RET013 Cardiopulmonary Pathology Student Activity Sheet (PDF)

RET013 (CARDIOPULMONARY PATHOLOGY) STUDENT ACTIVITY SHEET BS RESPIRATORY THERAPY / THIRD YEAR Session # 8 LESSON TITLE: PLEURAL EFFUSI...

RET013 (CARDIOPULMONARY PATHOLOGY) STUDENT ACTIVITY SHEET BS RESPIRATORY THERAPY / THIRD YEAR Session # 8 LESSON TITLE: PLEURAL EFFUSION AND PLEURISY Materials: Pen, paper, index card, book, and class List LEARNING OUTCOMES: Reference: At the end of the lesson, the respiratory therapy student can: Des Jardins, T. (2016). Clinical Manifestations And Assessment of Respiratory Disease (7th 1.List the anatomic alterations of the lungs associated with ed.). pleural diseases; 2. Describe the causes of pleural diseases; 3. Discuss the cardiopulmonary clinical manifestations St. Louis, Missouri: Cengage Learning. associated with pleural diseases; and, Loscalzo, J. (2010). Harrison’s Pulmonary and 4. Outline the general management of pleural diseases. Critical Care Medicine. USA: The McGraw-Hill Companies, Inc A. LESSON PREVIEW / REVIEW Instruction: Differentiate HAP and CAP. (Refer to session 7 for answers.) _________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ B. MAIN LESSON The instructor should discuss the following topics. Instruct students to take down notes. Anatomic Alterations of the Lungs A number of pleural diseases can cause fluid to accumulate in the pleural space; this fluid is called a pleural effusion, or, if infected, an empyema. Similar to free air in the pleural space, fluid accumulation separates the visceral and parietal pleura and compresses the lungs. In severe cases, atelectasis will develop, the great veins may be compressed, and cardiac venous return may be diminished. Pleural effusion and empyema produce a restrictive lung disorder. The major pathologic or structural changes associated with significant pleural effusion are as follows: ¾ Lung compression ¾ Atelectasis ¾ Compression of the great veins and decreased cardiac venous return 1 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Pleural Effusion It is a collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion.can result. Complicated and uncomplicated pleural effusions There are also complicated and uncomplicated pleural effusions. Uncomplicated pleural effusions contain fluid without signs of infection or inflammation. They’re much less likely to cause permanent lung problems. Complicated pleural effusions, however, contain fluid with significant infection or inflammation. They require prompt treatment that frequently includes chest drainage Causes Physicians determine the cause of the effusion based on the type of fluid that is accumulating. ¾ Transudative (watery fluid) effusions: Heart failure, pulmonary embolism, cirrhosis, post open heart surgery, trauma ¾ Exudative (protein-rich fluid) effusions: Pneumonia, cancers, pulmonary embolism, kidney disease, inflammatory diseases ¾ Pleural fluid may be bloody (hemorrhagic), chylous (thick and white), rich in cholesterol, or purulent. 2 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Signs and symptoms (Small effusions may not present with symptoms and may only be found via chest X-ray. Larger effusions can cause symptoms such as :) ¾ Decreased lung expansion ¾ Dyspnea ¾ Dry, non-productive cough ¾ Tactile fremitus ¾ Orthopnea ¾ Tachycardia 3 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Diagnostic Procedures ¾ Chest x-ray ¾ CT scan of the chest ¾ Ultrasound of the chest ¾ Thoracentesis ¾ Pleural fluid analysis via thoracentesis Medical Management ¾ Thoracentesis ¾ Pleurectomy- consists of surgically stripping the parietal pleura from the visceral pleura. This produces and inflammatory reaction that causes adhesion formation between the two layers as they heal. 4 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy)  ¾ Pleurodesis- involves the instillation of a sclerosing agent (talc, doxycycline, or tetracycline) into the pleural space via a thoracotomy tube. These agents cause the pleura to sclerose together. Pleurisy A condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed. Also called pleuritis, pleurisy causes sharp chest pain (pleuritic pain) that worsens during breathing. One pleural layer of tissue wraps around the outside of the lungs. The other pleural layer lines the inner chest wall. 5 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Between these two layers is a small space (pleural space) that's usually filled with a very small amount of liquid. Normally, these layers act like two pieces of smooth satin gliding past each other, allowing your lungs to expand and contract when you breathe. If you have pleurisy, these tissues swell and become inflamed. As a result, the two layers of the pleural membrane rub against each other like two pieces of sandpaper, producing pain when you inhale and exhale. The pleuritic pain lessens or stops when you hold your breath. Treatment of pleurisy involves pain control and treating the underlying condition. Symptoms Signs and symptoms of pleurisy might include: ¾ Chest pain that worsens when you breathe, cough or sneeze ¾ Shortness of breath — because you are trying to minimize breathing in and out ¾ A cough — only in some cases ¾ A fever — only in some cases Pain caused by pleurisy might worsen with movement of your upper body and can radiate to your shoulders or back. Pleurisy can be accompanied by pleural effusion, atelectasis or empyema: ¾ Pleural effusion. In some cases of pleurisy, fluid builds up in the small space between the two layers of tissue. This is called pleural effusion. When there is a fair amount of fluid, pleuritic pain lessens or disappears because the two layers of pleura are no longer in contact and don't rub