1 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 22 Pneumothorax

2 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.. Figure Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm; CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs. GA DD CL

3 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  Lung collapse  Atelectasis  Chest wall expansion  Compression of the great veins and decreased cardiac venous return Anatomic Alterations of the Lungs

4 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Gas can gain entrance to the pleural space in three ways: From the lungs through a perforation of the visceral pleura From the surrounding atmosphere through a perforation of the chest wall and parietal pleura or, rarely, through an esophageal fistula or a perforated abdominal viscus From gas-forming microorganisms in an empyema in the pleural space (rare) Etiology

5 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pneumothorax Classifications General Terms  Closed pneumothorax  Open pneumothorax  Tension pneumothorax

6 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pneumothorax Classifications Based on Origin  Traumatic pneumothorax  Spontaneous pneumothorax  Iatrogenic pneumothorax

7 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Traumatic Pneumothorax

8 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Sucking chest wound with accompanying pendelluft in an open pneumothorax. The large arrow illustrates the chest wall injury.

9 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The large arrow illustrates the chest wall injury. Figure Closed (tension) pneumothorax produced by a chest wall wound. The large arrow illustrates the chest wall injury.

10 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Spontaneous Pneumothorax

11 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Right pneumothorax produced by a rupture in the visceral pleura that functions as a check valve. Progressive enlargement of the pneumothorax occurs, producing atelectasis on the affected side.

12 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Iatrogenic Pneumothorax Iatrogenic Pneumothorax   An iatrogenic pneumothorax sometimes occurs during specific diagnostic or therapeutic procedures—for example   Pleural or liver biopsy   Thoracentesis   Intercostal nerve block   Cannulation of a subclavian vein   Tracheostomy   An iatrogenic pneumothorax is always a hazard during positive-pressure mechanical ventilation!

13 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Overview of the Cardiopulmonary Clinical Manifestations Associated with Pneumothorax The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by  Atelectasis

14 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.

15 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained at the Patient’s Bedside

16 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination Vital Signs  Increased respiratory rate (tachynea) Tachypnea occurs because of the following:  Stimulation of peripheral chemoreceptors (hypoxemia)  Pendelluft−see Figure 22-2  Decreased lung

17 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d) Vital Signs, (Cont’d)  Decreased lung compliance/increased ventilatory rate relationship  Activation of the deflation receptors  Activation of the irritant receptors  Stimulation of the J receptors  Pain/anxiety

18 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Venous admixture in pneumothorax.

19 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  Vital Signs, (Cont’d)  Increased Heart rate (pulse) Blood pressure  Cyanosis

20 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. The Physical Examination, (Cont’d)  Chest Assessment Findings  Hyperresonant percussion note over the pneumothorax  Diminished breath sounds over the pneumothorax  Tracheal shift  Displaced heart sounds  Increased thoracic volume on the affected side (particularly in tension pneumothorax)

21 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax, hyperresonant percussion notes are produced over the affected area.

22 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure Breath sounds diminish as gas accumulates in the intrapleural space.

23 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure As gas accumulates in the intrapleural space, the chest diameter increases on the affected side in a tension pneumothorax.

24 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Clinical Data Obtained from Laboratory Tests and Special Procedures

25 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT IRV ERV RV VC N or      IC FRC TLC RV/TLC ratio    N

26 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Small Pneumothorax) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) pH PaCO 2 HCO 3 PaO 2    (slightly) 

27 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute alveolar hyperventilation.

28 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Arterial Blood Gases (Large Pneumothorax) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) pH PaCO 2 HCO 3 PaO 2    (Slightly) 

29 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PaO 2 and PaCO 2 trends during acute or chronic ventilatory failure.

30 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Oxygenation Indices Q S /Q T DO 2 VO 2 C(a-v)O 2 O 2 ER SvO 2   N  (Severe)  

31 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Hemodynamic Indices Large Pneumothorax CVP RAP PA PCWP CO SV       SVI CI RVSWI LVSWI PVR SVR      

32 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Radiologic Findings  Chest radiograph  Increased translucency on the side of pneumothorax  Mediastinal shift to unaffected side in tension pneumothorax  Depressed diaphragm  Atelectasis

33 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure A, Development of a small tension pneumothorax in the lower part of the right lung (arrow). B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow). A B

34 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Figure A, A 19-year-old male patient, 6 feet 5inches tall, who experienced a sudden spontaneous left-sided pneumothorax while playing a round of golf. A spontaneous pneumothorax is not uncommon in people who are tall and thin. B, Chest radiograph of the same patient 45 minutes later in the emergency room. Note the shift of the heart and mediastinum to the right (toward the affected side), away from the tension pneumothrorax, and the depressed diaphragm on the patient’s left side. A B

35 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. General Management of Pneumothorax   The management of pneumothorax depends on the degree of lung collapse.   When the pneumothorax is relatively small (15% to 20%), the patient may need only bed rest or limited physical activity.   In such cases, resorption of intrapleural gas usually occurs within 30 days.   When the pneumothorax is larger than 20%, it should be evacuated.

36 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc.  When suction is used, the negative pressure need not exceed -12 cm HO; -5 cm HO is generally all that is needed.  When suction is used, the negative pressure need not exceed -12 cm H 2 O; -5 cm H 2 O is generally all that is needed.  After the lung has reexpanded and bubbling from the chest tube has ceased, the tube is left in place without suction for another 24 to 48 hours. General Management of Pneumothorax, (Cont’d)

37 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. PLEURODESIS   Chemical or medication injected into the chest cavity   Talc   Tetracycline   Bleomycin sulfate   Produces inflammatory reaction between lungs and inner chest cavity   Causes lung to stick to chest cavity General Management of Pneumothorax, (Cont’d)

38 Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. Respiratory Care Treatment Protocols  Oxygen Therapy Protocol  Lung Expansion Therapy Protocol  Mechanical Ventilation Protocol