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After my painful experience with pleural effusion back in 2009, I asked myself what is pleural effusion and why I contacted it before. So I made a little research after my recovery, and this blog is the result of my investigation.
In order to fully grasp the meaning of pleural effusion, certain terms must be defined at the outset and then a definition be given afterwards. Here are some of the terms related to the condition:
Pleura – a delicate membrane that encloses the lungs. The pleurae are divided into two areas separated by fluid: the visceral pleura, which cover the lungs, and the parietal pleura, which line the chest wall and cover the diaphragm.
Pleural cavity – the area of the thorax that contains the lungs
Pleural space – the area between the visceral and parietal layers of the pleurae
Pleural fluid – the fluid that is present in the pleural space necessary to lubricate the surfaces of the pleurae to make breathing smooth as it is.
Therefore, pleural effusion is the condition of having excess pleural fluid in the pleural space. It is more widely known, in layman’s term, as “water on the lungs.” Pleural effusion is not a disease per se, as others might have supposed, but rather an offshoot of an underlying cause.
This video explains the terms pleura, pleural fluid and pleural space.
Causes
Despite its rather unfamiliar name, pleural effusion is actually a common medical condition. According to the National Cancer Institute, the condition affects about 100,000 Americans every year.
An effusion is categorized based on the cause, and there are two types of pleural effusion: transudative and exudative. My pleural effusion belongs to the second type: exudative pleural effusion.
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A transudative pleural effusion is one producing a clear fluid. This is not a disease in the pleura itself, but rather an imbalance in the removal and intake of pleural fluid. It is caused by a number of factors, including pulmonary embolism, heart failure, post open heart surgery, and cirrhosis.
Exudative pleural effusion comes about when the pleura itself is diseased. The causes are several and varying, most common of which are infections due to bacterial pneumonia and tuberculosis. In developing countries, tuberculosis is noticed as the leading cause of pleural effusion.
However, pleural effusion is most likely related to bacterial pneumonia in as much as 50% of all cases. Other causes of exudative effusion are cancer, pulmonary embolism, inflammatory disease, and kidney disease.
Forty percent of the time, congestive heart failure is the known main cause of pleural effusion.
As a result, a bilateral type of effusion is usually observed. For a one-sided effusion, the right part of the lungs is frequently the one affected because people tend to lie on the right side.
Severity
The seriousness of an effusion case depends primarily on the main cause, likelihood of treatment, and whether or not breathing is compromised. Two important parameters are factored into the treatment: related mechanical issues and root cause of the problem.
Symptoms
A few patients having effusions do not show any symptoms, the problem only being discovered when they undergo chest x-ray for a different reason. The following are the most common symptoms of effusion:
- Dry cough
- Chest pain
- Breathing difficulty
Other symptoms include chills, loss of appetite and fever. When patients try to breathe deeply, pain increases, but this depends on the amount of liquid in the pleurae. The more liquid is there, the more it is difficult to breathe deeply.
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Diagnosis
The initial check-up often includes asking about the patient’s medical history and doing a physical exam. The latter normally involves tapping the chest with a finger while the doctor listens through the stethoscope for such things as reduced vibration, dullness to percussion, a friction rub and inaudible breath sounds.
If an effusion is suspected, other tests may be requested to confirm the finding. Doctors use several tests to confirm the presence of an effusion, such as the following:
- CT scan
- Chest x-ray
- Ultrasound
- Thoracentesis (to obtain a fluid sample)
- Pleural fluid analysis (studying the fluid sample extracted from the pleural space)
This video shows how thoracentesis is carried out.
Thoracoscopy
Thoracoscopy, a slightly invasive procedure, could be performed when earlier less intrusive techniques fail to diagnose the presence of an effusion. Thoracoscopy is otherwise known as video-assisted thoracoscopic surgery (VATS) done with the patient subjected to general anesthesia, allowing the surgeon to make a closer assessment of the pleura. In such cases, diagnosis and treatment are often combined.
Treatment
An effusion treatment is aimed at addressing the underlying cause of the problem and depends on whether or not serious respiratory issues occur, such as breathing difficulties or shortness of breath. Treatment can take days or months, depending on the severity of the case. Mine took two months of hospitalization after treatment fails one after another.
