FY 2022 VA-Funded Projects
Fluid On The Lungs In People With Cancer (pleural Effusion)
Cancer can cause fluid to collect around the lungs. This is called a pleural effusion. How does fluid build up around the lungs? There are two sheets of tissue that protect the lungs. They are called pleural membranes (or pleura). In between the pleura is the pleural space. It's normal to have a thin layer of fluid in this space. This helps the lungs to move easily when you breathe in and out. Cancer cells can spread to the pleura. This causes inflammation of the pleura and makes more fluid. The fluid builds up in the pleural space. This is called a pleural effusion. The increased amount of fluid stops your lungs from expanding fully, you have to take shallower breaths and make more of an effort to breathe.
Pulmonary oedema If your doctor or nurse talks about fluid on the lung they might mean pleural effusion. Or they might mean you have fluid collecting inside the lung. This is called pulmonary oedema. It is not usually possible to have this fluid drained. Pulmonary oedema is usually caused by heart problems. You might need treatment to stop the fluid collecting. The information on this page is about pleura effusion. Causes of pleural effusion Cancer is the third most common cause of pleural effusion. The other two main causes are heart failure and pneumonia (a severe chest infection). When cancer is the cause, you might hear doctors call this a malignant pleural effusion. A malignant pleural effusion is more likely to happen if you have: lung cancermesothelioma (a type of cancer of the pleura)breast cancer ovarian cancer Symptoms of a pleural effusion Feeling breathless may be the first and only symptom you have if you have a pleural effusion. But you may also have a cough and chest pain. If you suddenly become breathless or your breathing gets worse contact your hospital advice line or GP straight away. If you can't speak to someone quickly go to your local accident and emergency (A&E). You may need urgent treatment. How is a pleural effusion diagnosed? Your doctor needs to work out the cause of your symptoms. They will ask about your general health, your medical history and any medication you are taking. They will also want to examine you. You usually have a chest x-ray or a chest (thoracic) ultrasound scan
(TUS) to diagnose a pleural effusion. Some people may also have a CT scan if doctors need more information about the collection of fluid. These tests show where the fluid is and how much there is. Coping with shortness of breath when you have a pleural effusion Shortness of breath from a pleural effusion can be very uncomfortable. You might also feel anxious if you have difficulty breathing. You might find it more comfortable to sit on the edge of the bed or in an armchair. It might help to lean forward with your arms resting on a pillow on a bed table. This will allow your lungs to expand as fully as possible. Let your doctor or nurse know if you find it difficult to cope. They will do all they can to help relieve your symptoms and support you. Let family and friends know how you are feeling and accept any offers of help and support. Treatment for fluid on the lung (pleural effusion) Doctors treat a pleural effusion by removing the fluid. This should improve your breathing. Doctors drain the fluid by: pleural aspiration (thoracocentesis)pleural drainage pleurodesis - treatment to seal the space between the tissues covering the lung to stop fluid building up How long will I be in hospital? Depending on what procedure you have and how fit you are, you may need to stay in hospital. This might be overnight or longer. Your nurse or doctor will tell you how long you might need to stay in hospital and what you should bring with you. Pleural aspiration to treat a pleural effusion Doctors can do a pleural aspiration if there is a small collection of fluid around the lungs. This means using a needle and syringe to remove the fluid. It's not often used to treat fluid build up caused by cancer. This is because it's likely the fluid will build up again quite quickly afterwards. If your doctor thinks this is suitable for you, they usually arrange for you to have this as a day patient. To have this, you sit upright or sit while leaning over the side of a bed. Either way, they make sure you are comfortable before they start. First, you have an ultrasound scan to locate the fluid. You then have a local anaesthetic close to the area where the fluid is. This numbs the area. Your doctor makes a small cut into the skin. Using the ultrasound scan they guide a needle attached to a syringe through the cut and into the pleural space to aspirate the fluid. They then take out the needle and put a plaster over the cut on your skin. Your doctor sends the fluid or a sample of the fluid to the laboratory. The specialist looks for cancer cells or an infection in the fluid. Pleural drainage to treat a pleural effusion If you have a large collection of fluid you might have a chest drain. First, you have an ultrasound scan of the chest. This helps your doctor find the best place to put the chest drain. Then your doctor gives you a small injection of local anaesthetic to numb the area. When the anaesthetic has worked, the doctor makes a small cut into your chest usually through your side. They place a wide needle (cannula) into this cut in your chest. The tip of the needle goes into the pleural space, where the fluid is collecting. Once it's in the right place, the doctor attaches the needle to a drainage tube called a chest drain, which in turn is attached to a collecting bottle or bag. Your doctor puts a stitch around the tube to hold it in place. This is a purse string suture. The anaesthetic can sting at first and the needle can feel uncomfortable for some people. You might also feel some pressure, but it shouldn't be painful. Let your doctor know if you have any pain. You may need more local anaesthetic. 
