Pneumothorax

Fluid in the Pleural Space

Small amt of fluid in the pleural space that allows the lungs to move smoothly

Negative pressure

Extremely important because it helps to keep the lungs expanded and inflated

Pneumothorax definition

Increased amount of air in the pleural space that causes positive pressure in the lungs and can lead to lung collapse or respiratory distress

Air exchange will be the most effected

Open vs closed pneumothorax

Open: when there is an open wound in the chest wall, allowing air to enter the pleural space from the outside environment

Closed: when there is no open wound. Something is happening within the body that causes air (positive pressure) to enter the pleural space and collapse the lungs

Two types of a Spontaneous/Closed pneumothorax

Primary: usually occurs in healthy people

Secondary: usually occurs in people with an underlying lung disease

Air blebs in primary closed pneumothorax

Air blebs (bubbles) occurs on the visceral part of the pleura

Found most often in tall and thin people

Secondary to rupture of an air bleb (when the bleb ruptures, it is adding air to the space which is creating positive space and the positive space is causing the lung to collapse)

Why do blebs rupture?

Changes in air pressure (changes in altitude)

Sudden deep breaths

Smoking

not all blebs rupture and not all blebs rupture at once

Secondary closed pneumothorax and most common cause

Occurs with people with existing lung diseases that cause trapping of gasses and destruction of lung tissue

Most common cause: emphysema

Closed/Spontaneous pneumothorax solution

Can resolve itself

Tension pneumothorax

Occurs when air builds up in the pleural space with no escape route, causing increasing pressure on the lung and surrounding tissues/organs (mediastinal shift) due to a one-way valve effect

Can occur due to a penatrating or non-penatrating chest injury

Two aspects that effect the degree of the clinical manifestations

Size of the pneumothorax

Integrity of the underlying lung tissue (what was the state of the lungs before the pneumo occured)

Spontaneous clinical manifestations

Devel of ipsilateral (same side of the pneumo) chest pain

Tension clinical manifestations

Increase in RR (tachypnea) accompanied by dyspnea

Asymmetry of chest (will hear hyperresonace when percussed - like a drum bc of a air inside)

Breath sounds are decreased or diminished

Subcutaneous emphysema - means an accumulation of CO2

Hypoxemia (not enough O2 in blood or tissues)

How to assess for subcut emphysema

Need to inspect to see air bubbles on skin

Can also palpate the area and if it is present, you would hear a crunchy sound like rice crispies

Mediastinal Shift

When the organs in the mediastinum shifts to the unaffected space due to increased thoracic pressure

Late and life-threatening sign

Occurs in tension pneumothorax

Trachea location during mediastinal shift + what it affects

Deviated to the opposite side of the collapsed lung

Affect air exchange and resp rate/rhythm

Seen on assessment (pulse ox) and a chest x ray

Heart location during a mediastinal shift + its affects

Deviated to the unaffected side

Stroke volume (amt of blood pumped out during a contraction) is reduced and CO is decreased

Vena cava during the mediastinal shift

It is compressed and decreased venous return

Jugular neck vein distention occurs

Mediastinal shift and pressure

Pressure is now being applied to the unaffected area due to the mediastinal shift

Pneumothorax diagnosis

History and Physical Exam

Chest x-ray

CT scan

Ultrasonography

Pulse ox

Blood gas analysis (expect to see a decrease in O2 and CO2)

Spontaneous treatment

Only requires observation and follow up chest x ray

Supplemental O2 may be used

Needle aspiration

Immediate treatment that removes the air

Allows air to escape from the pleural space, and the lung to re-expand

Needle aspiration details

A hollow needle with a catheter is inserted between the ribs and into the pleural space

Needle is removed and a syringe is attached to the catheter

Syringe is used to remove the excess air

Chest tube purpose

Drain the pleural space

Reestablish negative pressure

Allow for proper lung expansion

Chest tube details

Chest x ray is used to confirm the affected space

Area is cleaned with an antiseptic solution

Provider will use a local anesthetic and make a small incision over the rib

A tube is inserted into the pleural space and attached to a drainage tube to pull the air out

Provider sutures the tube in place and closes the incision with sutures

Nursing considerations to tell the patient about the chest tube insertion

Arm will be raised above the head on the affected side to expose the mid-axillary area

Elevate pt’s head of bed 30-60 degrees to lower the diaphragm and reduce the risk of injury

Chest tube insertion site recovery

Wound is covered with an occlusive dressing (dressing filled with petroleum (airtight) gauze)

What to monitor after a chest tube insertion?

Vitals - pay close attention to resp rate and rhythm

Assess the function of the closed drain system

Potential complications of a chest tube insertion

Infection

Hemorrhage

Injury to the lung

Most impt thing if you had a patient come in with a very clear pneumothorax?

Apply a gauze dressing and tape it over the open wound on three sides

Allows air to leave the wound (creates a flap)