Respiratory Disorders: Pleural and Thoracic Injury by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN & Darlene “Cookie” Wilson, RN, MSN

Thoracic Cavity Point out organs

Normal Anatomy Thoracic cavity Chest wall Pleural space Fluid aka? Chest wall Pleural space Fluid What is this fluid called? Chest cavity Intra pleural space Pleural fluid

Terminology Pleura the thin serous membrane around the lungs and inner walls of the chest (2 layers) Pleural space thin space between the 2 layers of pleura Pleural cavity body cavity that surrounds the lungs Parietal Pleura Pleura that lines the inner chest walls and covers the diaphragm Visceral Pleura Pleura that lines the lung itself Pleural Fluid Fluid in the pleural space Parietal ---- of or related to the formation of bone, organ or cavity.

Pleural Fluid pH 7.6 – 7.64 1-2g/dL protein Less than 1000 WBC per cubic millimeter Glucose level similar to plasma LDH less than 50% that of plasma Na, K+, & Ca levels similar to that of interstitial fluid How much pleural fluid is in the pleural space? Constantly produced and resorbed Normal present at any one time --- 10mL

Visceral pleura – (Pulmonary Pleura) Covers surface of the lung Cannot be dissected away from the lung Parietal pleura- Lines the wall of the chest and covers the diaphragm Visceral Pleura or Pulmonary Pleura http://www.themesotheliomalibrary.com/pleural-effusions.JPG

Cross-section of Chest

Chest Trauma & Thoracic Injury 20-25% of trauma victims with chest trauma die 45% of trauma victims have some type of chest trauma BEWARE: External injury may appear minor

Categories for Traumatic Injuries Blunt trauma Penetrating trauma Give some examples? MVA Crush with heavy equipment Stab or gunshot wound

Traumatic Chest Injuries Mechanism of Injury Common Related Injury Blunt Trauma Blunt steering wheel injury to chest Rib fractures, flail chest, pneumothorax, hemopneumothorax, myocardial contusion, pulmonary contusion, cardiac tamponade, great vessel tears Shoulder harness seat belt injury Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac tamponade Crush injury (heavy equipment, crushing the thorax) Pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood return to heart with decreased cardiac output Penetrating trauma Gunshot, stab wound to chest Open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears

Respiratory Disorders: Pleural and Thoracic Injury Pleural Effusion A collection of excess fluid in the pleural space Is it normal to have fluid in this space? Would you consider a pleural effusion a disease? Classification Transudative ----- systemic causes Usually not caused by inflammatory processes Most common type Exudative ----- localized cause Usually caused by an inflammatory process Often recurrent, difficult to treat Yes ---- a small amount of fluid is normal - 10-25mls No ----- it is not a disease ---------------------sign of serious disease process or injury Causes of exudative fluid include infections (such as pneumonia), cancer, tuberculosis, and collagen diseases (such as rheumatoid arthritis and lupus). Causes of transudative fluid are congestive heart failure and liver and kidney diseases. Pulmonary emboli can cause either transudates or exudates in the pleural space. Classified according to protein content ---- high or low 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, GI disturbance--- perforated panc or esophogus. Pus-empyema

Empyema What is it? What causes it? How do we treat it? What is it? Pleural effusion that contains PUS (often call pleurisy – pain worsens with deep breath) By product of immune system – wbc’s fighting bacteria – inflammation occurs. Because of this pressure, the lungs are unable to expand properly and the patient often present Short of Breath & may be experiencing symptoms of chest pain or chest pressure. (Fever, Chills, Dehydration, bad breath.) What causes it? Pneumonia, TB, lung abscess, infection of surgical wounds of the chest Treatment? Chest tube drainage Antibiotics (thoracentesis) can relieve the pain and shortness of breath. If not treated – sepsis and death

Etiology: Pleural Effusion Identify the Class of Effusion Disease Process Classification of Effusion Heart Failure Transudate TB Exudate Lupus/RA Both Renal Disease Lung Cancer Trauma Pneumonia Liver Failure

Clinical Manifestations: Pleural Effusion Dyspnea O2 sats? Pleurisy What is this? Decreased breath sounds Why? Decreased chest wall movement Dullness on percussion PLEURISY aka pleuritis sharp or stabbing pain in your chest that gets worse when you breathe in deeply or cough or sneeze. may stay in one place or it may spread to your shoulder or back. Sometimes it becomes a fairly constant dull ache. (between breaths, you feel almost no pain

How do we diagnosis pleural effusions?