As long as the drainage bottle or bag is kept lower than your chest, the fluid drains out automatically. If there is a lot of fluid, this can take several hours. The fluid needs to drain slowly. This is because draining a large amount of fluid too quickly can make your blood pressure drop suddenly making you feel faint. Also, the lung expanding too quickly can make you more breathless. Your nurse will check you regularly while the fluid is draining. Once the fluid has stopped draining, your doctor or nurse will take the tube out and pull the stitch tight to close the small opening in your chest wall. The stitch stays in for about a week. Unfortunately, it is possible for the fluid to build up again. If the fluid keeps coming back, some people might go home with a thin chest tube (indwelling pleural catheter) that stays in place in the chest. It has a valve on the end to stop fluid leaking from it. When the fluid builds up you go to the hospital, the tube is attached to a drainage bottle, and the fluid is drained off. You might be shown how to do this at home with help from your nurse. Your specialist nurse will explain more about this if it is suitable for you. Your doctor may suggest you have treatment to stop the fluid coming back. This is called a pleurodesis. Treatment to stop fluid building up (pleurodesis) You might have a pleurodesis. This aims to stop fluid from building up and helps to relieve your symptoms. This treatment seals the space between the tissues covering the lung (pleura). There are a few different substances your doctor can use. One example is sterile talcum powder. These substances inflame the area around the lungs, so they stick together. Then there is no space for fluid to collect. You usually stay in hospital for a couple of nights or longer, especially if there is a lot of fluid to drain off first. Draining the fluid can take time and your nurses will want to keep an eye on you. This treatment doesn't treat the cancer. But stopping the fluid building up should make it easier for you to breathe afterwards. You can have this treatment again if it doesn't work completely the first time. How you have pleurodesis There are different ways of having this treatment, depending on whether you need to have fluid drained beforehand. Removing fluid and pleurodesis If you need to have fluid drained from between the pleura beforehand, you have a chest drain put in to remove the fluid as described above. Once the fluid has stopped draining, the doctor injects the powder into the pleural space through the drainage tube. They then clamp the tube. To help spread the powder around the pleural space, you need to lie in different positions. Your doctor will ask you to turn from one side to another. After that, the tube might be attached to some suction. This helps to stick the pleura together. Having pleurodesis can be uncomfortable. You have painkillers to take beforehand and afterwards. For most people, the soreness is mild and doesn't last long. But do tell your doctor or nurse if it is a problem for you. Having a pleurodesis using a chest scope (thoracoscopy) You might have a pleurodesis using a special chest scope if there is no fluid being drained. You usually have this under a general anaesthetic. So, you are asleep during the procedure. Your doctor makes one or more small cuts (incisions) in the chest wall. The scope goes into your chest through the cut until it is in the space between the lining of the lung. The doctor can see through the scope, so they know exactly where to put the sterile powder. They put the powder in through a tube in the thorascope. This way of doing pleurodesis is called video assisted thoracoscopy surgery. Afterwards you may have a chest drain that's attached to a drainage bottle. This allows any excess fluid that may have accumulated to drain away. It remains in place until there is no more fluid left to drain. You usually stay in hospital for about 2 to 3 nights afterwards. Your nurse will show you how to look after the small wounds before you go home. They will also give you a contact number to call if you have any problems or feel unwell when you are at home. 
Possible problems of drainage and pleurodesis There is a risk of problems or complications after these procedures. Your doctor will make sure the benefits of having fluid drained or pleurodesis outweigh the possible problems. These include: painbleedinginfectioninjury to the lungs, for example, a collection of air in the pleural space (pneumothorax)blocked drainage tube After pleurodesis, it's normal to have a raised temperature, and some breathlessness for a couple of days. Contact your 24 hour advice line or healthcare team straight away if this doesn't get better or you feel unwell. Your nurse will explain in more detail how you may feel and what to expect. Research into draining fluid from the lung There is ongoing research into ways of draining fluid from the lungs. The REPEAT trial In this study, researchers want to find out how long it takes for fluid around the lungs to come back after treatment. To do this, the study team asks people who are having treatment some questions. They will also ask permission from those taking part to use a sample of: their blood from a blood test the fluid that is drained from the pleural effusion The aim of this study is to look for biomarkers in the samples. They will try to work out if biomarkers can help them predict when the fluid is starting to build up again. What Are The Symptoms Of Empyema?
The formation of empyemaSymptoms that are used as diagnostic factors for empyemaReference Further reading
Empyema is an exudative effusion (an excessive collection of protein-rich fluid) accompanied by pus in the pleural cavity.
The pleural space Is also known as the pleural cavity or intrapleural space and is defined as the space between the pleurae of the pleural sack that surrounds each lung.
The symptoms of empyema typically include general ill-health, unexplained fever, loss of appetite, and weight loss. If a lung infection is present, cough and dyspnoea (difficulty breathing, shortness of breath) may also be present.
