Pulmonary embolism & Pleural disorders

Whats a pulmonary embolism (PE)

Obstruction of a pulmonary artery in the lung by a clot

What causes a pulmonary embolism

Blood clot forms in deep veins of the legs, then breaks off and travels to the lungs

Why does a pulmonary embolism impair oxygenation?

The obstruction limits blood flow through the pulmonary circulation, reducing area available for effective gas exchange

Pulmonary embolism risk factors

• Orthopedic surgery (i.e pelvic surgery, hip/knee replacement)

• Pregnancy

• DVT

• Obesity

• Atrial fibrillation

• Long bone / pelvic fractures

• Heart failure

• Immobility

What materials can cause an embolism

Air, fat, blood, or amniotic fluids

What happens to pulmonary artery pressure during a pulmonary embolism?

It increases

Symptoms of pulmonary embolism

• Breathing changes (dyspnea or tachypnea)

• Chest pain

• Cough, sometimes with hemoptysis

• Crackles

• S3/S4 heart sounds heard

• Apprehension/anxiety

• Syncope (severe cases)

• Respiratory alkalosis

What acid-base disturbance may occur with pulmonary embolism

Respiratory alkalosis

why may inotropics be used in pulmonary embolism?

To increased blood pressure and cardiac output

What is a vena caval filter?

Filter placed in vena cava to help prevent clots from traveling to lungs

What medication category is commonly used to treat/prevent pulmonary embolism

Anticoagulants, thrombolytics in severe cases

How is a pulmonary embolism diagnosed

• Chest Xray

• Spiral CT (contrast dye injected into vein, shows clots)

Pleurisy

Inflammation of visceral and/or parietal pleura

Why does pleurisy cause pain?

Inflamed pleural membranes rub against one another, causing friction and swelling

Medications used to treat pleurisy

NSAIDs (decreases inflammation and reduces pain)

Causes of pleurisy

• pneumonia

• tuberculosis

• upper respiratory infections

• post op complications

Symptoms of pleurisy

• Sharp chest pain (worse with deep breaths/cough)

• Dry cough

• auditory pleural friction rub on auscultation

Pleural effusion

Collection of fluid in the pleural space

Conditions that may cause / contribute to pleural effusion

• TB

• Heart failure

• Infection

How can malignancy be related to pleural effusion?

Malignancy can cause fluid to accumulate in the pleural space

What breath sound finding is associated with pleural effusion?

Decreased breath sounds

What may happen to the trachea with a severe pleural effusion?

Tracheal deviation

Findings that may suggest significant pleural effusion

• Dyspnea/Orthopnea

• Pleuritic chest pain

• Decreased breath sounds

• Dullness to percussion

• Chills/fever

• Tracheal deviation away from effected side

What is the purpose of thoracentesis for pleural effusion?

To remove fluid from the pleural space

What is pleurodesis?

Medical procedure that seals space between lungs / chest wall to prevent recurrent pleural fluid accumulation

What is a PleurX catheter?

A catheter used to provide ongoing drainage of pleural fluid

What are treatment options for pleural effusion?

• Thoracentesis

• Pleurodesis

• PleurX catheter

• Chest tube

What is the overall pathophysiology of pleural effusion?

Fluid accumulates in the pleural space, which can interfere with lung expansion and cause respiratory symptoms

Empyema

Thick, purulent fluid in the pleural space

What breath sound finding may occur with empyema?

Decreased breath sounds

What method is used to drain an empyema?

Chest tube

Empyema s/s

• Cough

• SOB

• Night sweats

• Fever/malaise

Empyema is often a complication of…

Pneumonia

Pneumothorax

Air in the pleural space, leading to partial or complete lung collapse

What is the major respiratory problem caused by a pneumothorax?

Reduced lung expansion and impaired gas exchange

S/s of pneumothorax

• Sudden chest pain

• Decreased/absent breath sounds on affected side

• Dry cough

• Fatigue

• Respiratory distress (tachypnea/dyspnea, accessory muscle use)

• Subcutaneous emphysema

• Hypotension

What is a primary (spontaneous) pneumothorax

Happens without underlying lung disease or injury

What is a secondary pneumothorax

Happens because of an underlying lung disease ie COPD, asthma, TB

What is a tension pneumothorax

Increasing pressure within the pleural space compromises lung expansion and builds high pressure that crushes the heart and lung

What is a traumatic pneumothorax

Caused by an injury- gunshot, stab wound, MVA

Atelectasis

Collapse of alveoli or part of the lung

Respiratory findings consistent with atelectasis

• Respiratory distress

• Decreased breath sounds on affected side

• Hypoxia

• Tachycardia

• Pleuritic chest pain

What is an important nursing intervention to help prevent atelectasis?

Encourage deep breathing, coughing and use of incentive spirometer

What device is commonly used to promote lung expansion and prevent atelectasis?

Incentive spirometer

ARDS (acute respiratory distress syndrome)

Severe inflammatory lung condition characterized by significant impairment of oxygenation

What can happen to pulmonary function during ARDS?

lung compliance decreases and the lungs become more difficult to ventilate

What type of oxygenation problem is characteristic of ARDS?

Severe hypoxemia that may be difficult to correct

Causes of ARDS

• Direct lung injury (pneumonia, aspiration, pulmonary contusion)

• Indirect lung injury (sepsis, shock, acute pancreatitis, multiple blood tranfusions)

S/s of ARDS

• SOB

• Stiff lungs, hard to ventilate

• Hypoxemia

• Multi-organ dysfunction

• Pneumonia-like infiltrates on imaging

What is pulmonary hypertension?

Abnormally increased pressure in the pulmonary arteries

What happens to the right side of the heart with chronic pulmonary hypertension?

the right ventricle must work harder to pump blood through the pulmonary circulation

Why does pulmonary hypertension cause right heart failure

It forces the right ventricle to pump against abnormally high resistance, which eventually exhausts the muscle and causes it to enlarge and fail

Pulmonary hypertension diagnostics

• Chest X-ray

• EKG

• Echocardiogram

• PFT

• Cardiac catheterization

What can prolonged pulmonary hypertension lead to?

Right-sided heart failure

Symptoms that may occur with pulmonary hypertension

• Dyspnea/SOB

• Fatigue

• Chest pain

• Decreased exercise tolerance

• Edema/ascites

• RUQ pain

• Cyanosis

Medications for pulmonary hypertension

• Calcium channel blockers

• Epoprostenol

• Diuretics

• Anticoagulants

• Digoxin

Symptoms that may occur with lung cancer

• Persistent cough

• Dyspnea

• Chest pain

• Hemoptysis

Flail chest

condition in which multiple adjacent ribs are fractured in multiple places, creating a segment of the chest wall that moves independently

What is paradoxical chest movement?

Movement of a chest-wall segment in the opposite direction from the rest of the chest during breathing

What happens to the flail segment during inspiration?

the unstable segment moves inward

What happens to the flail segment during expiration?

The unstable segment moves outward

What is the difference between atelectasis and pneumothorax?

atelectasis involves collapse of alveoli/lung tissue; pneumothorax involves air entering the pleural space and potentially causing lung collapse

What is the difference between pneumothorax and pleural effusion?

Pneumothorax involves air in the pleural space, whereas pleural effusion involves fluid in the pleural space

A patient with chronic pulmonary hypertension develops worsening fatigue, peripheral edema, abdominal swelling, and dyspnea. Which complication should the nurse suspect?

right-sided heart failure

What are the 3 basic options for voice restoration after total laryngectomy

1. artificial larynx speech

2. esophageal speech

3. tracheoesophageal speech