Pneumothorax and Hemothorax

Pneumothorax

Accumulation of air in the pleural space

Pneumothorax Pathophysiology

• Traumatic (blunt or penetrating trauma)

  • Open: wound is large enough that air is passed freely (sucking sound)

  • Closed

  • Iatrogenic: occurs because of procedure

• Spontaneous

  • Primary (PSP): occurs without any contributing factors

  • secondary (SSP): due to underlying pulmonary disease

Pneumothorax — Clinical Presentation

• Respiratory discomfort/pleuritic chest pain

• Increased RR/SOB

• Asymmetrical lung expansion

• Decreased tactile fremitus

• Hyperresonance with percussion (hollow)

• Decreased or absent lung sounds on affected side

Tension Pneumothorax

Air collects in the pleural space which causes air to be pushed outside of the lung into the thoracic cavity — results in shifting of structures in the mediastinum (trachea deviation)

Tension Pneumothorax — Clinical Presentation

Same clinical presentation symptoms of pneumothorax plus:

• Tachycardia (>134 bpm)

• Hypotension

• Tracheal deviation

• JVD

• Cyanosis

Hemothorax

Accumulation of blood in the pleural space

Hemothorax Pathophysiology

• Blunt trauma

• MVC

• Iatrogenic

• Vascular disease

• Infectious disease

Hemothorax — Clinical Presentation

Similar to pneumothorax, but:

• Blood in lungs (possibly)

• No JVD

• Hypovalemia

Pneumothorax/Hemothorax Risk Factors

• Smoking (tobacco, cannabis)

• Genetics (tall/thin, family hx, pregnancy, Marfan’s syn.)

• Environment (decreased atmospheric pressure)

• Age (PSP: males 20-30, SSs: females 60-65)

• Medical procedures (CVC placement, transthoracic procedures)

Pneumothorax/Hemothorax Health Impact

Age related changes

• Increased energy use

• Rigid chest wall — kyphosis

• Decreased lung capacity

• Decreased rib cage volume

• SpO2 range 93-94%

Pneumothorax/Hemothorax — Labs and Diagnostics

• CXR

• Ultrasonography

• Labs

• CT scan

Describe F.A.S.T.

Focused Assessment Sonography for Trauma — quick and portable method that helps identify free fluid (usually blood) in trauma patients.

What assessment finding would be most suggestive of a tension pneumothorax in a patient with chest trauma?

a. Dull percussion sounds on injured side

b. Severe respiratory distress and tracheal deviation

c. Muffled and distant heart sounds with decreasing BP

d. Decreased movement and diminished breath sounds on affects side

B

Pneumothorax/Hemothorax — Expected Findings

• Decreased SpO2 and increased PaCO2

• Diminished/absent breath sounds

• Hypotension

• Asymmetrical chest expansion

Pneumothorax/Hemothorax — Unexpected/Late Findings

• Severe hypoxemia

• Cardiopulmonary failure/shock

• Respiratory failure

• Cardiac arrest

What should the nurse’s priority solutions/plans be for a patient with Pneumothorax/Hemothorax?

• Decompress pneumothorax

• Eliminate blood collection

• Re-expand lung

What action should the nurse take to improve the condition of a patient with Pneumothorax/Hemothorax?

• High Fowler’s position

• Supplemental oxygen

• Splinting

• TCBD

• Analgesics

• Prepare for needle decompression or thoracentesis

• Prepare for chest tube insertion

What is the indication of a chest tube?

Removal of excess pleural fluid — postoperative drainage, pneumothorax, hemothorax

Steps for chest tube insertion

1. Place arm above head and elevated HOB to 30-60

2. Clean skin and apply local anaesthetic

3. Create a small incision and insert a digital probe

4. Insert chest tube

5. Connect tube to a collection device

6. Suture the tube in place and apply a occlusive dressing

7. CXR to verify placement

Chest Tube — Wet suction

Uses water to regulate suction pressure. The amount of water in the suction control chamber determines the negative pressure applied (continuous bubbling). Monitor the water in the chamber for evaporation and vigorous bubbling (tissue damage)

Chest Tube — Dry suction

Uses a regulator valve or dial to control suction. This type of suction is quieter because there is no water in the chamber. Monitor for air leaks.

What are some important key things to remember when transporting a patient with a chest tube?

• Keep collection device upright

• Tape connections

• Keep tubing loosely coiled

• Change system when full

• Do not clamp the tube

• If tubing is disconnected, reestablish water seal

Which findings indicate provider notification?

• Drainage > 1-1.5 L in first hour post chest tube insertion

• Drainage > 100 mL/hr after first hour

• Subcutaneous emphysema

• Respiratory distress

Why is it important NOT to strip (or milk) the chest tube?

• Create excess negative pressure

• Increases risk of lung trauma

• Can worsen clots or blockages

Subcutaneous Emphysema

Air becomes trapped in subcutaneous tissue (chest, neck, face). Crackles can be felt when palpating the area (like bubble wrap) — this is called crepitus

Steps for chest tube removal

• Premedicate prior to removal

• Valsalva maneuver during removal

• Apply occlusive dressing

• CXR

• Monitor for respiratory distress

• Observe dressing for drainage

A nurse is planning care for a client following placement of a chest tube 1 hour ago. Which of the following should the nurse include in the plan of care?

a. Clamp the chest tube if there is continuous bubbling in the air leak chamber

b. Keep the chest tube drainage system at the level of the right atrium

c. Tape all connection between the chest tube and drainage system

d. Empty the collection chamber and record the amount of drainage every 8 hours

C

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take?

a. Cover the insertion site with a hydrocolloid dressing after removal

b. Provide pain medication immediately after removal

c. Instruct client to perform the Valsalva maneuver during removal

d. Delegate removal of the chest tube to a LVn

C

An otherwise healthy 25 y.o. male arrived to the ED today with complaint of sudden shortness of breath and left-sided chest pain. A chest x-ray confirmed spontaneous left-sided closed pneumothorax. A chest tube was inserted into his left midaxillary area in the emergency department, and he was admitted and transported to a medical unit in the hospital. Currently he is alert, oriented, and anxious. He verbalized 6/10 pain using the pain intensity scale. Vital signs: BP 138/80 mmHg, HR 115 bpm, RR 24 (shallow). Left-sided breath sounds are absent upon auscultation. Oxygen saturation is 91%. His chest tube is attached to a three-chamber wall suction chest drainage unit. Are the nursing actions indicated, contraindicated, or nonessential?

a. Assess the air leak monitor for bubbling

b. Clamp chest tube so the client can easily ambulate to the bathroom

c. Avoid administration of pain meds to prevent respiratory depression

d. Provide instruction and encouragement for use of incentive spirometry

e. Encourage increased fluid intake

A. Indicated

B. Contraindicated

C. Contraindicated

D. Indicated

E. Nonessential