Chest & Lower Respiratory Tract Disorders Part 1

Lower Respiratory Tract

• Trachea (windpipe)

• Bronchi

• Bronchioles

• Alveoli

• Lungs

• Diaphragm

Lower Respiratory A&P

Alveoli is where the gas exchange takes place- these are the grapelike clusters . 

• Trachea → carries air to the lungs

• Bronchi → carry air into each lung

• Bronchioles → smaller airways

• Alveoli → gas exchange (O₂ in, CO₂ out)

• Lungs → organs for breathing

• Diaphragm → main muscle used for breathing

• Pleura → membranes surrounding the lungs

Air pathway: Trachea → Bronchi → Bronchioles → Alveoli

Inhale: diaphragm contracts ↓ → air enters
Exhale: diaphragm relaxes ↑ → air leaves

Lung Dynamics - Compliance

Ability to accept gases

Lung Dynamics - Resistance

Resistance to inflow of gases

Lung Dynamics - Elastic Recoil

Ability to accept gas and return to original state

Mechanics of Breathing

• Ventilation

• Diffusion

• Gas Transport

Ventilation

• Mechanical movement of gas/air into and out of the lungs via movement of chest wall and diaphragm

• Air pressure changes, compliance & resistance to air flow

• Requires neurologic control, intact muscle and skeletal support

• movement of air in and out of lungs

  • Inhale O₂ → exhale CO₂

Diffusion

• O₂ moves from high concentration in alveoli → low concentration in capillaries

• CO₂ moves from high concentration in capillaries → low concentration in alveoli

• Requires an intact alveolar-capillary membrane

• movement of gases between alveoli and blood

  • O₂ → blood

  • CO₂ → alveoli

Gas Transport

• O2 supplied & CO2 removed via circulation

• O2 supplied from blood to cell (arterial) 

• CO2 removed from cell to blood (venous) 

• Requires intact circulatory system and sufficient

• movement of gases through the blood

  • O₂ mainly carried by hemoglobin

  • CO₂ mainly carried as bicarbonate

Respiration

gas exchange between the lungs and blood and between the blood and tissues

Perfusion

the filling of the pulmonary capillaries with blood

Problems of Ventilation

• Pleuritis (pleurisy)

• Pleural effusion

• Pneumothorax

• Chest Trauma

Problems of Ventilation - Related Nursing Diagnoses

• Ineffective airway clearance

• Ineffective breathing pattern

Pleuritis/Pleurisy - Pathophysiology

• Inflammation of pleural layers 

• Caused by:

  • Upper & lower respiratory infections*

    • e.g. pneumonia, TB

  • Collagen disease

  • Chest trauma

  • Pulmonary infarction or Pulmonary embolus (PE)

  • Primary & metastatic cancers

  • s/p Thoracotomy

Pleuritis/Pleurisy

• Inflammation of the pleura

• Inflammation → swelling → more inflammation (cycle)

• Pleura has intercostal nerve endings, making it painful

• With breathing, the pleural layers rub against each other → pain

• Deep breath and holding it can temporarily lessen the pain

Pleuritis/Pleurisy - Clinical Manifestations

• Pleuritic pain – worse with breathing/movement

• Sharp, knifelike pain

• Worse with inspiration

• Improves when breath is held (less pleural movement)

• Usually unilateral and localized to affected side

• May radiate to shoulder or abdomen

• Deep breathing, coughing, or sneezing makes pain worse

• Pain may decrease as pleural fluid collects

• Pleural friction rub may be heard early

• Parietal pleura has nerve endings → causes pain

• Visceral pleura has no pain-sensitive nerve endings

• Assess pain using PQRST (what makes it better/worse, location, quality, severity, timing)

