Pathophysiology: right side of the image) on CT • “Accumulation of air scan of the chest with chest tube in place. or gas in the pleural cavity” 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: • 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 – Car crash – Fall – Crushing chest injury Pneumothorax Iatrogenic pneumothorax • D/T procedure / treatment 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 – Lung disease - COPD – Tall, thin men • Traumatic – A penetrating chest wound – Barotrauma • scuba divers • Iatrogenic Pneumothorax – * insertion of a central line – * thoracic surgery – * thoracentesis – * pleural or transbronchial biopsy. Pneumothorax Clinical Manifestations (all types) • 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) • Tachypnea • Mediastinal shift and tracheal deviation – To the unaffected side • Cardiac arrest • Distended neck veins Pneumothorax Dx exam and tests • HX & PE • Chest x-ray • ABG’s – Initial PaCO2 • Decreased • respiratory alkalosis – Later ABG’s • Hypoxemia • Hypercapnia • Acidosis 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 – 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 – “glue” – Very painful – Prep with analgesic • O2 • Surgery Pneumothorax Nursing interventions • Closely monitor resp status • Notify MD for: • Frequent assess – SpO2 < 90% or – LOC Change Greater – Color Than 5% – VS – Respiratory Distress – Chest pain? – Restlessness? – Inadequate Sedation • Chest Tube Peak Airway • Rest/Activity Balance Pressure (Especially • Sedation with Pressure • Provide a means for Control Mode) communicate • Educate patient & family Pneumothorax 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: B. hand ventilate the client. C. prepare for chest tube insertion. D. call the physician immediately. E. 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. What is the pathophysiology of a pneumothorax? 2. Describe the anatomy of the pleural membrane (including nerves endings) 3. What is a spontaneous pneumothorax? 4. What are some examples of an iatrogenic pneumothorax? 5. Define an open and closed pneumothorax. Small Group Questions 1. Describe the mediastial shift in an pneumothorax. 2. What is the first aid treatment of a traumatic pneumothorax (include assessment) 3. What is Pleurodesis? 4. What ABG’s would you expect to see late in a patient with a pneumothorax?