Respiratory Pleural and Thoracic Injury Marnie Quick, RN, MSN, CNRN

Thoracic cavity Lungs Lungs Mediastinum Mediastinum Heart Heart Aorta and great vessels Aorta and great vessels Esophagus Esophagus Trachea Trachea

Breathing: inspiration When the diaphragm contracts, it moves down, increasing the volume of the thoracic cavity When the volume increases, the pressure inside decreases When the diaphragm contracts, it moves down, increasing the volume of the thoracic cavity When the volume increases, the pressure inside decreases Air moves from an area of higher pressure, the atmosphere, to an area of lower pressure, the lungs Air moves from an area of higher pressure, the atmosphere, to an area of lower pressure, the lungs Pressure within the lungs is called intrapulmonary pressure Pressure within the lungs is called intrapulmonary pressure

Breathing: exhalation Exhalation occurs when the phrenic nerve stimulus stops Exhalation occurs when the phrenic nerve stimulus stops The diaphragm relaxes and moves up in the chest The diaphragm relaxes and moves up in the chest This reduces the volume of the thoracic cavity This reduces the volume of the thoracic cavity When volume decreases, intrapulmonary pressure increases When volume decreases, intrapulmonary pressure increases Air flows out of the lungs to the lower atmospheric pressure Air flows out of the lungs to the lower atmospheric pressure

Breathing This is normally an unconscious process This is normally an unconscious process Lungs naturally recoil, so exhalation restores the lungs to their resting position Lungs naturally recoil, so exhalation restores the lungs to their resting position However, in respiratory distress, particularly with airway obstruction, exhalation can create increased work of breathing as the abdominal muscles try to force air out of the lungs However, in respiratory distress, particularly with airway obstruction, exhalation can create increased work of breathing as the abdominal muscles try to force air out of the lungs If two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure If two areas of different pressure communicate, gas will move from the area of higher pressure to the area of lower pressure

Respiratory airways and unit

Lungs are surrounded by thin tissue called the pleura, a continuous membrane that folds over itself Parietal pleura lines the chest wall Parietal pleura lines the chest wall Visceral pleura (pulmonary) covers the lung Visceral pleura (pulmonary) covers the lung Pleural anatomy

Normally, the two membranes are separated only by the lubricating pleural fluid Fluid reduces friction, allowing the pleura to slide easily during breathing Pleural anatomy Parietal pleura Visceral pleura Normal Pleural Fluid Quantity: Approx. 25mL per lung Lung RibsIntercostal muscles

Pleural physiology The area between the pleura is called the pleural space (sometimes referred to as “potential space”) The area between the pleura is called the pleural space (sometimes referred to as “potential space”) Normally, vacuum (negative pressure) in the pleural space keeps the two pleura together and allows the lung to expand and contract Normally, vacuum (negative pressure) in the pleural space keeps the two pleura together and allows the lung to expand and contract During inspiration, the intrapleural pressure is approximately -8cmH 2 0 (below atmosphere) During inspiration, the intrapleural pressure is approximately -8cmH 2 0 (below atmosphere) During exhalation, intrapleural pressure is approximately -4cmH 2 0 During exhalation, intrapleural pressure is approximately -4cmH 2 0

When pressures are disrupted If air or fluid enters the pleural space between the parietal and visceral pleura, the -4cmH 2 0 pressure gradient that normally keeps the lung against the chest wall disappears and the lung collapses Intrapulmonary pressure: -4cmH 2 0 Intrapleural pressure: -8cmH 2 0

Pleural injury: Pneumothorax Etiology/Patho- air in pleural space Etiology/Patho- air in pleural space Closed Closed Open Open Tension Tension Clinical manifestations Emergency manag Clinical manifestations Emergency manag Lewis 586 Table Lewis 586 Table 28-20

Closed Pneumothorax Chest wall is intact Chest wall is intact Rupture of the lung and visceral pleura allows air into the pleural space Rupture of the lung and visceral pleura allows air into the pleural space Spontaneous- no apparent cause (thin individual) Spontaneous- no apparent cause (thin individual) Blunt trauma-CPR/fall Blunt trauma-CPR/fall Penetrating from fractured ribs Penetrating from fractured ribs

Open Pneumothorax Opening in the chest wall Opening in the chest wall Allows atmospheric air to enter/exit the pleural space during respiration Allows atmospheric air to enter/exit the pleural space during respiration Penetrating trauma: stab, gunshot, impalement Penetrating trauma: stab, gunshot, impalement

Tension pneumothorax Tension pneumothorax occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build Tension pneumothorax occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build That pressure is then transmitted to the mediastinum (heart and great vessels) That pressure is then transmitted to the mediastinum (heart and great vessels)

Mediastinal shift Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest These structures are compressed from external pressure and cannot expand to accept blood flow These structures are compressed from external pressure and cannot expand to accept blood flow Cardiovascular collapse Cardiovascular collapse

Which is more life threatening?

