1. 10/7/20151 Respiratory Disorders: Pleural and Thoracic Injury I. Disorders of the Pleura  A. Pleural Effusion  Definition: a collection of excess fluid in the pleural space.

2. 10/7/20152

3. 3 Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity

4. 10/7/20154 Etiology of Pleural Effusions:  Congestive Heart Failure  Liver Disease  Renal Disease  Lupus, Rheumatoid Arthritis  Pneumonia  TB  Lung Cancer  Trauma

5. 10/7/20155 What would you think is happening in this client?

6. 10/7/20156 Answer: Massive left sided pleural effusion in a patient presenting with lung cancer.

7. 10/7/20157 Pathophysiology of Pleural Effusion capillary pressure or plasma proteins Formation of excess fluid= Transudate capillary permeability= Exudate Accumulation of pus in the pleural space=Empyema

8. 10/7/20158 Transudate vs Exudate Non-inflammatory Trans means movement of fluid due to changes in pressure gradients What do you remember about oncotic pressure and serum albumin levels??? What is hydrostatic pressure? Inflammatory in nature Exudate means there is a release of fluid. Exudative pleural effusion are due to changes in capillary permeability. The capillaries are inflammed and are not as selective and allow fluid to leak into the pleural space.

9. 10/7/20159 Let’s try to classify Transudative or Exudative Pleural Effusion…. Etiology of Pleural Effusions:  Congestive Heart Failure  Liver Disease  Renal Disease  Lupus, Rheumatoid Arthritis  Pneumonia  TB  Lung Cancer  Trauma  ARDS

10. 10/7/201510 Clinical Manifestations of Pleural Effusion Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement

11. 10/7/201511 Diagnostic Tests Pleural Effusion CXR CT scan ABG’s/O2 Saturation

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13. 10/7/201513 Therapeutic Interventions Thoracentesis-needle aspiration of fluid in pleural space. Usually 1200-1500ml /time. Antibiotics if due to infectious process. Chest tube to drain fluid/air. Pleurodesis-instillation of chemical agent (doxycycline) into pleural space to create inflammatory response (scar tissue) to adhese the visceral and parietal pleura. Treat underlying condition that is causing the effusion.

15. Nursing Diagnosis #1 Ineffective breathing pattern related to decreased lung expansion of left lung secondary to accumulation of fluid in the pleural space, pain and discomfort of breathing deeply secondary to inflammation and irritation of pleural space, and poor positioning in bed secondary to inability to reposition self without assistance.

16. Nursing Diagnosis #2 Impaired gas exchange related to ineffective capillary – alveolar gas exchange secondary to presence of atelectasis in lower left lung and respiratory fatigue caused by presence of pleural effusion in left lung compromising ability to inspire deeply and causing pain.

17. PleurX ® Pleural Catheter System

18. 10/7/201518 B. Spontaneous Pneumothorax  Definition-accumulation of air in the pleural space  Pathophysiology  Rupture of bleb on the lung surface allows air into the pleural space Primary pneumothorax- affects previously healthy individuals Secondary pneumothorax-affects individuals with preexisting lung disease –Which diseases can you think of???

19. 10/7/201519 Clinical Manifestations of Spontaneous Pnemo Abrupt onset Pleuritic chest pain SOB, dyspnea respiratory rate, tachycardia Unequal chest excursion Decreased breath sounds on affected side

20. 10/7/201520 C. Traumatic Pneumothorax  Definition/Pathophysiology:  Accumulation of air into pleural space due to blunt or penetrating trauma of chest wall/lungs.  Types of Traumatic Pneumothorax Closed Pneumo Open Pneumo Iatrogenic Pneumo

21. 10/7/201521 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, fractured ribs that penetrate the pleura. Occurs in stabbings, gunshot wounds, impalement injury. Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation

22. 10/7/201522 I’m just asking…. The client has a spontaneous pneumothorax….which type of pneumothorax is this: A- Iatrogenic B- Open C- Closed D- Gee… I dunno

23. 10/7/201523 Clinical Manifestations of Pneumothorax Dyspnea Pleuritic Pain RR, pulse respiratory excursion Absent breath sounds on affected side

24. 10/7/201524 D. Tension Pneumothorax Definition: air/blood/fluid rapidly enters pleural space and unable to escape Lung collapses Emergency situation!

