all right continuing the review for the chest tube series and talking about the different disorders that disrupt the plural space in this lesson we finish out these disruptions by quickly covering the plural effusion [Music] alright you guys welcome back to another video Lesson from ICU Advantage my name is Eddie Watson and my goal is to give you guys the confidence to succeed in the ICU by making these complex Critical Care subjects easy to understand I truly hope that I'm able to do just that and if I am I do invite you to subscribe to the Channel Down Below when you do make sure you hit that Bell icon and select all notifications so you never miss out when I release a new lesson as always the notes for this lesson as well as all the previous videos are available exclusively to the YouTube and patreon members you can find links to join both of those down in the lesson description below also don't forget to head over to icuadvantage.com or follow that link down in the lesson description to take a quiz on this lesson test your knowledge while also being entered into a weekly gift card as well as don't forget that you can help support this Channel Through the purchase of an ICU Advantage sticker again those are found at the web website icoadvantage.com forward slash support link down in the description and once again for these lessons it is helpful to have a good understanding of the mechanics behind how we breathe if you do need a review on that I'm going to link to that lesson up above where I cover just that so let's start out talking about what is a plural effusion so a plural Fusion is essentially an abnormal collection of excessive fluid in the plural space and it's really the most common plural disease and it's potentially the result of actually many different conditions which I'm going to discuss here shortly so the collection of fluid here in the plural space takes up that space and then also puts pressure on the lung tissue this then leads to the decreased expansion of the lung decreasing the availability for gas exchange and can also impact the normally negative intrapleural pressure leading to a collapse of the lung the impact on the gas exchange is what often leads to the symptoms that our patient presents with but the size of the fusion is not necessarily directly correlated with the severity of the symptoms so let's talk a about some of our types and causes so we can actually classify the pleural effusion a couple of different ways so let's actually talk a little bit about our pathophysiology here so normally we have a small amount of the serous Pleural fluid in the pleural space now this fluid actually originates from the vasculature of the parietal pleura or the pleura that if you remember Lions the chest wall and then it's actually reabsorbed by dependent parts of the parietal pleura and these are going to be primarily in our mediastinal as well as our diaphragmatic areas and so it's actually hydrostatic pressure from these vessels that supply the parietal pleura is what actually drives this interstitial fluid into the pleural space giving it a decreased protein count when we compare it to the serum and so if we end up with an accumulation of this fluid then it can really either be the result of increased production and or decreased reabsorption and so that leads us to one of our ways of classifying specifically looking at the pathophysiology and that's going to be something that we call transitative and so this results from changes in either the hydrostatic or oncotic pressure so we can see increased hydrostatic pressure inside the vasculature or decreased oncotic pressure in the vasculature both of these causing excessive fluid to enter the pleural space so really kind of think of this one as a pressure driven fluid leak without any capillary damage and then some of the common causes that you would see that would lead to a transitative pleural fusion would be things like our congestive heart failure or CHF cirrhosis severe hypoalbum anemia nephrotic syndrome acute atelectasis mixed edema as well as potentially peritoneal dialysis now another potential type is actually going to be something that we call exudative and then this here results from increased mesothelial and capillary permeability allowing excessive fluid to leak into the plural space so you can kind of think of this one as an inflammatory fluid leak and so some of the causes that might make sense with this would be pneumonia cancer trauma and surgery just general inflammation pulmonary embolism or PE as well autoimmune disorders and pancreatitis just to name a few and then from there we can just have generally impaired lymphatic drainage or leakage of some other fluids now another way that we can also classify these pleural fusions is based on the origin of the fluid so we can have our normal serous or Pleural fluid and this is going to be something that we refer to as a hydrothorax we can have blood which is something we referred to as a hemothorax if you haven't watched that lesson I'm going to link to that up above we can have Chile or a child of thorax and this is basically going to be like a Milky fluid that consists of both lymph and emulsified fats and or fatty acids and then our typical cause for this is usually going to be trauma or some sort of neoplastic damage we can also have pus or a pyothorax or or also referred to as an empyema and then our typical causes for this are going to be pneumonia surgery abscesses or some sort of penetrating trauma that had a secondary infection we can also see urine or a urinary thorax although this one is pretty rare and then finally we have some iatrogenic sources here now these are typically going to be caused by misplaced feeding tubes so think of the case where it actually ends up in the lung and perforates through and then let's say feeding was started and now we have tube feeding in the pleural space or another potential cause would be perforation of vasculature with a central line and then again we started infusing fluids through there so now we have some sort of IV fluids being infused into the plural space all right so with those out of the way let's talk about our signs and symptoms and again many of the signs and symptoms of a pneumothorax are also going to be seen with our pleural fusion so these are going to be things like our chest pain shortness of breath our destiny and tachypnea hypoxemia hypercapnia decreased or absent breath sounds again on that