Pleuritis/Pleurisy - Assessment

• Pleural friction rub –before fluid collects

• Listen with your stethc

Pleuritis/Pleurisy - Diagnostics

• CXR (chest X-ray) – most common

• CT scan – identifies cause/complications

• EKG – rule out cardiac cause of chest pain

• CBC – check for infection/inflammation

• Cardiac enzymes/troponin – evaluate for cardiac injury

Pleuritis/Pleurisy - Medical Mgmt

• Treat the underlying cause

• Analgesics – relieve pain

• Anti-inflammatory medications – e.g., indomethacin

• Intercostal nerve block – for severe pain; uncommon

• Avoid opioids

Pleuritis/Pleurisy - Nursing Management

• Provide comfort and pain relief

• Splint the chest

  • Turn onto the affected side → decreases depth of inspiration and pain

  • Hold a pillow against the chest when coughing/deep breathing

• Give analgesics and anti-inflammatory medications

• Encourage TCDB (turn, cough, deep breathe), despite discomfort

• Monitor for pleural effusion

• Look for guarding of the affected side

• Assess lung sounds

  • q2–4 hr depending on acuity

  • q1 hr if acutely ill

Pleural Effusion - Pathophysiology

• Excess fluid in the pleural space

• Normally, there is a small amount of fluid (<15 mL) to lubricate the pleural surfaces

• Often occurs secondary to another problem, such as pleuritis

• Common causes:

  • Heart failure

  • TB

  • Respiratory infections - espically viral

  • Pneumonia

  • SLE/connective tissue disorders

  • Nephrotic syndrome

  • Pulmonary embolism

  • Neoplasms

Pleural Effusion

Pleural Effusion - Fluid characteristics: Clear/Serous

Hydrothorax

• Clear or straw-colored fluid

Pleural Effusion - Fluid characteristics: Sanguinous

Hemothorax

• Blood in the pleural space

Pleural Effusion - Fluid characteristics: Purulent

Empyema

• Thick, greenish/pus-like fluid

• Often caused by pneumonia or lung abscess

• Patient may be acutely ill

• May require surgical drainage/removal

• Pseudomonas can be a cause

Pleural Effusion - Clinical Manifestations

• Symptoms depend on the underlying cause

• Severity depends on:

  • Amount of fluid

  • Speed of fluid collection

  • Underlying disease

• Common symptoms:

  • Chest pain

  • Cough

  • Fever

  • Dyspnea

  • Tachypnea

Pleural Effusion - Assessment

• Decreased/absent breath sounds

• Decreased tactile fremitus

  • less vibration felt through the chest when the patient speaks.

  • when the patient says “99,” you feel less vibration on the affected side.

• Dull/flat percussion

• Dyspnea/respiratory distress if large effusion

• Tracheal deviation away from affected side if large effusion

Pleural Effusion - Diagnostics

• CXR – detects fluid in the pleural space

• Chest CT – gives a more detailed view

• Thoracentesis – removes pleural fluid for testing

• Pleural fluid analysis:

  • C&S – culture & sensitivity

  • Gram stain – checks for bacteria

  • AFB – checks for TB

  • Cell count

  • Glucose

  • Protein

  • Amylase

  • LDH

  • Cytology – checks for abnormal/cancer cells

  • pH

• Pleural biopsy – removes a small tissue sample to identify the cause

Pleural Effusion - Medical Management

• Treat the underlying cause

  • Infection → antibiotics

  • Prevents further fluid buildup

  • To relieve discomfort

• Thoracentesis

  • Removes pleural fluid

  • May be guided by ultrasound or at the BS

• Chest tube

  • Used for large or complicated effusions

• Pleurodesis

  • Chemical irritant (e.g., talc) closes the pleural space

  • Helps prevent fluid from reaccumulating

  • Often used for malignant/recurrent effusions & require repeated thoracentesis (taps)