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When an effusion is caused by a medical problem such as congestive heart failure, diuretics and medications specifically used to treat the medical condition may be administered. For malignant cases, treatment may require radiation therapy, chemotherapy, or medication infusion in the chest.
If the effusion has been causing respiratory problems, thoracostomy (the process of inserting a tube in the chest) or thoracentesis may be required to drain the fluid. To prevent the relapse of effusion, pleural sclerosis may be done using sclerosing agents such as doxycycline, talc, and tetracycline. This technique has shown 50 percent success rates.
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Less Invasive Treatment
As the name implies, the following treatment is done prior to performing any surgical procedure to the patient. Administration of medications is normally the first option to treat pleural effusion, and surgery is the extreme solution. For me, surgery is not a good idea because it incurs a permanent damage to the body. This is similar to opening up the engine of a motorcycle for overhaul. Its performance would never be the same again.
#1 – Thoracentesis
Thoracentesis is used both in diagnosis and treatment. In treatment, a syringe is attached to a needle that is inserted in the chest to draw out fluid. This procedure can remove only more than six cups of fluid at a time. Patients who have only small amounts of pleural fluid and respond clinically to antibiotic therapy are not required to have thoracentesis.
This video shows how thoracostomy is done.
#2 – Thoracostomy
If the effusion is not totally eliminated by thoracentesis, doctors normally presume the existence of locules. If the accumulation of fluid is fast, thoracostomy, or drainage with a chest tube, is generally opted for. Only surgeons perform this procedure.
Waiver
Before performing the procedure, surgeons have the family and the patient sign a waiver, absolving the hospital and the physicians of any criminal liability for any untoward incidence that may happen during the process. This seems unfair on the part of the patient and his family, but it can’t be helped. Medical professionals make money without worrying about the possible criminal obligations in the course of carrying out their professions.
This video shows another example of thoracostomy tube insertion.
Procedure
Depending on the surgeon, a patient may sit erect on a chair or lie down on the bed with his hand placed at the back of his head. The chest thoracoscopy tube (CTT) is inserted into the pleural area between the ribs on the patient’s side. The tube’s diameter is commonly as big as a small finger.
The CTT is left in place for several days or even weeks until drainage stops or is minimally low. Also, the CTT will not be removed if air appears in the chest x-ray result. Frequent chest x-ray or ultrasound is done to monitor the amount of fluid remaining in the pleural space.
Surgical Procedures
Surgical treatment may be performed if the effusion cannot be dealt with using less invasive procedures outlined above. There are two types of surgical procedures applied for effusion:
#1 – VATS
VATS means video-assisted thoracoscopic surgery. This procedure involves making from one to three small incisions in the chest. This method is applied when it is hard to drain the fluid in the pleural space and when fluid recurs as a result of malignancy.
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#2 – Thoracotomy (open surgery)
This method is done when an infection is involved. In this procedure, an incision is made in the chest whose size runs from 6 to 8 inches. Thoracotomy is done to get rid of all the fibrous tissue and assists in eliminating the infection from the pleura. Chest tubes may be retained from one to two weeks following surgery to ensure fluid is drained completely.
The surgeon will cautiously assess the patient's case to identify the safest treatment method available and make you aware of the potential risks and benefits of each method. Unless absolutely necessary and if the case requires immediate attention, I can say that open surgery should not be considered as an option.
Possible Complications
You should be aware of the following potential complications of pleural effusion and the applied treatment so that you have an idea on the right course of action to take when a situation arises.
• A lung may collapse if it is surrounded with excess fluid for a long time.
• An infected pleural fluid may become an abscess, otherwise known as empyema, which needs sustained drainage with a chest tube.
• The thoracentesis procedure may cause buildup of air in the pleural space. Air sometimes comes in through the needle, or the needle creates a hole in the lung. However, a hole heals itself naturally.
• Clogging can be a major complication of CTT placement. Reinsertion (even multiple reinsertions) is often applied to completely remove the fluid.
These complications are obtained from my own experience coupled with research on the topic. This information should make you understand what could happen when you have this medical condition.
Warning: This blog is my original work. Please don't plagiarize.
