1. Chapter 22 Pneumothorax CL GA DDCL GA DD
Figure Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm; CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs.

2. Anatomic Alterations of the Lungs
Lung collapse
Atelectasis
Chest wall expansion
Compression of the great veins and decreased cardiac venous return

3. Etiology—3 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)

4. Pneumothorax Classifications General Terms
Closed pneumothorax
Open pneumothorax
Tension pneumothorax

5. Pneumothorax Classifications Based on Origin
Traumatic pneumothorax
Spontaneous pneumothorax
Iatrogenic pneumothorax

6. Figure 22-3. Closed (tension) pneumothorax produced by a chest wall wound.

7. Figure Pneumothorax produced by a rupture in the visceral pleura that functions as a check valve.

8. Spontaneous Pneumothorax

9. Iatrogenic Pneumothorax

10. Overview of the Cardiopulmonary Clinical Manifestations Associated with PNEUMOTHORAX
The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Atelectasis (see Figure 9-7)—the major anatomic alterations of the lungs associated with pneumothorax (see Figure 22-1).

11. Figure 9-7. Atelectasis clinical scenario.
Figure 9-7. Atelectasis clinical scenario.

12. Clinical Data Obtained at the Patient’s Bedside
Vital signs
Increased respiratory rate
Stimulation of peripheral chemoreceptors
Other possible mechanisms
Decreased lung compliance
Activation of the deflation receptors
Activation of the irritant receptors
Stimulation of the J receptors
Pain/anxiety
Increased heart rate, cardiac output, blood pressure

13. Figure 22-5. Venous admixture in pneumothorax.

14. Clinical Data Obtained at the Patient’s Bedside
Cyanosis
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

15. Figure Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax, hyperresonant percussion notes are produced over the affected area.

16. Figure 22-7. Breath sounds diminish as gas accumulates in the intrapleural space.

17. Figure As gas accumulates in the intrapleural space, the chest diameter increases on the affected side in a tension pneumothorax.

18. Clinical Data Obtained from Laboratory Tests and Special Procedures

19. Pulmonary Function Study: Lung Volume and Capacity Findings
VT RV FRC TLC
N or    
VC IC ERV RV/TLC%    N

20. Arterial Blood Gases Small Pneumothorax
Acute alveolar hyperventilation with hypoxemia
pH PaCO HCO PaO2
   (Slightly) 

21. Alveolar Hyperventilation
Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
100 90
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70 60
PaO2
PaO2 or PaCO2 50 40 30
PaCO2 20 10
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.

22. Arterial Blood Gases Large Pneumothorax
Acute ventilatory failure with hypoxemia
pH PaCO HCO PaO2
   (Slightly) 

23. Alveolar Hyperventilation Acute Ventilatory Failure
Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
Acute Ventilatory Failure
100
Point at which disease becomes severe and patient begins to become fatigued 90
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors 80 70
PaCO2
Pa02 or PaC02 60 50 40 30
PaO2 20 10
Figure PaO2 and PaCO2 trends during acute ventilatory failure.

24. Oxygenation Indices QS/QT DO2 VO2 C(a-v)O2   Normal (severe)
O2ER SvO  

25. Hemodynamic Indices (Large Pneumothorax)
CVP RAP PA PCWP
   
CO SV SVI CI
   
RVSWI LVSWI PVR SVR
   

26. Radiologic Findings Chest radiograph Increased translucency
Mediastinal shift to unaffected side in tension pneumothorax
Depressed diaphragm
Lung collapse
Atelectasis

27. Figure 22-9. Left-sided pneumothorax (arrows)
Figure Left-sided pneumothorax (arrows). Note the shift of the heart and mediastinum to the right away from the tension pneumothorax.

28. A B
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).

29. General Management of Pneumothorax
>20%—gas should be evacuated
Negative pressure—5 to 12 cm H2O
Should not exceed negative 12 cm H2O

30. General Management of Pneumothorax
Respiratory care treatment protocols
Oxygen therapy protocol
Hyperinflation therapy protocol
Mechanical ventilation protocol

31. General Management of Pneumothorax
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