• Surgical pleurectomy

  • Removes part of the pleura

  • Drainage or shunt

  • Usually considered with malignant effusions

Pleural Effusion - Nursing Management

• Care based on underlying condition and symptoms

• Manage pain

• Prepare for procedures

• Document drainage amount

• Collect and properly label specimens

• Monitor chest tubes

  • Suction

  • Drainage

  • Water seal

• Provide comfort measures and position of comfort

• Administer analgesics as ordered

• Educate patient about procedures and pleural catheter/drain care

• Support the HCP and monitor the patient’s response to treatment

  • Provider obtains informed consent

  • RN may witness consent and reinforce teaching

  • RN does not obtain the informed consent for the procedure

Thoracentesis

• Invasive procedure to remove fluid from the pleural space

• Performed by the HCP, not the RN

• RN provides supportive care and may assist/observe

• Fluid can be sent to the lab for analysis

Documentation: Describe the drainage by amount, color, and consistency.

Pneumothorax - Pathophysiology

• Collapsed/deflated lung- partial or complete and air accumulates in pleural space

• Loss of negative pressure leads to entry of positive atmospheric pressure allowing air in

• Air enters the pleural space

• Causes the lung to partially or completely collapse

• Normally, pleural pressure is negative, keeping the lung inflated

• A breach in the pleura allows air to enter → loss of negative pressure

• Positive pressure causes the lung to collapse

• Lung collapse → decreased gas exchange/oxygenation

Pneumothorax - Types

• Simple

• Traumatic

• Tension

Simple Pneumothorax

• Spontaneous

  • occurs without trauma

• Often from rupture of a bleb (small air-filled blister) or bronchopleural fistula

• Can occur in otherwise healthy people

• More common in tall, thin males

Simple Pneumothorax - Clinical Presentation

• Symptoms depend on size of pneumothorax

• Sudden chest pain

• Dyspnea

• Tachypnea

• Tachycardia

• Decreased/absent lung sounds on affected side

• Hyperresonance on percussion on affected side

Simple Pneumothorax - Risks factors:

• Smoking

• Emphysema

• Tall, thin stature in a healthy person

• Marfan syndrome - genetic d/o that affects the connective tissue

• Pregnancy

• Familial pneumothorax

Traumatic Pneumothorax

• Pleural disruption from a chest wall wound

• Air enters through chest wall & trachea

• Medical Emergency!

Traumatic Pneumothorax - Causes

• Blunt trauma

• Penetrating trauma (e.g., knife wound)

• Medical procedures that puncture the pleura

Traumatic Pneumothorax - Open Pneumothorax

• Air moves in and out through the chest wall opening

• May cause a “sucking chest wound”

• Can cause mediastinal shift/swing:

  • Inspiration → mediastinum shifts toward the unaffected side

  • Expiration → shifts back toward the affected side

Traumatic Pneumothorax - Clinical presentation:

• Same signs and symptoms as simple

• Presence of OPEN SUCKING CHEST WOUND on inspiration

Hemothorax

• Pleural disruption → bleeding

• Blood collects in the pleural space

• Usually caused by trauma

• Can cause rapid, massive blood loss

• May lead to:

  • Lung collapse

  • Hypovolemic shock

• Treatment focuses on removing the blood, usually with a chest tube

• Hemopneumothorax = air + blood in the pleural space

• Severe cases may require immediate surgical intervention

Hemothorax - Clinical Presentation

• Same as simple pneumo

• Signs of shock!

  • Fast HR

  • Low BP

  • Pale, cool, clammy skin

  • Weak pulse

  • Fast breathing

  • Confusion/restlessness

  • ↓ urine output

• Diminished breath sounds on affected side

• Dullness on percussion affected side

Tension Pneumothorax

Life-threatening emergency!

