Chapter 22

Pneumothorax

CL

GA

DD

Figure 22-1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm;
CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs.
Slide 1 Copyright © 2006 by Mosby, Inc.
 Anatomic Alterations of the Lungs
 Lung collapse
 Atelectasis
 Chest wall expansion
 Compression of the great veins and
decreased cardiac venous return

Slide 2 Copyright © 2006 by Mosby, Inc.

 Etiology—3 Ways
 From the lungs through a perforation of the
visceral pleura
 From the surrounding atmosphere through a
perforation of the chest wall and parietal
pleura or, rarely, through an esophageal
fistula or a perforated abdominal viscus
 From gas-forming microorganisms in an
empyema in the pleural space (rare)

Slide 3 Copyright © 2006 by Mosby, Inc.

 Pneumothorax Classifications
General Terms
 Closed pneumothorax
 Open pneumothorax
 Tension pneumothorax

Slide 4 Copyright © 2006 by Mosby, Inc.

 Pneumothorax Classifications
Based on Origin
 Traumatic pneumothorax
 Spontaneous pneumothorax
 Iatrogenic pneumothorax

Slide 5 Copyright © 2006 by Mosby, Inc.

 Figure 22-3. Closed (tension) pneumothorax produced
by a chest wall wound.
Slide 6 Copyright © 2006 by Mosby, Inc.
 Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura
that functions as a check valve.
Slide 7 Copyright © 2006 by Mosby, Inc.
 Spontaneous Pneumothorax

Slide 8 Copyright © 2006 by Mosby, Inc.

 Iatrogenic Pneumothorax

Slide 9 Copyright © 2006 by Mosby, Inc.

 Overview of the Cardiopulmonary
Clinical Manifestations Associated
with PNEUMOTHORAX
The following clinical manifestations result from
the pathophysiologic mechanisms caused (or
activated) by Atelectasis (see Figure 9-7)—the
major anatomic alterations of the lungs
associated with pneumothorax (see Figure 22-1).

Slide 10 Copyright © 2006 by Mosby, Inc.

 Figure 9-7. Atelectasis clinical scenario.
Slide 11 Copyright © 2006 by Mosby, Inc.
 Clinical Data Obtained at the
Patient’s Bedside
Vital signs
 Increased respiratory rate
 Stimulation of peripheral chemoreceptors
 Other possible mechanisms
• Decreased lung compliance
• Activation of the deflation receptors
• Activation of the irritant receptors
• Stimulation of the J receptors
• Pain/anxiety

 Increased heart rate, cardiac output, blood pressure

Slide 12 Copyright © 2006 by Mosby, Inc.
 Figure 22-5. Venous admixture in pneumothorax.
Slide 13 Copyright © 2006 by Mosby, Inc.
 Clinical Data Obtained at the
Patient’s Bedside
 Cyanosis
 Chest assessment findings
 Hyperresonant percussion note over the
pneumothorax
 Diminished breath sounds over the pneumothorax
 Tracheal shift
 Displaced heart sounds
 Increased thoracic volume on the affected side
• Particularly in tension pneumothorax

Slide 14 Copyright © 2006 by Mosby, Inc.

 Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a
pneumothorax, hyperresonant percussion notes are produced over the affected area.
Slide 15 Copyright © 2006 by Mosby, Inc.
 Figure 22-7. Breath sounds diminish as gas accumulates in the intrapleural space.
Slide 16 Copyright © 2006 by Mosby, Inc.
 Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter
increases on the affected side in a tension pneumothorax.
Slide 17 Copyright © 2006 by Mosby, Inc.
 Clinical Data Obtained from
Laboratory Tests and Special
Procedures

Slide 18 Copyright © 2006 by Mosby, Inc.

 Pulmonary Function Study:
Lung Volume and Capacity Findings

VT RV FRC TLC
N or    

VC IC ERV RV/TLC%
   N

Slide 19 Copyright © 2006 by Mosby, Inc.

 Arterial Blood Gases
Small Pneumothorax
 Acute alveolar hyperventilation with
hypoxemia

pH PaCO2 HCO3- PaO2

   (Slightly) 

Slide 20 Copyright © 2006 by Mosby, Inc.

 Time and Progression of Disease
Disease Onset Alveolar Hyperventilation
100

90 Point at which PaO2

declines enough to
80 stimulate peripheral
oxygen receptors
70
PaO2 or PaCO2

60
PaO2
50

40

30

20

10

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Slide 21 Copyright © 2006 by Mosby, Inc.
 Arterial Blood Gases
Large Pneumothorax
 Acute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

   (Slightly) 

Slide 22 Copyright © 2006 by Mosby, Inc.

 Time and Progression of Disease
Disease Onset Alveolar Hyperventilation Acute Ventilatory Failure
100

90 Point at which disease

becomes severe and patient
Point at which PaO2
begins to become fatigued
80 declines enough to
stimulate peripheral
70 oxygen receptors
Pa02 or PaC02

60

50

40

30

20

10

0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Slide 23 Copyright © 2006 by Mosby, Inc.
 Oxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

  Normal (severe)

O2ER SvO2
 

Slide 24 Copyright © 2006 by Mosby, Inc.

 Hemodynamic Indices
(Large Pneumothorax)

CVP RAP PA PCWP

   

CO SV SVI CI
   

RVSWI LVSWI PVR SVR

   

Slide 25 Copyright © 2006 by Mosby, Inc.

 Radiologic Findings

Chest radiograph
 Increased translucency
 Mediastinal shift to unaffected side
in tension pneumothorax
 Depressed diaphragm
 Lung collapse
 Atelectasis

Slide 26 Copyright © 2006 by Mosby, Inc.

 Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the heart and
mediastinum to the right away from the tension pneumothorax.
Slide 27 Copyright © 2006 by Mosby, Inc.
 A B

Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the right lung (arrow).
B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away
from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow).
Slide 28 Copyright © 2006 by Mosby, Inc.
 General Management of
Pneumothorax
 >20%—gas should be evacuated
 Negative pressure—5 to 12 cm H2O
 Should not exceed negative 12 cm H2O

Slide 29 Copyright © 2006 by Mosby, Inc.

 General Management of
Pneumothorax
Respiratory care treatment protocols
 Oxygen therapy protocol
 Hyperinflation therapy protocol
 Mechanical ventilation protocol

Slide 30 Copyright © 2006 by Mosby, Inc.

 General Management of
Pneumothorax
PLEURODESIS
 Chemical or medication injected into the
chest cavity
 Talc
 Tetracycline
 Bleomycin sulfate
 Produces inflammatory reaction between
lungs and inner chest cavity
 Causes lung to stick to chest cavity
Slide 31 Copyright © 2006 by Mosby, Inc.
 Classroom Discussion
Case Study: Pneumothorax

Slide 32 Copyright © 2006 by Mosby, Inc.