Malignant pleural effusions are collections of excess body fluid in the pleural space. The pleural space is located between the visceral and parietal pleura. Normally, fluid is shifted from the parietal pleural surface to the pleural surface, over the intrapleural space, and then reabsorbed through the visceral pleura. The pleural space contains 0.13 mL of pleural fluid (composed of hypoproteinemic plasma) per kilogram of body mass (about 7 mL per lung). This fluid reduces friction between the lung and the chest wall.
Approximately 100 to 200 mL of fluid moves across the pleural space daily (Noppen et al., 2000). A balance between the osmotic and hydrostatic pressures governs the secretion and reabsorption of pleural fluid. Pleural fluid develops in the pleural membrane vessels and is reabsorbed by pleural lymphatics (which absorb protein) and capillaries (which absorb fluids). An increase in the amount of fluid moving into the pleural space can result from increased permeability of the endothelial tissue and increased microvascular pressure. A decrease in the amount of fluid exiting the pleural space can result from cytokine-mediated lymphatic constriction; damage to the lymphatics caused by medications, radiation, surgery, malignancy; or increased systemic venous pressure (Spiea & Brahmer, 2004).
Specifically, malignant pleural effusions can develop as a result of increased fluid production or obstruction of pleural lymphatic drainage. Pulmonary neoplasms can cause obstruction by direct pleural invasion or through seeding and deposits of malignant cells, which alter capillary permeability (Schrump & Nguyen, 2001). A decrease in the amount of fluid exiting the pleural space can be caused by cytokinine-mediated lymphatic constriction (infection or tumor); damage to lymphatics from chemotherapy, radiation, or surgery; or invasion of the lymphatics by malignancy.
The development of a malignant pleural effusion indicates a grave prognosis. The condition is associated with distressing symptoms such as dyspnea, chest pain, pleuritic chest pain, cough, orthopnea, hemoptysis, fever, and dysphagia. Nurses can manage symptoms and provide supportive care to patients and their caregivers.
EPIDEMIOLOGY AND ETIOLOGY
The incidence of malignant pleural effusion is about 40% to 50% in patients with cancer (Schrump & Nguyen, 2001; Walker & Casciato, 2001). An estimated 200,000 to 250,000 new cases of malignant pleural effusions are diagnosed annually as a result of the increasing incidence of breast and lung cancer (Light, 2002). Approximately 75% of malignant pleural effusions are caused by lung and breast cancers and lymphomas (Table 38-1) (Shuey & Payne, 2005).
| *Includes causes of malignant effusion each less than 1%: Endocrine, head and neck cancer; mesothelioma; soft tissue sarcoma; bone cancer; and myeloma. | ||
| Cause | Number | Percentage |
|---|---|---|
| Total malignant effusions | 1283 | 100 |
| Lung cancer | 450 | 35 |
| Breast cancer | 246 | 20 |
| Lymphomas and leukemia | 256 | 20 |
| Unknown primary (adenocarcinoma) | 154 | 12 |
| Unknown primary (all types) | 95 | 7 |
| Reproductive tract | 70 | 5 |
| Gastrointestinal tract | 90 | 7 |
| Genitourinary tract | 66 | 5 |
| All other | 39 | 3 |
RISK PROFILE
• Lung and breast cancer, lymphomas, leukemia, and adenocarcinoma of unknown primary cause.
• Cancers resistant to chemotherapy.
• Advanced cancer.
PROGNOSIS
Upon diagnosis of malignant pleural effusion, 54% of patients die within 1 month, and 84% die within 3 months (Schrump & Nguyen, 2001). Survival time is also related to the underlying tumor histology. Patients with lung or gastric carcinomas may survive only months; those with ovarian cancer may survive 9 months; and those with breast cancer may survive a year or longer (Schrump & Nguyen, 2001).
PROFESSIONAL ASSESSMENT CRITERIA (PAC)
1. Dry, nonproductive cough; chest discomfort near the involved lung; pleuritic pain; dyspnea on exertion; and increased fatigue.
2. Decreased or absent breath sounds, crackles at the superior border of the effusion.
3. Decreased chest expansion during inspiration.
4. Absence of fremitus.
5. Dullness on percussion over involved lung.
6. Hypertension
7. Tachypnea
9. Cyanosis or decreased oxygen saturation.
10. Chest x-ray films (posteroanterior, lateral, and decubitus) showing an opaque shadow in the involved lung and costophrenic angle blunting, with possible mediastinal shift if a large pleural effusion is present.
11. CT scan is helpful for evaluating masses, nodules, and pleural-based thickening.
12. Thoracentesis with pleural fluid analysis may be done for diagnosis and treatment planning.
• Transudative fluid: Strawlike color; results from altered hydrostatic/colloid forces; low protein, low cellular content; usually a non-inflammatory process.
• Exudative fluid: Pusslike color; formed by active secretion, inflammation, or leakage; increased cellular or protein content. Fluid is considered exudative if:
• The ratio of pleural to serum protein is greater than 0.5.
• The LDH level is greater than 2/3 of the upper limit for the serum reference range.
• The ratio of protein to serum LDH is greater than 0.6.
• Fluid analysis results with regard to malignancy may include the following studies:
• pH: Less than 7.3.
• Cell count: Hypercellular, predominantly lymphocytes and monocytes.
• Albumin gradient (serum albumin minus pleural albumin): Less than 1.2 g/dL.
• Cholesterol: Elevated with exudative fluid.
• Glucose and tumor markers may be evaluated, although these results have not been found to be useful clinically.
NURSING CARE AND TREATMENT
1. Vital signs: Assess for hypertension, tachycardia, tachypnea, chest discomfort, or fever.
2. Obtain and interpret O2 saturation values.
3. Administer oxygen as needed.
4. Assess for nonproductive cough.
5. Obtain pleural fluid analysis and review results.
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