Pleural injury: Hemothorax Blood in pleural space Blood in pleural space Caused by trauma; lung Caused by trauma; lung malignancy; pulmonary embolus; complication anticoagulant therapy malignancy; pulmonary embolus; complication anticoagulant therapy Like pneumothorax- lung can collapse Like pneumothorax- lung can collapse Manifestations similar to pneumothorax; blood loss symptoms; dull percussion over blood Manifestations similar to pneumothorax; blood loss symptoms; dull percussion over blood

Rib fractures

Free floating rib fracture may result in Flail chest with paradoxic respirations

Pleural effusion Fluid in the pleural space is pleural effusion Fluid in the pleural space is pleural effusion Transudate is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure Transudate is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure Exudate is a cloudy fluid with cells and proteins that collects when the pleura are affected by malignancy or diseases such as tuberculosis and pneumonia. Pus-empyema Exudate is a cloudy fluid with cells and proteins that collects when the pleura are affected by malignancy or diseases such as tuberculosis and pneumonia. Pus-empyema

Pleural effusion- common manifestations and collaborative care Common manifestations Common manifestations Dyspnea, pleuritic pain, dec/absent breath sounds, limited chest wall movement Dyspnea, pleuritic pain, dec/absent breath sounds, limited chest wall movement Diagnostic tests- Chest X-ray; CT; analysis of aspirated fluid from thoracentesis Diagnostic tests- Chest X-ray; CT; analysis of aspirated fluid from thoracentesis Treatment- Treatment- Thoracentesis- insert needle into space to drain fluid Thoracentesis- insert needle into space to drain fluid Treat underlying cause Treat underlying cause administer O2 administer O2

Thoracentesis- needle to remove fluid

Collaborative care for pleural/thoracic Injuries Diagnostic tests- chest X-ray; CT; O2 sats; ABG’s/CBC; analysis of aspirated fluid; pulmonary function studies Diagnostic tests- chest X-ray; CT; O2 sats; ABG’s/CBC; analysis of aspirated fluid; pulmonary function studies High Fowlers; O2; rest to dec O2 demand High Fowlers; O2; rest to dec O2 demand Treatment depends on severity- chest tube to restore negative pressure Treatment depends on severity- chest tube to restore negative pressure Emergency management chest trauma (Lewis p 567 Table 28-21) Emergency management chest trauma (Lewis p 567 Table 28-21) Emergency management thoracic injury (Lewis p 566 Table 28-20) Emergency management thoracic injury (Lewis p 566 Table 28-20)

Chest Surgeries Lewis 567 Table Exploratory thoracotomy Exploratory thoracotomy Incision into thorax to look for injured or bleeding tissue Incision into thorax to look for injured or bleeding tissue Thoracotomy not involving lung Thoracotomy not involving lung VATS VATS Video-assisted thoracic surgery to do lung biopsy, lobectomy, ect Video-assisted thoracic surgery to do lung biopsy, lobectomy, ect

Chest Tubes– to remove air & fluid Also called “thoracic catheters” Different sizes From infants to adults Small for air, larger for fluid Different configurations Curved or straight Types of plastic PVC Silicone Coated/Non-Coated Heparin Decrease friction

Chest tube insertion Choose site Explore with finger Place tube with clamp Suture tube to chest Photos courtesy trauma.org

Different placement of chest tubes to remove air & to remove fluid

Chest tubes in place

Prevent air & fluid from returning to the pleural space Chest tube is attached to a drainage device Allows air and fluid to leave the chest Allows air and fluid to leave the chest Contains a one-way valve to prevent air & fluid returning to the chest Contains a one-way valve to prevent air & fluid returning to the chest Designed so that the device is below the level of the chest tube for gravity drainage or attached to suction Designed so that the device is below the level of the chest tube for gravity drainage or attached to suction What happens if you clamp the chest tube? What happens if you clamp the chest tube?