Pleural Effusion -- Diagnositcs CXR --- how will the order be written? Thoracic CT Chest Ultrasound – why would we need to do this? Thoracentesis For the CHF pt – what do you think his CXR will show? PA/Lat – upright ----- NOTE ---pleural fluid will move according to gravity Upright PA – fluid will be inferior/posterior Costraphrenic Angle --- PA film of more than 175mls – will show blunting of the usually pointed downward angel where the diagphragm meets the ribs ---- LATERAL --- free fluid will layer – if layer is 1 cm thick – abt 200ml – Thoracentesis: Removal of fluid in the pleura through a needle. A CT scan can be very helpful in detecting trapped pockets of pleural fluid as well as in determining the nature of the tissues surrounding the area. Ultrasound --- localizes the effusion to guide instrument placement Ultrasound is also a very sensitive method of detecting the presence of pleural fluid. CHF --- bilateral effusions with enlarged heart shadow

Posteroanterior upright chest radiograph shows isolated left sided pleural effusion and loss of left lateral costophrenic angle. Image courtesy of Allen R. Thomas, MD. http://emedicine.medscape.com/article/807375-media

Chest radiograph, lateral view shows loss of bilateral posterior costophrenic angles. Image courtesy of Allen R. Thomas, MD

Interventions: Pleural Effusion Thoracentesis Diagnostic vs. Therapeutic Diagnostic ---- find out cause Exudates have high protein & LDH content ---- usually yellow or amber is color - cloudy Transudates have low or no protein content ---- usually clear or straw colored Therapeutic when breathing is impaired --- consider pt condition

Interventions: Pleural Effusion What are your nursing responsibilities post thoracentesis? Puncture site determined by XRAY Percussion for maximum dullness HOW sit over edge of bed, lean on bedside table clean with antiseptic & give local anesthesia Needle inserted into intercostal space Syringe or collecting bottle Nursing Responsibilities Monitor resp status, O2 sats, lung sounds, insertion site, ensure chest xray is completed

Interventions: Pleural Effusion Chest tube placement/ PleurX catheter

Interventions: Pleural Effusion Treat underlying condition – especially in transudative CHF/Renal failure Pneumonia Liver Disease Lupus/RA Malignancy Pleurodesis (what is this?) Parietal Pleurectomy Chest tube/indwelling catheter insertion Allow to resolve when would this be an option? CHF --- diuretics & na restirction, bp meds MEDICAL MANAGEMENT Pneumonia – antibiotics Liver Disease – low protein diet, TIPS procedure. PLEURODESIS ---- A procedure used to cause the layers of the lung lining (the pleura) to stick together. A chemical or medication is inserted into the space between the 2 layers of the pleura, causing inflammation that effectively glues the layers together. malignancy usually causes a return of Pleural Effusion Chemical Chemicals such as bleomycin, tetracycline, povidone iodine, or a slurry of talc can be introduced into the pleural space through a chest drain. The instilled chemicals cause irritation between the parietal and the visceral layers of the pleura which closes off the space between them and prevents further fluid from accumulating.[2]. --- assists with sclerosis of lung Chemical pleurodesis is a painful procedure, so patients are often premedicated with a sedative and analgesics. A local anesthetic may be instilled into the pleural space, or an epidural catheter may be placed for anesthesia. Done by Thoracoscopy --- may turn pt side to side if can tolerate it ------ 82% success rate with talc – can recur though PLUERECTOMY --- high mortality rate --- remove parietal pleura – viseral pleura adhear to chest wall, remove pleural space RESOLVE ON OWN --- malignancy --- Usually stage III or IV

Complications of Pleural Effusion Trapped Lung What is this? Recurrent effusions Why does this happen? Pneumothorax Trapped lung Fibrous peel around the pleura – causes severe restriction may need decortication – removal of peel Recurrent Especially in malignancy Pneumo

Empyema causing trapped lung A collection of pus in the space b/t the lung and the inner surface of the chest wall (pleural space).

PNEUMOTHORAX 3 types Closed Open Iatrogenic aka? What nursing interventions do we implement? Iatrogenic What does this mean? Closed - Tension Open --- sucking chest wound --- the sound of air flowing into the pleural space Occlusive dressing --- taped on 3 sides ---- or special occlusive dressing that allows for ventialation. Iatrogenic relating to illness/event caused by medical examination or treatment.

No opening from external chest. Open Pneumothorax Closed Pneumothorax No opening from external chest. Open Pneumothorax Opening from external chest wall into pleura. Iatrogenic Pneumothorax Puncture or laceration of visceral pleura during medical tx Occurs in crashes, falls, MVAs, CPR, COPD, fractured ribs that penetrate the pleura. Occurs in stabbings, gunshot wounds, impalement injury. Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation, cardiac surgery, GI surgery Spontaneous pneumo ----- 20-40years old underweight, tall, smokers accumulation of air in pleural space without an apparent antecendent event Other causes mechanical ventilation insertion of subclavian catheter ruptured blebs in copd pts perforation of the esophogus

What type of pneumo would this cause? ww Spontaneous Pneumo. What is a bleb? Blebs are weakened out-pouchings in the upper lung, which can rupture, causing pneumothorax. Common causes of spontaneous pneumothorax in young children and adults. The affected tissue can be resectioned out and this usually resolves the problem. What is a bleb? What type of pneumo would this cause? http://images.google.com/imgres?imgurl=http://graphics8.nytimes.com/images/2007/08/01/health/adam/15210.jpg&imgrefurl=http://www.nytimes.com/slideshow/2007/08/01/health/100150Pneumothoraxseries_4.html&usg=__VZn79dHtqdr7izJf1jBM0r5R4ig=&h=320&w=400&sz=44&hl=en&start=3&sig2=06HaoI7v1pH1SPxnpU_4Vg&um=1&tbnid=l0LTfAdhVxUVSM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dblebs%2Bon%2Blungs%2Bcausing%2Bpneumothorax%26hl%3Den%26rlz%3D1T4DMUS_enUS282US282%26sa%3DN%26um%3D1&ei=lGWJSvXaGIawtAOVxtidBw