together. ¾ Atelectasis. A large amount of fluid in the pleural space can create pressure, compressing your lung to the point that it partially or completely collapses (atelectasis). This makes breathing difficult and might cause coughing. ¾ Empyema. The extra fluid can also become infected, resulting in an accumulation of pus. This is called an empyema. ¾ An empyema is often accompanied by fever. Diagnosis ¾ Blood tests. A blood test might tell your doctor if you have an infection. Other blood tests also might detect an autoimmune disorder, such as rheumatoid arthritis or lupus, in which the initial sign can be pleurisy. ¾ Chest X-ray. A chest X-ray can show if your lungs are fully inflating or if there is air or fluid between the lungs and ribs. ¾ Computerized tomography (CT) scan. A CT scan combines a series of X-ray images taken from different angles around your body and uses computer processing to create cross-sectional images that look like slices of your chest. These detailed images can show the condition of the pleura and if there are other causes of pain, such as a blood clot in the lung. ¾ Ultrasound. This imaging method uses high-frequency sound waves to produce precise images of structures within your body. Your doctor might use ultrasound to determine whether you have a pleural effusion. ¾ Electrocardiogram (ECG or EKG). Your doctor might recommend this heart-monitoring test to rule out certain heart problems as a cause for your chest pain. 6 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Diagnostic procedures In some cases, your doctor might remove fluid and tissue from the pleural space for testing. Procedures might include: ¾ Thoracentesis. In this procedure, your doctor injects a local anesthetic between your ribs to the area where fluid was seen on your imaging studies. Next your doctor inserts a needle through your chest wall between your ribs to remove fluid for lab analysis and to help you breathe better. Your doctor might insert the needle with the help of ultrasound guidance. ¾ Thoracoscopy. If TB or cancer is a suspected cause of your condition, your doctor might perform a thoracoscopy also called a pleuroscopy — in which a tiny camera (thoracoscope) is inserted through a small incision in your chest wall. This procedure allows for a direct view inside your chest to look for any abnormalities or to get a tissue sample (biopsy). 7 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) Treatment Treatment for pleurisy focuses primarily on the underlying cause. For example, if bacterial pneumonia is the cause, an antibiotic will be prescribed to manage the infection. If the cause is viral, pleurisy may resolve on its own. The pain and inflammation associated with pleurisy is usually treated with nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others). Occasionally, your doctor may prescribe steroid medication. The outcome of pleurisy treatment depends on the seriousness of the underlying disease. If the condition that caused pleurisy is diagnosed and treated early, a full recovery is typical. Respiratory Care Treatment Protocols Oxygen Therapy Protocol Oxygen therapy is used to treat hypoxemia, decrease the work of breathing, and decrease myocardial work. The hypoxemia that develops in pleural effusion is mostly caused by the atelectasis and pulmonary shunting associated with the disorder. Hypoxemia caused by capillary shunting is often refractory to oxygen therapy Lung Expansion Therapy Protocol Lung expansion techniques are often administered to offset the alveolar atelectasis associated with pleural effusions, and are particularly helpful once the pleural fluid has been removed by thoracentesis or thoracostomy. Mechanical Ventilation Protocol Because acute ventilatory failure and hypoxemia may be seen in severe pleural effusions, continuous mechanical ventilation may be required to maintain an adequate ventilatory status. Continuous mechanical ventilation is justified when the acute ventilatory failure is thought to be reversible. CHECK FOR UNDERSTANDING 1. Which of the following causes of pleural effusion is Transudative? a. Rheumatoid Arthritis b. PE c. Pancreatitis d. Systolic Heart Failure 2. A pleural effusion is a buildup of fluid where in the body? a. pleural space b. pleural cavity c. alveoli d. bronchi 3. Pleural effusions that have fluids indicating the presence of inflammation or infection are categorized as what? a. Transudative b Simple 8 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy) c. exudative d. Complex 4. What type of pleural effusion can cause permanent lung damage? a. Uncomplicated b. Complicated c. Simple d. Complex 5. Pleurisy can be accompanied by following, EXCEPT? a. pleural effusion b. atelectasis c. empyema d. pneumonitis LESSON WRAP-UP AL Activity: Minute Paper Instruction: 1. Reserve a few minutes at the end of class session. Leave enough time to ask the questions, to allow students to respond, and to collect their responses. 2. Pass out slips of paper on index cards for students to write on. You may also ask students to bring out and write on a half sheet of paper instead. 3. Collect the responses as or before students leave. One way is to station yourself at the door and collecting “minute papers” as student file out. 4. Respond to students’ feedback during the next class meeting or as soon as possible. 1) What was the most useful or the most meaningful thing you have learned this session? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 2) What question(s) do you have as we end this session? _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ 9 of 9 This document and the information thereon is the property of PHINMA Education (Department of Respiratory Therapy)