NCM 118 (4)

PNEUMOTHORAX 1.

HEMOTHORAX
Pneumothorax

• Any chest injury that

allows air to enter the
pleural space results in a
rise in intrathoracic
pressure.

Hemothorax

• is a collection of blood in
the pleural space
Spontaneous Pneumothorax
– Spontaneous pneumothorax in most patients occurs
due to the rupture of bullae or blebs.

A. Primary Spontaneous Pneumothorax

KEY POINTS TO REMEMBER ABOUT PNEUMOTHORAX
B.
• It can be a partial or total collapse of the lung (mainly affects one
lung).
• Causes include but not limited to: spontaneous (without warning),
trauma to the chest (blunt or penetrating), lung disease, medical
procedures (central line placement, mechanical ventilation).
• occurs in people without lung disease, but
these patients had asymptomatic bullae or blebs on
thoracotomy
• tend to be young <30 years of age
• Occurs in tall and thin male holding his breath
• Smokers, due to increased inflammatory cell
Secondary Spontaneous Pneumothorax
• Occurs in people with lung disease
• Commonly, chronic obstructive pulmonary disease;
others may include tuberculosis, sarcoidosis, cystic
fibrosis, malignancy, idiopathic pulmonary fibrosis, and
pneumocystis jiroveci pneumonia.

• It is diagnosed with a chest x-ray, ultrasound, or CT scan.

• A small pneumothorax usually resolves on its own.

• A large pneumothorax usually requires treatment like a chest tube to

remove air from intrapleural space or needle aspiration (as with a
tension pneumothorax).

PATHOPHYSIOLOGY

• Negative pressure. The negative pressure is required to maintain

lung inflation.

• Breach. When either pleura is breached, air enters the pleural space.

• Collapse. When positive pressure has entered the pleural space, the
lung or a portion of it collapses.

TYPES OF PNEUMOTHORAX

1. Spontaneous Pneumothorax
a. Primary spontaneous pneumothorax 2. Traumatic Pneumothorax
b. Secondary spontaneous pneumothorax – An opening in the chest wall that causes
a passage between outside air and the
2. Traumatic Pneumothorax intrapleural space.
a. Close pneumothorax – This allows air to pass back and forth
b. Open pneumothorax during inspiration and expiration.
Therefore, the body will shunt air
3. Tension Pneumothorax through the chest wall opening instead
of the trachea
– Causes: Stab wounds, Gunshot,
Penetrating traumas
  Open "sucking" chest wounds are treated initially with a
three-sided occlusive dressing. Further treatment may
require tube thoracostomy and chest wall defect repair.
Clinical Diagnosis of Tension Pneumothorax
• Asymmetry of the thorax
• Tracheal Deviation to the unaffected side
• Respiratory distress
• Absence of breath sounds on one side
• Distended neck veins
• Cyanosis
• Hypertympanic sound on percussion over the affected side

A. Closed Pneumothorax
• Air leaks into the intrapleural space
without any outside wound
• Example of what can cause this: a rib
fracture where the sharp, bony part
of the bone punctures the lung
causing air to be released into the
intrapleural space.
• Blunt traumas
• Causes of Blunt Traumas:
Motor Vehicular Accident
COLLABORATIVE MANAGEMENT
ASSESSMENT
Signs and Symptoms
Remember the mnemonic: COLLAPSED
 Chest pain (sharp and sudden and worst on inspiration), Cyanosis
 Overt tachycardia and tachypnea
 Low blood pressure
 Low SpO2
 Absent lung sounds on affected side
Fall or Physical Abuse  Pushing of trachea to unaffected side (tension pneumothorax
 Subcutaneous emphysema (escaping carbon dioxide collecting in
the skin…crunchy bulges on the skin), Sucking sound with open
pneumothorax
 Expansion of chest rise and fall unequal
 Dyspnea

ASSESSMENT AND DIAGNOSIS

• Thoracic CT: Studies show that CT is more sensitive than x-ray in
detecting thoracic injuries, lung contusion, hemothorax, and
pneumothorax. Early CT may influence therapeutic management.