Clinical Manifestations: Pneumothorax Respiratory Describe these manifestations Cardiac Manifestations are dependent upon what? The size of the pneumothorax, hemothorax Respiratory--------- Dyspnea Pleuritic pain Increase in respiratory rate Decrease respiratory excursion Absent breath sounds Cough with our without hemoptysis Cyanosis around mouth face & nail beds SUBQ EMPHYSEMA ----- AIR TRAPPED UNDER SKIN Cardiac Tachycardia Rapid thready pulse Muffled heart sounds Asymetric bps in arms Narrowed pulse pressure ----- poor cardiac output

Tension Pneumothorax Air/blood/fluid rapidly entering the pleural space Lung collapses Emergency situation What is the emergency here? Does it occur in open or closed pneumos? Emergency air causes tension on great vessels and heart intrathoracic pressure increases mediastinal shift occurs ---- compressure unaffected side BOTH open – flap may act as one way valve --- allow air in but not out --- on inspiration closed --- mechanical ventilation & cpr also if Chest Tubes are clamped or blocked

Pathophysiology: Tension Pneumo Increase in intrapleural pressure Compression of lung Compresses against trachea, heart, aorta, esophagus Ventilation and cardiac output greatly compromised Medical EMERGENCY

Clinical Manifestations: Tension Pneumothorax Severe dyspnea Tracheal deviation Decreased cardiac output Distended neck veins Increased respiratory rate Increased heart rate Decreased blood pressure Shock

Treatment Tension Pneumothorax Emergency --- quick intervention Needle decompression Chest tube placement

Other Types Hemothorax Hemothorax blood in the intrapleural space usually in open penumo ----- called hemopneumothorax causes – anticoagulant tx, trauma, malignancy, PE Chylorthorax lymphatic fluid in pleural space causes ----- malignancy, trauma, surgical procedures

Intervention: Pneumothorax High Fowlers position Oxygen as ordered Rest to decrease oxygen demand ***Chest tube insertion Pleurodesis Surgery What about open pneumo? How do we resolve tension pneumos? Open pneumo vented dressings, sealed on three sides – open on one allows air to escape --- preventing WHAT? --------- tension pneumo Tension pneumo needle decompression ---- large bore needle into chest wall release air

Clinical Manifestations: Rib Fractures Ribs 5-10 most commonly fractured Why? Pain On inspiration or expiration? Splinting & Rapid, shallow respirations What is a complication of this? Decreased breath sounds Crepitus Signs/symptoms of pneumothorax RIBS least protected from chest muscles Pain especially on inspriation Splinting atelectasis --- lungs are not fully inflated

Treatment: Rib Fractures Reduce or minimize pain Do we wrap or bind the chest? Do we use opiods? Goal? Do we wrap? No--- do not wrap or bind chest --- could reduce lung expansion Do we use opiods? Individual dicision – could reduce resp rate Goal? Want adequate chest expansion & breathing

Pathophysiology: Flail Chest 2 or more ribs fractured 2 or more separate places Unstable / free floating chest Usually involves anterior or lateral fx Paradoxical respirations During inspiration the unstable area will move IN During expiration the unstable area will bulge OUT

Free floating Rib Fractures may result in a Flail chest with paradoxic respirations

Rib fractures

Clinical Manifestations: Flail Chest Dyspnea with rapid, shallow inspiration Pain Palpable crepitus Decreased breath sounds Unequal chest expansion Tachycardia Is flail chest always apparent in all patients? Dyspnea- SOB, or air hunger, is the subjective. No, In the unconscious pt --- you will see it In the conscious pt --- may be splinting – must inspect

Interventions: Flail Chest Oxygen as ordered Elevate HOB *Analgesia Suction Splint affected side? *Intubation *Mechanical ventilation GOAL? Re-expand lung Ensure adequate oxygenation Pain control Initially may need intubation ----- until lung issues resolved

Pathophysiology: Pulmonary Contusion Abrupt chest compression then rapid decompression Intra-alveolar hemorrhage Interstitial/bronchial edema Decreased surfactant production Increase pulmonary vascular resistance Decrease blood flow Chest trauma causing a bruise on the lung Cappillaries destroyed

Pulmonary Contusion

Clinical Manifestation: Pulmonary Contusion Increased SOB Restlessness Anxiety Chest pain Copious sputum Increased respiratory Increased heart rate Dyspnea Cyanosis

Intervention: Pulmonary Contusion Intubation Mechanical ventilation Bronchoscopy Fluids Volume expanders Pulmonary artery pressure monitoring PAWP 5-12

Chest Surgeries Exploratory thoracotomy VATS Incision into thorax to look for injured or bleeding tissue VATS Video-assisted thoracic surgery to do lung biopsy, lobectomy

http://www.thoracicgroup.com/images/about_vats_photo.jpg

Questions?