1. Gail L. Lupica PhD, RN, CNE Nurs 211

3.  The diaphragm contracts down, and the external intercostals muscles move the chest wall outward. Air rushes into the chest cavity.  “ Negative Pressure Breathing ”

5.  Even when the system is relaxed, the lung is continually pulling in, and attempting to get to its smaller relaxed size.  This process creates a negative intrapleural pressure, and explains why air is pulled into the chest when the chest wall is punctured.

7.  a collection of air in the pleural space

11.  Pneumos can occur after central line insertion, after chest surgery, after trauma to the chest, or after a traumatic airway intubation.  Important to remember: if the air continues to collect in the chest, the pressure in that collection can rise, and push the whole mediastinum over to the other side - this is called a :

12.  “ tension pneumothorax ”, and is definitely life- threatening. Call the surgeon.

14.  If the chest wall is penetrated (knife wound, gun shot wound), air can enter the pleural space from the outside. = OPEN PNEUMOTHORAX

15.  Air can also enter from the inside (from the lung itself) if the lung is torn or ruptured. One of the most common causes of spontaneous non-traumatic pneumothorax is a pulmonary bleb. This is a weakness and out-pouching of the lung tissue, which can rupture. This introduces air into the pleural space. = CLOSED PNEUMOTHORAX

16.  Specific findings:  Decreased breath sounds on the affected side Why do you think that is?  Hyperresonance on the affected side Why do you think that is?

17.  Non specific findings:  SOB  Chest pain (pleuritic type- increases with coughing)  Tachycardia  Tachypnea  SQ emphysema

18.  What to Do?  OPEN: Cover it immediately. ◦ (Preferably with sterile gauze taped on 3 sides so air escapes on exhalation.  To surgery!  Chest Tube insertion.

19.  Closed: Chest tube!  (Although if very small; <15%, M.D. may opt to allow lung to re-expand without chest tube intervention.)  Chest tubes are removed when lung is expanded (2-10 days),  or fluid has been removed (3-4 days).

22.  Tell the patient to take a breath in and bear down slightly on inspiration, while the chest tube is being removed, so no air enters the pleural space.

23.  Tension Pneumothorax  What To Do?  Large bore needle insertion  (Rapidly decompresses thorax by releasing air; 14- 16G)

27. FLAIL CHEST FLAIL CHEST refers to a serious breech in the integrity of the ribcage from more than one broken rib broken in more than one place each. Instead of holding the normal shape of the chest, a segment of the chest wall flails back and forth in the opposite direction…

28. FLAIL CHEST Paradoxic motion: Inspiration. Area of the lung underlying unstable chest wall sucks in on inspiration. Expiration. Unstable area balloons out. Note movement of mediastinum toward opposite lung during inspiration

30.  Dictated by the clinical condition and degree of respiratory distress.  Local anesthetic block of the affected ribs  Hypoxemic? Intubated and mechanically ventilated_ PEEP.  Firm chest wrap  Laying the patient with the flail segment down. FLAIL CHEST-treatment

31. FLAIL CHEST You tube…

32.  Ready for a Case Study!????