• Air enters pleural space but cannot escape on expiration

• Air becomes trapped

• With each breath → pressure increases

• Increased intrathoracic pressure causes:

  • Lung collapse on affected side

  • Mediastinal shift toward the unaffected side

  • Compression of the heart and great vessels

  • ↓ venous return

  • ↓ cardiac output (CO)

  • Can lead to PEA (pulseless electrical activity)

Tension Pneumothorax - Clinical Presentation

• Severe difficulty breathing (dyspnea)

• Chest pain (CP)

• Markedly diminished/absent breath sounds on affected side

• Hypotension → ↓ cardiac output

• Distended neck veins (JVD) → compression of great vessels

• Late signs:

  • Cyanosis

  • Tracheal deviation AWAY from the affected side (toward opposite side)

Pneumothorax - Assessment

depends on severity. Some simple pneumothoraces may resolve on their own, but patients may be observed/admitted for monitoring.

• Oxygenation

  • Pallor → early sign

  • Cyanosis/duskiness → late sign

• Skin temperature

  • Cool if patient is in shock

• Vital signs

  • ↑ HR (tachycardia)

  • ↑ RR (tachypnea), often rapid/shallow

  • ↓ BP if severe/shock

• Tracheal alignment

  • Deviates away from affected side → tension pneumothorax

• Chest expansion

  • Decreased and asymmetrical

• Breath sounds

  • Diminished or absent on affected side

• Percussion

  • Hyperresonance → pneumothorax (air)

  • Dullness → hemothorax (blood)

• Subcutaneous emphysema

  • Air escapes into tissue under the skin

  • Feels/sounds like crackling or “crunching” (crepitus)

• “Air Hunger”

  • Anxious

  • Agitated/restless

  • Diaphoretic

  • Short of breath

Subcutaneous Emphysema

• Air escapes the pleural space and enters the subcutaneous tissue under the skin.

• Usually occurs after chest trauma or injury to the pleura/lung.

• Can affect the thorax, neck, and/or head.

• Area may appear swollen/edematous due to trapped air.

• Tactile crepitus when palpated → feels like Rice Krispies/crackling under the skin.

• If air spreads into the neck, it may compromise the airway.

• Can be distressing for the patient.

• Usually resolves over time as the air is absorbed or expelled.

Pneumothorax - Diagnostics

• SpO2 and/or ABGs

• Chest X-ray - everyday

• Chest CT*

• US

Pneumothorax - Medical Management

• Based on severity, type, and cause

• Goal: remove blood/air from the pleural space and to allow reinflation of the lung

• Supplemental O₂

• Chest tube insertion

  • Removes air or fluid/blood

  • Smaller tube → usually for air

  • Larger tube → usually for blood/fluid

  • Connected to suction as ordered

  • blood more dense so at bottom, air on top

• Antibiotics → may be given to prevent/treat infection

• Needle decompression → emergency treatment for tension pneumothorax

  • Used to rapidly release trapped air and decrease pressure

  • Followed by chest tube placement

• Autotransfusion → may be used with significant hemothorax to return the patient's own blood