IATROGENIC CAUSES OF PNEUMOTHORAX • Chest x-ray: Reveals air and/or fluid accumulation in the pleural
space; may show a shift of mediastinal structures (heart).
• Mechanical Ventilation (PEEP)
• Subclavian CVC • ABGs: Variable depending on the degree of compromised lung
• Thoracentesis function, altered breathing mechanics, and the ability to
• Pleural Biopsy compensate. Paco2 occasionally elevated. Pao2 may be normal or
• CPR decreased; oxygen saturation usually decreased.
• Thoracentesis: Presence of blood/serosanguineous fluid indicates
3. Tension pneumothorax: hemothorax.
− A complication of a pneumothorax (can
happen with open or closed
pneumothorax).
− This is a medical emergency.
− It happens when the opening to the
intrapleural space creates a one-way valve
MEDICAL MANAGEMENT
where air collects into the space but never
leaves. • For patients with associated symptoms and showing signs of
− This causes major compression on the lungs instability, needle decompression is the
and heart. treatment of a pneumothorax.
• This usually is performed with a 14- to 16-gauge
and 4.5 cm in length angiocatheter, just superior
Anatomy changes with a Tension Pneumothorax
to the rib in the second intercostal space in the
midclavicular line.
• Mediastinal shift causes heart, trachea, esophagus, and vessels to
shift to the UNAFFECTED side and this will compress the unaffected • After needle decompression or stable pneumothoraces, the
lung and venous vessels. treatment is inserting a thoracostomy tube.
• Major Signs and Symptoms of Tension Pneumothorax:
• Major: Tachycardia, Tachypnea, Hypotension and Hypoxia • Chest Tube Thoracostomy - tube is usually placed between the mid
• As well as: Respiratory distress, jugular venous distention, to anterior axillary line in the fourth or fifth intercostal space
tracheal deviation (LATE SIGN) tracking above the rib.
• If a patient is on mechanical ventilation w/ PEEP (positive end- • Maintain a closed chest drainage system. Be sure to tape
expiratory pressure) they are at risk for a tension pneumothorax due all connections, and secure the tube carefully at the
to barotrauma which causes buildup of pressure in the intrapleural insertion site with adhesive bandages.
space from rupture of the visceral pleura.
 • Regulate suction according to the chest tube system 1. Acute pain related to the positive pressure in the pleural space.
directions; generally, suction does not exceed 20 to 25 cm 2. Ineffective breathing pattern related to respiratory distress.
H2O negative pressure. 3. Ineffective peripheral tissue perfusion related to severe
hypoxemia.
4. Anxiety related to difficulty in breathing.
NURSING CARE PLANNING AND GOALS

• Monitor a chest tube unit for any kinks or bubbling. These could
indicate an air leak, but do not clamp a chest tube without a physician’s
order because clamping may lead to tension pneumothorax.
• Troubleshooting if drain comes out or system breaks
• Water seal chamber: It may have intermittent
bubbling as air is drained from the pleural space.
• The water seal chamber fluctuates as the patient
breathes in and out.
• If it stops fluctuating there may be a kink somewhere
or the lung has re-expanded. NOT normal to have
excessive bubbling in the water seal chamber (air
leak somewhere).
Nursing Responsibilities in Chest Tube
• Monitoring vital signs as directed, observing for pain and signs of
infection, and assessing the tube and drain system.
• Recording the amount and color of chest drainage
• Ensuring proper function
• Change any dressings and provide necessary wound care
• Routine observation of the chest tube insertion site. Chest tubes are
commonly sutured to the skin to hold the tube in place. The
insertion site is covered with a dressing to protect the area.
• Clamping the Tube. With the exception of tunneled catheters, as a
general rule, chest tubes should not be clamped unless it is
necessary to replace the drain system or it is ordered by the
provider.
 Relief of pain.
 Adherence to the prescribed pharmacological regimen.
 Establishment of a normal, effective respiratory pattern as
evidenced by the absence of cyanosis.
 Demonstration of increase in perfusion.
 Be relaxed and report anxiety is reduced to a manageable level.
NURSING INTERVENTIONS FOR PNEUMOTHORAX
• Monitor breath sounds (equal sounds on both sides), equal rise
and fall of the chest
• Vital signs (HR, blood pressure, oxygen saturation), and patient
effort of breathing
• Look for subq emphysema (can be found on the face, abdomen,
armpits, neck (affects breathing)
• Administering oxygen as ordered.
• Maintain chest tube drainage system if placed by physician
• Keep HOB of the bed elevated…Fowler’s position
DISCHARGE AND HOME CARE GUIDELINES
 Asepsis. The site of incision should be handled aseptically to avoid
occurrence of infection.
 Medications. Medications prescribed such as analgesics and
antibiotics should be taken religiously.
 Follow up. Follow up appointments should be attended to allow
the physician to assess the surgical site and the state of your
respiratory system.
 Activity. Alternate rest and activities to avoid over exhaustion and
difficulty in breathing.

• If the tube is completely pulled out from the patients’ chest,

immediately apply pressure and apply a sterile petroleum
impregnated gauze over the site and call the physician
immediately
• Kinks & Clots. If the water seal is not fluctuating with breath, you
may have a kink or clot. The water seal is not fluctuating because
the tube cannot drain past the blockage. Kinks are easy to fix:
simply straighten out the tube or resolve kinked connections.

MEDICAL MANAGEMENT (cont.)

• Autotransfusion. Autotransfusion involves taking the patient’s

own blood that has been drained from the chest, filtering it, and
then transfusing it back into the vascular system.
• Antibiotics. Antibiotics are usually prescribed to combat infection
from contamination.
• Oxygen therapy. The patient with possible tension pneumothorax
should immediately be given a high concentration of
supplemental oxygen to treat the hypoxemia.

SURGICAL MANAGEMENT
If more than 1500 ml of blood is aspirated initially by thoracentesis, the rule
is to open the chest wall surgically.

• Thoracotomy. The chest wall is opened surgically to remove the

blood or air trapped in the pleural space.

COMMON NURSING DIAGNOSIS