DISTURBANCE IN OXYGENATION

PNEUMOTHORAX

Prepared by; ALINGAN, M. TOMADA, S.

INTRODUCTION
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Pneumothorax is a collection of air or gas in the chest or pleural space that causes part or all of a lung to collapse. Normally, the pressure in the lungs is greater than the pressure in the pleural space surrounding the lungs. However, if air enters the pleural space, the pressure in the pleura then becomes greater than the pressure in the lungs, causing the lung to collapse partially or completely. Pneumothorax can be either spontaneous or due to trauma. If a pneumothorax occurs suddenly or for no known reason, it is called a spontaneous pneumothorax. This condition most often strikes tall, thin men between the ages of 20 to 40. In addition, people with lung disorders, such as emphysema, cystic fibrosis, and tuberculosis, are at higher risk for spontaneous pneumothorax. Traumatic pneumothorax is the result of accident or injury due to medical procedures performed to the chest cavity, such as thoracentesis or mechanical ventilation. Tension pneumothorax is a serious and potentially life-threatening condition that may be caused by traumatic injury, chronic lung disease, or as a complication of a medical procedure. In this type of pneumothorax, air enters the chest cavity, but cannot escape. This greatly increased pressure in the pleural space causes the lung to collapse completely, compresses the heart, and pushes the heart and associated blood vessels toward the unaffected side.

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 Review- Pleural 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

Pneumothorax
Anatomy review - Breathing  Diaphragm  & 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 ()   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

Pneumothorax

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.

Pneumothorax
Classifications of pneumothorax  Spontaneous pneumothorax
 

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

Pneumothorax
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.

Pneumothorax
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

Pneumothorax

Traumatic Pneumothorax

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

Pneumothorax
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

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

Pneumothorax
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

Pneumothorax
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

Pneumothorax

Pneumothorax
Etiology / Contributing factors  Spontaneous
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Traumatic
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Lung disease - COPD Tall, thin men A penetrating chest wound Barotrauma

Iatrogenic Pneumothorax
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scuba divers

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

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

Pneumothorax
Clinical Manifestations (all types)  Respiratory distress  O2 Sats  decreased  Tachypnea  Tachycardia  Restlessness/ Anxiety

Pneumothorax
S&S of open pneumothorax

Crepitus

(subcutaneous emphysema)

Sucking chest wound”

Pneumothorax
S&S Tension pneumothorax   cardiac output  Hypotension  Tachycardia
(compensatory)
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Tachypnea Mediastinal shift and tracheal deviation

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Cardiac arrest Distended neck veins

To the unaffected side

Pneumothorax
Dx exam and tests  HX & PE  Chest x-ray  ABG’s

Initial PaCO2
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Decreased respiratory alkalosis Hypoxemia Hypercapnia Acidosis

Later ABG’s
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Pneumothorax
Treatment - First aid: Open pneumothorax  Cover immediately with an occlusive dressing, made air-tight with petroleum jelly or clean plastic sheeting.

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

Remove with small bore needle inserted into the pleural space

Pneumothorax
Tx: Larger pneumothorax  Chest tube  Surgery repair  Pleurodesis
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“glue” Very painful Prep with analgesic

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O2 Surgery

Pneumothorax
Nursing interventions  Closely monitor resp status  Frequent assess  LOC  Color  VS  Chest pain?  Restlessness?  Chest Tube  Rest/Activity Balance  Sedation  Provide a means for communicate  Educate patient & family

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

Pneumothorax
Complications  Recurrent pneumothorax

D/C  smoking  high altitudes  scuba diving  flying in unpressurized aircrafts

Cardiac damage

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