Pneumothorax

Pathophysiology: Accumulation of air or gas in the pleural cavity

Left-sided pneumothorax (on the right side of the image) on CT scan of the chest with chest tube in place.

Pneumothorax
Anatomy ReviewPleural cavity Visceral pleura
Encases lungs

Pleural space/cavity
Area between pleura Contains fluid (4ml) Fluid prevents friction Fluid circulated by
lymph system

Parietal pleura
Lines chest wall

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Anatomy review - Breathing Diaphragm i & accessory muscles move outward Negative pressure in the thoracic cavity Negative pressure pulls air into the lungs via the nose and mouth Diaphragm & accessory muscle relax (h) air exhaled

Pneumothorax
If the visceral pleural is perforated or the chest wall & parietal pleural are perforated
air enters the pleural space negative pressure is lost Lung on the affected side collapses

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An abnormal chest x-ray shows the presence of an air pocket (arrows) in the pleural sac surrounding one lung, which has collapsed. This finding is typical of a severe pneumothorax. A normal chest x-ray is shown on the right for comparison; the heart (H), lungs (L), vertebrae (v), and collarbone (C) can be seen.

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Classifications of pneumothorax Spontaneous pneumothorax
with out injury Air enters the pleural cavity via the airway Farther classified as:
Primary Secondary

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Spontaneous (Primary) Pneumothorax

Pt. with no known lung disease. D/T a rupture of a bulla in the lung. Most often tall, thin men between 20 and 40 years old.

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Spontaneous Secondary Pneumothorax occurs in pt. with known lung disease most often COPD Other lung diseases commonly assoc. with Tuberculosis Pneumonia Asthma lung cancer Often severe & life threatening

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Traumatic Pneumothorax
D/T injury to the chest wall Further classified as Open or closed

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Open Pneumothorax Air enters pleural cavity via outside A free communication between the exterior and the pleural space as through an open wound
blowing wound sucking wound

may be caused by a penetrating injury

stab wound, gunshot wound impaled object

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Closed pneumothorax Air enters the pleural cavity via lungs D/t/ blunt chest trauma
Car crash Fall Crushing chest injury

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Iatrogenic pneumothorax D/T procedure / treatment

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Tension Peumothorax air accumulates in the pleural space with each breath. The remorseless increase in intrathoracic pressure massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels cardiovascular collapse

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Tension Pneumonthorax a piece of tissue forms a one-way valve that allows air to enter the pleural cavity but not to escape, overpressure can build up with every breath

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Etiology / Contributing factors Spontaneous
Lung disease - COPD Tall, thin men A penetrating chest wound Barotrauma
scuba divers

Traumatic

Iatrogenic Pneumothorax
* insertion of a central line * thoracic surgery * thoracentesis * pleural or transbronchial biopsy.

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Clinical Manifestations (all types)
Sudden sharp chest pain Asymmetrical chest expansion dyspnea Cyanosis Percussion Hyper resonance or tympany Breath sounds diminished Absent

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Clinical Manifestations (all types)
Respiratory distress O2 Sats
decreased

Tachypnea Tachycardia Restlessness/ Anxiety

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S&S of open pneumothorax
Crepitus
(subcutaneous emphysema)

Sucking chest wound

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S&S Tension pneumothorax i cardiac output Hypotension Tachycardia
(compensatory)

Tachypnea Mediastinal shift and tracheal deviation

To the unaffected side

Cardiac arrest Distended neck veins

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Dx exam and tests HX & PE Chest x-ray ABGs
Initial PaCO2
Decreased respiratory alkalosis

Later ABGs
Hypoxemia Hypercapnia Acidosis

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Treatment - First aid: Open pneumothorax Cover immediately with an occlusive dressing, made airtight with petroleum jelly or clean plastic sheeting.

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Tx: Small pneumothorax Spontaneous recovery
Bed rest resolve on its own in 1 to 2 weeks

Remove with small bore needle inserted into the pleural space

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Tx: Larger pneumothorax Chest tube Surgery repair Pleurodesis
glue Very painful Prep with analgesic

O2 Surgery

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Nursing interventions Closely monitor resp status Frequent assess
LOC Color VS Chest pain? Restlessness?

Notify MD for:
SpO2 < 90% or Change Greater Than 5% Respiratory Distress Inadequate Sedation h Peak Airway Pressure (Especially with Pressure Control Mode)

Chest Tube Rest/Activity Balance Sedation Provide a means for communicate Educate patient & family

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Complications Recurrent pneumothorax
D/C
smoking high altitudes scuba diving flying in unpressurized aircrafts

Cardiac damage

Question?
A client who has been on a ventilator for two days experiences acute respiratory distress accompanied by distended neck veins. The best action of the nurse is to: A. hand ventilate the client. B. prepare for chest tube insertion. C. call the physician immediately. D. perform emergency chest decompression.

 The question is asking what the nurse should do when a client on a ventilator has these symptoms. When acute respiratory distress occurs along with neck vein distension, cyanosis and tracheal shift are evident, a tension pneumothorax has probably occurred. The client should be removed from the machine and ventilated by hand. Then the physician should be notified (option c). Equipment for chest tube insertion should be gathered (option b) so it will be ready for immediate use by the physician. Emergency chest decompression (option d) should only be attempted after specific training and if the physician will be delayed.

Small Group Questions

1. 2. What is the pathophysiology of a pneumothorax? Describe the anatomy of the pleural membrane (including nerves endings) What is a spontaneous pneumothorax? What are some examples of an iatrogenic pneumothorax? Define an open and closed pneumothorax.

3. 4. 5.

Small Group Questions

6. Describe the mediastial shift in an pneumothorax. 7. What is the first aid treatment of a traumatic pneumothorax (include assessment) 8. What is Pleurodesis? 9. What ABGs would you expect to see late in a patient with a pneumothorax?