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

2. Thoracic Cavity
Point out organs

3. 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

4. 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.

5. 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 mL

6. 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

7. Cross-section of Chest

8. 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

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

10. 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

11. 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 mls
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

12. 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

13. 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

14. 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

16. How do we diagnosis pleural effusions?

17. 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

18. Posteroanterior upright chest radiograph shows isolated left sided pleural effusion and loss of left lateral costophrenic angle. Image courtesy of Allen R. Thomas, MD.

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

20. 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

21. 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

22. Interventions: Pleural Effusion Chest tube placement/ PleurX catheter

23. 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 % 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

24. 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

25. 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).

26. 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.

27. 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 years 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

28. 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?

29. 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

30. 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

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

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

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

34. 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

35. 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

36. 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

37. 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

38. 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

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

40. Rib fractures

41. 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

42. 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

43. 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

44. Pulmonary Contusion

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

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

47. 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

49. Questions?