• Emergency Thoracotomy

  • Thoracotomy = surgical opening of the chest

  • thoracotomy if >1500 ml of blood is aspirated or chest tube has > 200 ml/hr

Pneumothorax - Nursing Management

• Monitor Vitals/respiratory status

  • Reassess for signs of distress or hypoxia

  • Monitor SpO2 

  • Watch for Shock

• Assess for pain/anxiety

  • provide comfort measures

  • administer/analgesia

• Manage and Monitor chest chest tubes- amount/type of drainage

Chest Tubes & Drainage - 3 chamber system

• Collection chamber

• Seal chamber

• Suction chamber

Chest Tubes & Drainage - 3 chamber system: Collection chamber

• Collects pleural drainage

• Monitor the amount, color, and consistency of drainage

Chest Tubes & Drainage - 3 chamber system: Seal chamber

• Allows air to leave the patient

• Prevents air from entering the chest through the chest tube

• Acts as a one-way valve

• Traditional water seal: fill to 2 cm sterile water

• Dry seal: uses a mechanical one-way valve

Chest Tubes & Drainage - 3 chamber system: Suction chamber

• Controls/limits the amount of suction

• Wet suction: uses sterile fluid

• Dry suction: uses a mechanical device

• Usually set to 20 cm H₂O

• With low-vacuum suction, you may see bubbling in the suction chamber

Chest Tubes & Drainage - One way valve

• 7-12 Fr allows air out but no air in

• Smaller pneumothorax

Chest Drainage Systems - Water seal and wet suction

Chest Drainage Systems - Water seal and dry suction

Chest Tube Nursing Management

Action	Reason
1. Fill water-seal chamber with sterile water to the level specified by manufacturer (usually 2 cm).	Allows pleural air to escape while preventing air from going back into the chest.
2. Fill water-suction chamber to the ordered level, usually 20 cm H₂O.	Controls the amount of suction. If using dry suction, set the dial to the prescribed level.
3. Attach chest tube to collection chamber and tape all connections.	Keeps the system closed and prevents air leaks/disconnection.
4. Connect suction chamber to wall suction until gentle bubbling is present.	With wet suction, the amount of suction is determined by the water level (e.g., 20 cm H₂O), not by how much it bubbles.
5. Measure, mark, and record drainage.	Helps monitor blood/fluid loss. Frequency depends on how quickly the patient is draining (e.g., q15 min vs. q1 hr). Drainage should generally decrease over time.

Water seal = keeps air from going back in
Suction = controls negative pressure
Collection = measures drainage

Chest Tubes and Drainage - Nursing Management

Insertion Site

• Cover with occlusive, petroleum-based dressing

• Secure with tape

• Document tube placement based on post-procedure chest X-ray

• Keep tubing coiled on the bed

• Keep tubing free of kinks and dependent loops

Water-Seal Chamber

• Maintain fluid level at 2 cm

• Keep drainage unit upright

• Monitor for:

  • Fluid fluctuation (tidaling)

  • Air leaks

Collection Chamber

• Keep drainage unit below heart level

• Notify provider if:

  • Initial drainage >1,000 mL

  • Hourly drainage >200 mL/hr

• Document amount and characteristics/color of drainage

Suction Chamber

• Check fluid level

• Check suction gauge

• Check for bubbling

FOCA

• Assess and document fluctuation, output, color of drainage, and air leak

• Emergency  dislodgement-immerse tubing in sterile water

Chest Tubes and Drainage - Special Considerations

Chest Tube Clamping

• Avoid clamping unless specifically ordered or required by hospital policy.

• Clamping can cause tension pneumothorax by trapping air.

Chest Tube Milking/Stripping

• Avoid unless specifically ordered/per hospital policy.

• Can create excessive negative pressure in the pleural space.

Changing the Drainage System

• Change when the collection chamber is full or according to facility policy.

Chest Tubes and Drainage - If the tube comes OUT of the patient:

• Cover the insertion site with an occlusive dressing.

• use a 4 × 4 dressing and tape 3 sides, leaving one side untaped to allow air to escape.

• Notify the provider/emergency team.

Chest Tubes and Drainage - If the tubing becomes disconnected from the drainage system:

• Place the end of the chest tube into sterile water about 2 cm deep to create a temporary water seal.

• Reconnect to a new drainage system as soon as possible.

Flail Chest - Pathophysiology

• Usually results from blunt chest trauma

  • Examples: MVC, steering wheel, airbag injury

• 3 or more adjacent ribs are fractured in 2 or more places

  • Creates a free-floating/flail segment of the chest wall

  • Chest wall becomes unstable

• Causes paradoxical chest movement: opposite of rest of chest

  • Inspiration → flail segment moves IN

  • Expiration → flail segment moves OUT

• Leads to:

  • Severe difficulty breathing (DIB)