Water suction on left Dry suction right Lewis p. 570 Fig 28-8

Prevent air & fluid from returning to the pleural space Most basic concept Most basic concept Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw Most basic concept Most basic concept Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw Just like a straw in a drink, air can push through the straw, but air can’t be drawn back up the straw Tube open to atmosphere vents air Tube from patient

Prevent air & fluid from returning to the pleural space For drainage, a second bottle was added For drainage, a second bottle was added The first bottle collects the drainage The first bottle collects the drainage The second bottle is the water seal The second bottle is the water seal With an extra bottle for drainage, the water seal will then remain at 2cm With an extra bottle for drainage, the water seal will then remain at 2cm

Restore negative pressure in the pleural space Many years ago, it was believed that suction was always required to pull air and fluid out of the pleural space and pull the lung up against the parietal pleura Many years ago, it was believed that suction was always required to pull air and fluid out of the pleural space and pull the lung up against the parietal pleura However, recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own However, recent research has shown that suction may actually prolong air leaks from the lung by pulling air through the opening that would otherwise close on its own If suction is required, a third bottle is added If suction is required, a third bottle is added

Restore negative pressure in the pleural space The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator

How a chest drainage system works Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest Suction can improve the speed at which air and fluid are pulled from the chest

From bottles to one box

At the bedside Keep drain below the chest for gravity drainage Keep drain below the chest for gravity drainage This will cause a pressure gradient with relatively higher pressure in the chest This will cause a pressure gradient with relatively higher pressure in the chest Fluid, like air, moves from an area of higher pressure to an area of lower pressure Fluid, like air, moves from an area of higher pressure to an area of lower pressure Same principle as raising an IV bottle to increase flow rate Same principle as raising an IV bottle to increase flow rate

Setting up the Chest drainage system Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber (unless a different level is ordered) Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber (unless a different level is ordered) Connect 6' patient tube to thoracic catheter Connect 6' patient tube to thoracic catheter Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber

Setting up suction Vigorous bubbling is loud and disturbing to most patients Vigorous bubbling is loud and disturbing to most patients Will also cause rapid evaporation in the chamber, which will lower suction level Will also cause rapid evaporation in the chamber, which will lower suction level Too much bubbling is not needed clinically in 98% of patients – more is not better Too much bubbling is not needed clinically in 98% of patients – more is not better If too much, turn down vacuum source until bubbles go away, then slowly increase until they reappear, then stop If too much, turn down vacuum source until bubbles go away, then slowly increase until they reappear, then stop

Monitoring Water seal is a window into the pleural space Water seal is a window into the pleural space Not only for pressure Not only for pressure If air is leaving the chest, bubbling will be seen here If air is leaving the chest, bubbling will be seen here Air meter (1-5) provides a way to “measure” the air leaving and monitor over Air meter (1-5) provides a way to “measure” the air leaving and monitor over time – getting better or worse? time – getting better or worse?

Disposable chest drains Collection chamber Collection chamber Fluids drain directly into chamber, calibrated in mL fluid, write-on surface to note level and time When full will need to change ENTIRE system Fluids drain directly into chamber, calibrated in mL fluid, write-on surface to note level and time When full will need to change ENTIRE system Water seal Water seal One way valve, U-tube design, can monitor air leaks & changes in intrathoracic pressure One way valve, U-tube design, can monitor air leaks & changes in intrathoracic pressure Suction control chamber Suction control chamber U-tube, narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure U-tube, narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure

Portable chest drainage system

What about dependent loops?

If chest tube comes out? Three sided taped gauze! What happens if all 4 sides taped?

Nursing assessment and pertinent nursing problems/interventions Health history-respiratory disease, injury, smoking, progression of symptoms Health history-respiratory disease, injury, smoking, progression of symptoms Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea Physical exam- degree of apparent resp distress, lung sounds, O2 sat, VS, LOC, neck vein distention, position of trachea All require observation for lung symptoms All require observation for lung symptoms Pertinent nursing problems Pertinent nursing problems Acute pain Acute pain Ineffective airway clearance Ineffective airway clearance Impaired gas exchange Impaired gas exchange Home care Home care Nursing Care Plans Thoracotomy 28-2 & Chest tube Nursing Care Plans Thoracotomy 28-2 & Chest tube 28-21

Atrium chest video -Website If desire more information go to the website If desire more information go to the website Once on website- go to the bottom of the page and select video player to view videos Once on website- go to the bottom of the page and select video player to view videos st_Drains/edu-ocean.asp st_Drains/edu-ocean.asp st_Drains/edu-ocean.asp st_Drains/edu-ocean.asp

Est of thoracic expansion: A. Exhalation B. Maximal inhalation

Normal auscultatory sounds

Lung percussions areas & sounds