does, is that that closes out this potential space that we had in here, and if we can close out that potential space, well then we take away the chances of having a pleural effusion. Again, this would be for somebody that really has a recurrent issue with this pleural effusion. Now sometimes this can actually reverse itself. So meaning that the spaces can separate and you might end up with a pleural effusion again. So this is a pretty invasive procedure that we do for those that really suffer from it very often. Now another thing that we can do, that's more invasive as well, would be a pleuroperitoneal shunt. And as the term suggests, we would actually put in some type of drainage device into the pleural space, and where we have this pleural effusion. So you see where I have my needle, where I did my thoracentesis, we can put in a shunt. So imagine now that this needle has turned into a drainage device. And we can have this actual shunt, we can have it redirect. So I'm going to follow it somewhere else. We can have it redirect into our peritoneal space. And when we talk about our peritoneal space, we're really talking about the space that's in our abdominal cavity. So let's pretend this is our abdominal cavity. And the fluid that's in here, the fluid that's in the pleural space will empty into this peritoneal cavity and it will be absorbed and excreted out through there. So our thoracentesis would be our first line of treatment as far as to get rid of the fluid, and then pleurodesis or peritoneal shunting, pleuroperitoneal shunting, those would be more invasive procedures for someone that really has been suffering from this a lot. Now when you're dealing with things like pleural effusion, we always want to treat the underlying cause. So if there's an infection, think about giving antibiotics for it. If there's a malignancy, something that's cancerous like a tumor, that perhaps is causing a blockage in the lymphatic system, so we can't drain fluid properly and that's how we got it, well then we want to treat the malignancy. So chemotherapy might be appropriate as well. Now it's really, really important that we treat a pleural effusion. Now why? Let's go back to our image here. If we leave a pleural effusion untreated, over time it can turn into an empyema. So let's write that word down. I'm going to write it in a different color. It can become an empyema. So now you see where we're building up a vocabulary of some big words. Now an empyema essentially is an infection of this fluid. And what happens is that early on empyema is going to turn into pus-like, right? So I'm going to start drawing some other colors in here. It's going to get pus-like and it'll be easy flowing early on, but if we leave it alone, this infection is going to cause an inflammatory response And as such we can end up with scar tissue in our lung area, and around all of our pleural spaces here, pleural membranes. We'll end up with scar tissue. And it can start to, you see how it's making these rooms, it can start to loculate, which means that they're kind of blocking off areas of this pleural effusion. And as these are loculated, or kind of put into their own rooms, their own cavities, they're going to become less fluid-like and more hard. And it's going to become like cottage cheese consistency. And as that happens, we call that organizing. Because it's organizing into this new form, not organizing like clean, that's not what's happening. And once they've loculated and they've organized, well now it's really hard to get to. It's difficult to drain and it's difficult to treat. And this infection can actually spill over into our blood vessels, and cause some serious damage. Because remember, we actually have blood vessels, right? That run all along our lungs and if this infection gets into contact, and I'm just going to draw some blue ones too, if this infection gets into contact with our blood vessels, it can get into our circulatory system and we can become septic. So treating it early on is a very important thing to do.