Pleural Effusion

KEYPOINTS

• Approximately half of all patients with metastatic cancer will develop a pleural effusion
• Lung and breast cancer are the most common causes of a malignant pleural effusion although it can occur in almost any type of cancer
• Patients may experience dyspnea, dull aching chest pain, or dry cough due to this fluid accumulation
• Thoracentesis (removal of the fluid) can be helpful in relieving dyspnea in some patients
• Pleurodesis (after thoracentesis and drainage) is sometimes used to try and prevent re-accumulation of the fluid
• Pleural effusion may be the first presenting sign of cancer, or suggestive of recurrent or advanced disease

• Children may fear invasive procedures such as thoracentesis
• It is important to explain what will happen and gain the child’s consent depending on his or her ability to understand

ASSESSMENT

(see Foreword)

• A moderate to large pleural effusion can most often be diagnosed by clinical exam alone (decreased breath sounds and dullness to percussion)
• A good clinical assessment can also help to identify the underlying cause of the pleural effusion
• Pleural effusions can be caused by malignant or non-malignant processes
• Non-malignant processes include:
  • Congestive heart failure
  • Pneumonia
  • Low albumin (hypoalbuminemia)
  • Pulmonary embolus
  • Pancreatic disease
  • Interstitial lung disease
  • Ascites
• Investigations to consider may include:
  • Chest X-ray to assess extent of effusion and evidence of other diagnoses (eg. pneumonia)
    • If the fluid amount is > 200 to 300 ml it can usually be detected by chest X-ray
    • Smaller amounts of fluid can sometimes be detected using ultrasound or a CT scan
• Analysis of the pleural fluid (if removed) may help in diagnosing the underlying cause of the effusion. Malignant pleural effusions are typically exudative but on rare occasion can be transudative

MANAGEMENT

• The management of dyspnea and cough are covered in other areas of this handbook and should be followed if these symptoms are present
• A small effusion that is not causing the patient any distress does not normally need to be drained
• Pleural effusions can sometimes resolve on their own with effective treatment of the underlying disease, e.g., congestive heart failure
• Consider drainage of the pleural fluid (thoracentesis) if the patient is highly symptomatic

Consider only if patient is well enough to benefit

• Risks and benefits of a thoracentesis should be explained to the patient before proceeding. These would include hemothorax, pneumothorax and infection

Thoracentesis Procedure (adapted from Oxford Handbook of Palliative Care)

• The patient should be sitting, leaning forward on a bedside table
• Choose a point in the posterior chest wall, medial to the angle of the scapula, one intercostal space below the upper limit of dullness to percussion
• On insertion, be careful to avoid the inferior border of the rib
• Inject local anaesthetic. Wait for the area to be anaesthetized then advance the needle until pleural fluid is obtained
• Introduce a large bore IV cannula with a syringe attached until fluid is just obtained, then advance a further 0.5-1 cm to ensure that the cannula is in the pleural space
• Ask the patient to exhale against pursed lips (this will increase the intrathoracic pressure) and remove the metal trochar or needle and then attach a large syringe with a three-way tap
• Aspirate 50 ml at a time until:
  • Drainage complete or
  • Patient starts to cough or
  • Light-headedness or chest discomfort occurs
  • Remove the cannula, having asked the patient to take a breath, and immediately seal with an appropriate dressing
• Sometimes a chest tube is left in place while the fluid continues to drain
• Pleurodesis is sometimes carried out following thoracentesis and drainage
  • It occurs by inducing inflammation of the pleura by the introduction of a sclerosing agent administered by a chest tube or indwelling catheter into the chest cavity
  • Talc is the most effective sclerosing agent used for pleurodesis
  • Pleurodesis is not always effective and does have procedure-related side-effects including increased pain
  • Patients should be evaluated on an individual basis when deciding whether or not to undergo pleurodesis. It should only be done if the patient has an expected survival of at least several months and is not debilitated

• During thoracentesis check vital signs
• Remove the quantity of fluid that gives optimum symptomatic relief. Not more than 10% of body fluid by volume/24h

PITFALLS/CONCERNS

In patients in the final terminal phase – ie. hours to days, it would be normally inappropriate to drain a pleural effusion (treatment should be as least invasive as possible)
In patients in the final terminal phase – ie. hours to days, symptomatic relief through pharmacologic and other means would be preferred

PALLIATIVE TIPS

• The decision whether to repeatedly perform thoracentesis must be carefully weighed against the patient’s wishes, available resources, the patient’s ability to tolerate the procedure, the risks involved with repeated thoracentesis, the knowledge that the fluid will likely reaccumulate and the ability to symptomatically control dyspnea by other non-invasive means
• It is important to remember that malignant effusions usually recur and the fluid can re-accumulate in as little as a few days. Serial thoracentesis may result in loculated fluid and worsening of symptoms
• Repeated thoracentesis, especially if the fluid rapidly reaccumulates, is usually not indicated

SOURCES/REFERENCES

1. Houlihan NG, Inzeo D, Joyce M, Tyson LB. Symptom management of lung cancer. Clinical Journal of Oncology Nursing 2004;8(6):645-642.
2. Kvale PA, Simoff M, Prakash UB. American College of Chest Physicians. Lung cancer. Palliative care. Chest 2003;123(1 Suppl):284S-311S. http://www.ncbi.nlm.nih.gov/pubmed/12527586
3. Neragi-Miandoab S. Malignant pleural effusion, current and evolving approaches for its diagnosis and management. Lung Cancer 2006;54(1):1-9. http://www.ncbi.nlm.nih.gov/pubmed/16893591
4. Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev 2004(1):CD002916. http://www.ncbi.nlm.nih.gov/pubmed/14973997
5. Shuey K Payne Y. Malignant pleural effusion. Clinical Journal of Oncology Nursing 2005;9(5):529-532. http://www.ncbi.nlm.nih.gov/pubmed/16235579
6. Tassi GF, Cardillo G, Marchetti GP, Carleo F, Martelli M. Diagnostic and therapeutical management of malignant pleural effusion. Ann Oncol 2006;17(Suppl 2):ii11-12. http://annonc.oxfordjournals.org/cgi/reprint/17/suppl_2/ii11
7. Watson M, Lucas C, Hoy A, Back I. Oxford handbook of palliative care. Oxford: Oxford University Press; 2005

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