  • Inability to take a deep breath

  • ↓ Lung compliance

  • ↓ Gas exchange/oxygenation

• Mediastinum shifts toward the affected side → ↓ cardiac output

• 
  

Flail Chest

Flail Chest - Clinical Presentation

• Dyspnea

• Chest wall pain

• Hypoxemia/hypercarbia

• Hypotension

• 1st signs = paradoxical chest movement & Mediastinum

Flail Chest - Assessment (depends on severity)

• Paradoxical chest movement –moves in during inspiration and out during expiration

• Tenderness on palpation with bony crepitus

• Use of accessory muscles and increased work of breathing---- resp. distress

• Tachypnea, Hypotension

• Cyanosis

Flail Chest - Diagnostics

• Chest x-ray

• ABG

  • usually acidosis

Flail Chest - Medical Management

• Based on severity 

• Pain Control-intercostal nerve blocks, high thoracic epidural blocks, IV opioids

• Controlling secretions

• Mild- moderate

  • -clear airway by positioning, pain management, Chest PT

• Severe-

  • - intubation, mechanical ventilation with positive pressure -stabilizes chest wall, allows healing of fractures and pulmonary contusions, and improves gas exchange

  • rare surgical repair 

Flail Chest - Nursing Management

• Assess respiratory status

• Monitor oxygenation- SpO2

• Reassess pain and administer analgesia

• Monitor VS, I & O

• Manage secretions-positioning and suctioning

• Manage care needs re: intubation/ventilator

Pulmonary Contusion - Pathophysiology

• Lung injury from direct trauma

  • Usually blunt trauma

  • Can also occur from deceleration or high-velocity bullet wounds

• Damage causes blood to leak into the lung tissue (parenchyma)

• Leads to:

  • Hemorrhage

  • Edema

  • Protein/plasma leaking into the interstitial and alveolar spaces

• Frequently associated with flail chest

• Can affect one or both lungs

• Severity depends on:

  • Size of the contusion

  • Damage to the alveolar-capillary membrane

  • Development of atelectasis/infiltrates

• Respiratory status can worsen gradually, so patients need close monitoring.

Pulmonary Contusion

bruises

Pulmonary Contusion - Clinical Presentation

• May begin with subtle S&S

• Ranges from mild to severe  

• Dyspnea

• Ineffective cough at clearing secretions

• Hemoptysis/frank bloody secretions - coughing up blood

• Chest pain

Pulmonary Contusion - Assessment

• AIRWAY

• Chest wall contusions or abrasions

• Decreased breath sounds, crackles

• Tachypnea and tachycardia

• Hypoxemia

• Cyanosis

• Mental status changes-combativeness

Pulmonary Contusion - Diagnostics

• Chest x-ray-initial may be normal until infiltrates appear 1-2 days later

• ABG

• SpO2

• Hypercapnia (high carbon dioxide in the blood)

Pulmonary Contusion - Medical Management

Goals: Maintain airway, provide adequate oxygenation, and control pain.

Mild

• Supplemental O₂

• IV fluids and PO fluids to loosen secretions → avoid fluid overload

• Chest physiotherapy

• Coughing/deep breathing (TCDB)

• Incentive spirometer

• Tracheal suctioning as needed

• Pain control: intercostal nerve blocks or PCA opioids

• Antibiotics

Moderate

• Bronchoscopy → removes secretions

• Intubation + mechanical ventilation with PEEP

• Diuretics + fluid restriction → decrease pulmonary edema

• NGT → decompress stomach

Severe

• Respiratory failure may be present

• Intubation/mechanical ventilation

• PEEP

• Fluid restriction + diuretics → reduce pulmonary edema

• IV fluids as needed to treat hypovolemia

• Antibiotics → prevent/treat infection and pneumonia

Pulmonary Contusion - General Nursing Management

• Frequent reassessment and vital signs for signs of respiratory compromise

• Manage secretions-positioning and suctioning

• Strict I & O

  • subtract to see if negative or positive

• Reassess pain and administer analgesics

• Manage ventilator support

• Administer antibiotics