An elevated white blood cell count may also be present, and respiratory failure may result if it persists.
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Empyema formation is divided into three stages: the executive, the fibrinopurulent, and the organizational stage. During the exudative phase, pleural fluid accumulates in the pleural space. This fluid is sterile and secondary to inflammation and increased permeability of the visceral pleura.
The second stage, stage 2 (fibrinopurulent), begins with the invasion by bacteria of the pleural space, and a hallmark feature of this is the deposition of fibrin on the visceral and parietal pleural membranes.
In this stage, fibrinous septae (thickenings due to structural alterations; fibrous septae form narrow, rigid bands that pull the surrounding tissue downwards), loculations (localized failure of the pleural space to drain fluids), and adhesions form.
The high metabolic activity of the bacteria in this region results in a drop in the pleural fluid glucose concentration and pH. In addition, the lysis of neutrophils causes an increase in lactate dehydrogenase levels.
If the infection continues, the empyema reaches the organized stage, stage 3, which is characterized by the formation of thick, non-elastic plural peel and dense fibrinous septations. This causes a condition called trapped lung, as these structures inhibit the expansion of the lung volume because of the proliferation of fibroblasts.
Empyema and Pleural EffusionsPlay
Symptoms that are used as diagnostic factors for empyemaThe key diagnostic factors that cause suspicion of empyema include risk factors, including immunocompromised and comorbidities predisposing the individual to develop pneumonia. Moreover, pre-existing lung disease is a significant risk factor.
In the pleural space, Iatrogenic interventions, the causation of a disease, a harmful complication, or other ill-effects by any medical activity may increase the likelihood of empyema. Male sex and extremes of the age spectrum (very young or old) also predispose an individual to empyema.
The presentation of symptoms is referred to as subacute. Subacute denotes a short duration and implies that the onset was recent. Patients usually present with a one-to-two-week history of symptoms. Within this time frame, they exhibit signs of a productive cough. This is defined as a cough that produces green or rust-colored sputum.
This may also be present in pneumonia. In addition, patients may complain of chest pain when they inspire, a feature which occurs because of information about the parietal pleurae (the outermost of the pleural membranes, which are comprised of a single layer of flat cuboidal cells between 1 and 4 μm thick, supported by loose connective tissue which forms a lining for the chest cavity that contains the lungs).
Another hallmark of empyema is dyspnoea. This occurs in large pleural effusions; the patient may also be breathless if there is associated pneumonia.
Patients with anaerobic empyemas (those involving anaerobic bacterial infection) can present with a more indolent (slow progression does not pose an immediate threat to health), an illness characterized by weight loss, constitutional upset, and fatigue.
Constitutional upset refers to a group of symptoms that affect several systems in the body; they are non-specific and jeopardize the patient's sense of well-being.
The most cardinal symptoms include headache, pain, fatigue, loss of appetite, malaise, night sweats, and weight loss.
Reference Further readingImproving Treatment Of Malignant Pleural Effusion
Malignant pleural effusion (MPE) is a collection of cancerous fluid around the lung. MPE is common, affecting 750,000 people across Europe and the US each year. It causes severe breathlessness and poor quality of life, and can often come back. Average survival from diagnosis is only 4-6 months, with a lot of variation between patients. Most require pleurodesis (sealing the cavities around the lung) to prevent it coming back, typically with talcum powder. This usually requires a long hospital stay and isn't suitable for many patients.
What translational research was done?Our Cochrane analysis of results across trials showed the need for better treatment options and the importance of patient choice. With our patient involvement group, we highlighted the need to improve early prediction of a patient's outcomes to guide treatment decisions, and better ways to achieve pleurodesis without a hospital stay.
Combining data from our own and international cohorts, we developed and validated the first scoring system (LENT) to predict death in those with MPE.
Our three pilot studies explored the best way to deliver pleurodesis to outpatients. The SEAL-MPE trial of an internal long-term pleural catheter that slowly releases medication (IPC) suggested it was safe, with rapid, effective pleurodesis.
We also evaluated an implantable pleural-bladder pump for outpatients. This was effective but wasn't very acceptable to patients and the tubing could get blocked.
Lastly, we evaluated inserting a standard IPC as a day case, followed by talc pleurodesis via the IPC as an outpatient option. This was successful and well-tolerated.
Translation into later phase research, clinical practice and patient benefitOur LENT score is used internationally and has been incorporated into national guidelines helping clinicians and patients make complex treatment decisions. Data from SEAL-MPE led to the device being provisionally approved by the FDA. An international randomized trial (SWIFT) rolled it out further. However, results were disappointing, with the catheter causing complications. It is being adapted to avoid tube blockages ahead of further studies.
Following our talc-via-IPC research, we designed and conducted the IPC-Plus trial, a UK multicentre, placebo-controlled randomized study. This treatment was safe and effective, and defined a new outpatient option for MPE. It has been incorporated into guidelines and offered to patients in the UK and internationally.
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