Caring for a patient with malignant pleural effusion.

Abstract

Mrs. Peters is a 65-year old married woman with a known history of right breast cancer, diagnosed and treated 10 years ago. In the past several weeks, she has a new nonproductive cough and is a bit fatigued and short of breath with physical activity. Her husband finally convinces her to see her health care provider who obtains her history and completes a physical exam. On listening to her lungs, an absence of breath sounds is found in the lower half of the right lung. When percussed, there is dullness in the areas of absent breath sounds. Heart sounds are normal. There is no pedal edema. An in office pulse oximetry is 91% on room air. A chest x-ray including lateral, anterioposterior and decubitus films demonstrate a right-sided pleural effusion. Mrs. Peters is admitted for a work up of a presumptive diagnosis of metastatic breast cancer with malignant pleural effusion (MPE). This article will discuss the clinical presentation, diagnosis, treatment and nursing management of the patient with a MPE. What is MPE? A pleural effusion is a collection of fluid between the parietal and visceral pleural layers of the lung. Pleural effusions are often associated with advanced malignancies such as carcinoma of the lung or breast. However, many other malignancies are known to produce MPE, such as mesothelioma, renal, ovarian, and sarcomas (Porcel & Vives, 2003). Relatively common, over 150,000 new cases of MPE are diagnosed each year (Neragi-Miandoab, 2006). The pleural space lies between the 2 layers of the pleura. The visceral layer covers the lungs and the parietal layer lines the chest wall cavity. Under normal circumstances, a maximum of 50 mLs of pleural fluid is present in the pleural space. The fluid allows the lung layers to move easily during respiration. The capillaries contained in the parietal pleura manufacture pleural fluid and the visceral pleura reabsorb the fluid (Taubert, 2001). Anything that disturbs this balance can result in the development of a pleural effusion, such as a reduction in or obstruction of lymphatic drainage, increased or decreased oncotic pressure in the capillaries, increased capillary permeability, or increased negative pressure in the lungs from atelectasis (Putman, 2002; Taubert). A common etiology of pleural effusion in patients with a malignancy is lymphatic obstruction (Shuey & Payne, 2005). Effusions may be unilateral or bilateral. Several types of pleural effusions occur including transudative and exudative, but most MPE are exudative (Taubert) characterized by high protein and high LDH levels, and a high white blood cell count (Goldman, 2004). The fluid is yellowish, cloudy or blood-tinged (Goldman). Fluid obtained during a diagnostic procedure is always sent for these diagnostic studies. In addition, other diagnostic studies useful in pleural fluid assessment are Gram stain, culture and sensitivity, cytology, glucose, amylase, and albumin (Light, 1999). However, the fluid LDH and the fluid to serum ratio of total protein are the most accurate tests available to distinguish a transudative effusion from an exudative effusion with the pleural fluid LDH; more than two-thirds of the upper limit of normal of the serum LDH is diagnostic for an exudative effusion (Tassi, Cardillo, Marchetti, Carleo, Martelli, 2006). Transudative effusions are seen in patients with lymphoma but most often are associated with nonmalignant conditions (Taubert). Characterized by low levels of protein and a watery fluid, transudative effusions are associated with cirrhosis or congestive heart failure.