 Hello and thank you for watching Nursing School Explained. Today's topic is plurial effusion. So let's look at how this happens. So remember that normally we have about 5 to 15 mL of lubricating fluid between the visceral and the parietal pleura. So these are the different layers that surround the lungs that allow for expansion of the chest and the lungs with inhalation and exhalation so that there's no rubbing against those two cavities and everything happens smoothly. So that's just like oil in a car allows for lubrication and smooth movement. Now an effusion basically means an increased fluid in that space. An effusion can apply to anything. For example, you can have a joint effusion in your knee if you have an injury and that fluid escapes the joint capsule. So an effusion is always an abnormally high amount of fluid in a specific place where it doesn't belong. And so a plurio effusion means an abnormal amount of fluid in the pleural cavity. So normally the way that this fluid is regulated is a nice balance of hydrostatic pressure, oncotic pressure as well as capillary membrane permeability. So what that means is the hydrostatic pressure remember is the pressure that's exerted against the blood vessels by a fluid as well as the oncotic pressure which helps to draw fluid into the blood vessels and that's usually done with the help of plasma proteins such as albumin and then capillary membrane permeability basically meaning how likely is the capillary bed to let things seep through the membrane and regulate the fluid that way. So now when this regulation is out of balance then we'll have a plurio effusion. So this abnormal regulation usually happens because of increased pulmonary capillary pressure, decreased oncotic pressure or increased pulmonary plurio membrane permeability or obstruction of lymphatic flow. That can be another reason. And plurio effusions there are two different types. One of them is exodative and the other one is transudative. So exodative think about exodate as in pus and that usually is because of inflammation. So some sort of inflammation is happening which makes all the inflammatory cells attracted to that site and increases the pleural cavity permeability and that is usually because of infection or malignancy and that fluid is then usually cloudy and yellow thick kind of pus look in exodative type of fluid. Where in transudative plurio effusion those are non-inflammatory conditions that cause that. And so when the hydrostatic pressure increases the blood pressure increases the heart works harder. It causes heart failure and therefore all that fluid is back and up into the lungs causing the plurio effusion as well as when we have decreased oncotic pressure. So decreased blood albumin usually because of liver and renal disorders but will have transudative plurio effusions and that fluid is usually clear and very pale yellow not so inflamed infected looking as in the exodative. And that's just kind of a background so that you understand how these mechanisms happen. And mostly the most common causes for plurio effusions that I've seen in my practice was heart failure, liver failure as well as malignancy so tumors can cause that. So now let's look over here signs and symptoms. So now if we have increased fluid in the pleural cavity where there should be gas exchange the patient is going to be feeling short of breath. They might have a cough remember in a plurio effusion pulmonary edema that cough can be pink and frothy that's kind of a telltale sign. The patient a lot of times will have sharp non-radiating chest pain that increases with inhalation so every time the lungs expand in their pleural cavity it puts more pressure because now that fluid has been displaced and causes pain. The patient will have decreased breast sounds because now we have fluid and not air in that pleural cavity that we can also hear by dullness on percussion. So usually lung percussion should be resonant nice hollow sound but now if we have fluid in that cavity where it doesn't belong it's going to be sounding more dull such as if you're percussing over an organ like the liver. Now diagnostic tests will be chest x-ray or chest cat scan to really see the extent of the pleural effusion and the location specifically and we'll get into that when we talk about treatment. So treatment here is always treating the underlying cause. So if this is due because of heart failure we want to treat the heart failure by getting rid of some of that fluid with administering diuretics as well as placing the patients on a low sodium diet and if it's cancer then we certainly want to treat that cancer in whatever way would be recommended and then in order to get rid of this pleural effusion we a lot of times a procedure called a thoracentesis is recommended and think about synthesis means removal of fluid in this case it's from the thorax so it's a thoracentesis if we have an effusion in the knee then we talked about before so increased fluid in the knee that would be an arthrocentesis so and removal of fluid from the joint so synthesis meaning removal of fluid and so the we this is usually something that the physician the provider will do sometimes it's done in the interventional radiology department and the best position is the patient dangling at the edge of the bed usually supporting themselves over a bedside table so that the intercostal spaces here open up given the physician or the provider easier access to that area and certainly they are going to check the results of the radiology studies to see the location and where they need to put this tool so it is much like the insertion of an IV catheter remember an IV catheter has a needle as well as this plastic cannula so in order to get the needle in the right spot first of all they'll numb the patient up with some local lidocaine and then they will insert the needle into the intercostal space again usually it's on the lower lungs because fluid will usually settle down with gravity and then there's a tube so basically they'll use that needle to guide that tube just into the right space and then they withdraw that needle just like in an IV insertion and the tube will remain in that plural space and that's usually a pretty long tube that is connected to usually a one liter of kind of a vacutainer so that's a similar mechanism as when you get your blood drawn so that this vacutainer just draws the fluid out by creating this negative pressure and sometimes more than one of these vacutainers will be needing depending on the size of that plural effusion now when it's all drained we will have to remove that tube and that will again be the physician or the provider and we'll have to put a sterile occlusive dressing there because it's a direct line into the plural cavity so we want to make sure that we don't cause any infection there from the procedure now keep in mind usually about one liter to 1200 milliliters of fluid are removed it is not really recommended to remove more volume than that because removal of large volumes or rapid removal of fluids remember whenever you lose fluid your overall blood pressure can drop and that is mostly if we are talking about hydrostatic and oncotic pressures here so we're removing some of the fluid we have low albumin already now we're not having enough fluid in the intravascular space causing hypotension patient can also become hypoxemic as well as that pulmonary edema can expand so again it'll be up to the provider or the physician to determine how much fluid they want to drain from that patient's plural space but whenever there's more than this volume keep in mind that you have to stay with the patient and really observe them for these things and nursing care here involves monitoring vital signs after the procedure every vital sign all the five vital signs including pain and for sure the O2 sat and also monitoring the patient for signs and symptoms of respiratory distress and usually because this is considered a semi-surgical it's not really an OR type procedure but like I mentioned it can be done in the interventional radiology department so a lot of times nursing care and monitoring of vital signs involves maybe monitoring the vital signs q5 minutes for the first 15 minutes and then q15 minutes for an hour and then q30 minutes for the next two to four hours so depending on how the patient is doing now this can be done as an inpatient as well as an outpatient basis so some patients who might have this chronically from a lung tumor for example they might come into the interventional radiology department and have this done on a semi-regular schedule so thank you for watching this video on pleural effusion and the mechanisms and pathophysiology if you have need to review these topics of hydrostatic and narcotic pressure I would recommend that you watch my other videos on fluid volume excess and deficit as well as the basic IV fluid videos that explain these principles thank you for watching nursing school explain and I look forward to seeing you again next time