25. 10/7/201525 Tension Pneumothorax Is this a right sided or left sided tension pnemothorax?

26. 10/7/201526 Pathophysiology of Tension Pnemothorax Increase in Intrapleural pressure Compression of lung to other side Compresses against trachea, heart, aorta, esophagus Ventilation and Cardiac Output greatly compromised

27. 10/7/201527 Clinical Manifestations/Complications of Tension Pneumo Severe Dyspnea Tracheal Deviation Decreased Cardiac Output Distended Neck Veins RR, pulse, blood pressure Shock

28. 10/7/201528 Therapeutic Interventions for Pneumothorax High Fowlers position O2 as ordered Rest to decrease O2 demand Chest tube insertion Pleurodesis Surgery: Thoracotomy to remove blebs, partial excision of parietal pleura done using VATS (video assisted thorascopic surgery)

29. 10/7/201529 II. Trauma of the Chest/Lung Chest injury is the leading cause of death from trauma May involve chest wall, lungs, heart, great vessels, esophagus Life threatening chest injuries include:  Airway obstruction  Tension pneumo, open pneumo, massive hemothorax  Flail chest with pulmonary contusion

30. 10/7/201530 Pathophysiology of Thoracic Injury Acceleration-Deceleration Injury Rapid change in velocity Body stops suddenly Chest cavity organs/tissues move forward

31. 10/7/201531 A. Rib Fracture Simple rib fracture in an at risk client may lead to pneumonia, atelectasis, respiratory failure Displaced rib fractures can result in pnemo/hemothorax, intrathoracic vessel tears, liver or spleen injury

32. 10/7/201532 Clinical Manifestations of Rib Fractures Pain on inspiration/coughing Voluntary splinting Rapid, shallow respirations Decreased breath sounds Crepitus on palpation Signs/symptoms of pneumo/hemothorax

33. 10/7/201533 B. Flail Chest Etiology/Pathophysiology  Occurs when 2+ consecutive ribs are fractured in multiple places  Segment of chest wall becomes “free- floating” or flail  Flail segment of chest wall is sucked in during inspiration and moves outward with expiration

34. 10/7/201534 The client presents in the ED: Chest trauma client http://www.youtube.com/watch?v=PyDcGB- i7OQ&feature=related http://www.youtube.com/watch?v=PyDcGB- i7OQ&feature=related What did you note in this client? What would you do 1st? 2nd? What did you note in this client? What would you do 1st? 2nd?

35. 10/7/201535 Clinical Manifestations of Flail Chest Dyspnea Pain especially on inspiration Palpable crepitus Decreased breath sounds Unequal Chest expansion

36. 10/7/201536 What assessment finding is present???

37. 10/7/201537 Flail Chest Right lung affected

38. 10/7/201538 Therapeutic Interventions Flail Chest O2 as ordered Elevate HOB Intercostal nerve block or epidural analgesia to decrease pain Suction as ordered Splint affected area Preferred treatment= Intubation and positive pressure ventilation

39. 10/7/201539 Internal/External fixation of ribs in Flail Chest

40. 10/7/201540 Judet Plates for Fractured Ribs/Flail Chest

41. 10/7/201541 Sanchez Plates for Fractured Ribs/Flail Chest

42. 10/7/201542 C. Pulmonary Contusion Etiology/Pathophysiology  Left Pulmonary contusion

43. 10/7/201543 Abrupt Chest Compression then Rapid Decompression Intra-alveolar Hemorrhage Interstitial/bronchial Edema surfactant production leads to decreased lung compliance Airway obstruction, Atelectasis, Impaired O2/CO2 exchange Pulmonary vascular resistance blood flow

44. 10/7/201544 Clinical Manifestations of Pulmonary Contusion SOB Restlessness, Anxiety Chest Pain Copius Sputum (blood tinged) RR, Pulse, Dyspnea, Cyanosis

45. 10/7/201545 Therapeutic Interventions Pulmonary Contusion Intubation/Mechanical Ventilation Bronchoscopy to remove secretions, cellular debris Fluids, Volume expanders to treat shock Pulmonary Artery pressure monitoring