affected side as well well as decreased tactile fremitus and vocal resonance again on that affected side some other different signs and symptoms that we would see would be and this is also similar to our hemothorax but dullness to percussion again on that affected side now just like with our hemothorax and pneumothorax a large plural Fusion can also lead to something that we refer to as tension hydrothorax and this again leads to that decreased cardiac output and then causes severe respiratory and cardiac compromise so if your patient has this going on you again would see things like tachycardia jvd cyanosis that tracheal deviation away from the affected side profound hypoxemia and hypotension respiratory failure and potentially cardiac arrest so definitely in a serious situation with this as well just like with the others so again let's talk about some of our Diagnostics here and typically the pleural fusion is something that we're going to be diagnosing through a combination of their medical history the exam and then confirming things with Imaging so first we've got our chest x-ray and again our posterior anterior or our PA chest x-ray is going to be commonly used to diagnose the pleural fusion and so here's a good example of this here it's going to be very similar to seeing this on x-ray as with a hemothorax if you remember you're not going to be able to distinguish between the two with just an x-ray so here we can see on the patients right here we do see the blunting of that costophrenic angle as well as the opacification of the affected hemothorax and then again just like with the hemothorax for supine patients that the fluid can kind of layer in the pleural space leading to a general haziness of one of the hemothoraxes when compared to the other and then again like I said you're not going to be able to distinguish between the types of pleural fusions or distinguish whether it's a hemothorax or pleural fusion anything like that now again another Diagnostic Imaging tool that we have is going to be our computed tomography or CT scan and so here again this is going to give us the best look at the location and size of the pleural fusion so here's an example of this here this one's actually kind of interesting because you can see a bilateral pleural fusions obviously the one side is larger than the other but you can definitely see that the two areas of collection of fluid here and here and then the rest of this and this is going to be our lung tissue and then finally the last bit of Imaging again is going to be our ultrasound just like with the hemothorax so the bedside ultrasound can be used here and the nice thing is they actually show that this is as sensitive as a CT scan and again more sensitive than an x-ray so another quick easy option to to throw a probe on there and check and see if they have a pleural effusion so again let's move on and talk about our treatment options so again our treatment options are really going to depend on the size of the effusion the cause of the effusion as well as the patient's symptoms so we've got our conservative treatment and so these are going to be for pleural fusions that are smaller than 300 MLS and these patients typically may not have any symptoms and so we may elect to do nothing and just kind of monitor the patient if the primary problem is corrected then the fluid is really going to be absorbed back into the body over time and thus it may require very little on our end in terms of treatment and for these patients we're just typically going to treat with analgesics if needed and then follow-up Imaging now another treatment option is actually going to be the thoracentesis and this is actually commonly used to drain the fluid from the pleural space here in the cases of chloral Fusion so this is going to allow us to sample as well as differentiate the type of effusion that they have and then for this ultrasound guidance is often going to be used and this is going to be to help us make sure we get the needle in the actual fluid in the right place as well as helping to prevent a pneumothorax and then again as you can imagine another potential treatment option is going to be our chest tube and so for larger pleural fusions we're often going to insert a chest tube now we do need to be careful though especially for patients that have very large pleural fusions we want to be careful that we're not draining too much fluid initially so if we drain more than 1500 MLS and this can actually lead to a rapid re-expansion of the lung and potentially can result in pulmonary edema so for these chest tubes we're typically going to insert them at either the fourth or fifth intercostal space mid-axillary line we are going to have these chest tubes inserted posteriorly as well as potentially downward toward the base of the lung to potentially Aid with drainage now we may or may not use suction depending on the size of the effusion and sometimes even we actually use something as simple as a simple vacuum tube that we use to kind of collect instead of the full chest tube drainage setup and then for our pleural effusions we're actually typically going to use smaller chest tubes so in the 14 to 16 French size as well as some small boar pigtails and these are 10 to 14 gauge and then our final treatment option is potentially surgery and then these are really going to be for either recurrent pleural fusions or kind of depending on the source of the fluid that we may have to resort to surgery now a lot of times though this can actually be done with the video assisted thorochoscopy surgery or the Vats but it can also be an open thoracion me as well and then chemical or surgical pleurodesis may also be warranted for patients who do have these recurrent effusions all right and that was our review of the pleural effusion as well as kind of rounding out the review over the different disorders that we see when it comes to that plural space we covered a lot of good information in this lesson as well as the previous couple lessons talking about these disorders but this should give you guys a good foundation as we move into the next couple lessons where we're actually talking about the management of the chest tube system so do make sure you guys keep an eye out for those so I hope that you guys found this information useful if you did please leave me a like on the video down below it really helps YouTube know to show this video to 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