Pneumothoraks

Chapter 22 PneumothoraxCL GA DD Figure 22-1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm; CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs. Slide 1 Copyright © 2006 by Mosby, Inc. Anatomic Alterations of the Lungs     Lung collapse Atelectasis Chest wall expansion Compression of the great veins and decreased cardiac venous return Slide 2 Copyright © 2006 by Mosby, Inc. 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) Slide 3 Copyright © 2006 by Mosby, Inc. Pneumothorax Classifications General Terms    Closed pneumothorax Open pneumothorax Tension pneumothorax Slide 4 Copyright © 2006 by Mosby. . Inc. . Inc.Pneumothorax Classifications Based on Origin    Traumatic pneumothorax Spontaneous pneumothorax Iatrogenic pneumothorax Slide 5 Copyright © 2006 by Mosby. Slide 6 Copyright © 2006 by Mosby.Figure 22-3. . Closed (tension) pneumothorax produced by a chest wall wound. Inc. . Pneumothorax produced by a rupture in the visceral pleura that functions as a check valve. Slide 7 Copyright © 2006 by Mosby.Figure 22-4. Inc. Spontaneous Pneumothorax Slide 8 Copyright © 2006 by Mosby. . Inc. Inc. .Iatrogenic Pneumothorax Slide 9 Copyright © 2006 by Mosby. Slide 10 Copyright © 2006 by Mosby.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). Inc. . Slide 11 Copyright © 2006 by Mosby. .Figure 9-7. Inc. Atelectasis clinical scenario. Slide 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. Inc. blood pressure Copyright © 2006 by Mosby. cardiac output. . Inc. Slide 13 Copyright © 2006 by Mosby. Venous admixture in pneumothorax.Figure 22-5. Inc.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 Copyright © 2006 by Mosby. Slide 14 . Figure 22-6. hyperresonant percussion notes are produced over the affected area. Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax. Inc. Slide 15 Copyright © 2006 by Mosby. . Slide 16 Copyright © 2006 by Mosby. .Figure 22-7. Inc. Breath sounds diminish as gas accumulates in the intrapleural space. As gas accumulates in the intrapleural space.Figure 22-8. . Slide 17 Copyright © 2006 by Mosby. the chest diameter increases on the affected side in a tension pneumothorax. Inc. Inc. .Clinical Data Obtained from Laboratory Tests and Special Procedures Slide 18 Copyright © 2006 by Mosby. Pulmonary Function Study: Lung Volume and Capacity Findings VT N or  RV  FRC  TLC  VC IC ERV RV/TLC%    N Slide 19 Copyright © 2006 by Mosby. . Inc. . Inc.Arterial Blood Gases Small Pneumothorax  Acute alveolar hyperventilation with hypoxemia PaCO2  HCO3 (Slightly) PaO2  pH  Slide 20 Copyright © 2006 by Mosby. PaO2 and PaCO2 trends during acute alveolar hyperventilation. Slide 21 Copyright © 2006 by Mosby. .Time and Progression of Disease Disease Onset 100 90 80 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Alveolar Hyperventilation PaO2 or PaCO2 70 60 50 40 30 20 10 0 PaO2 Figure 4-2. Inc. Arterial Blood Gases Large Pneumothorax  Acute ventilatory failure with hypoxemia pH  PaCO2  HCO3 (Slightly) PaO2  Slide 22 Copyright © 2006 by Mosby. Inc. . Inc. PaO2 and PaCO2 trends during acute ventilatory failure. Alveolar Hyperventilation Acute Ventilatory Failure Point at which PaO2 declines enough to stimulate peripheral oxygen receptors Point at which disease becomes severe and patient begins to become fatigued .Time and Progression of Disease Disease Onset 100 90 80 Pa02 or PaC02 70 60 50 40 30 20 10 0 Figure 4-7. Slide 23 Copyright © 2006 by Mosby. Inc. .Oxygenation Indices QS/QT  DO2  VO2 Normal C(a-v)O2 (severe) O2ER  SvO2  Slide 24 Copyright © 2006 by Mosby. Inc. .Hemodynamic Indices (Large Pneumothorax) CVP  RAP  PA  PCWP  CO  RVSWI  SV  LVSWI  SVI  PVR  CI  SVR  Slide 25 Copyright © 2006 by Mosby. . Inc.Radiologic Findings Chest radiograph   Increased translucency Mediastinal shift to unaffected side in tension pneumothorax Depressed diaphragm    Lung collapse Atelectasis Slide 26 Copyright © 2006 by Mosby. .Figure 22-9. Left-sided pneumothorax (arrows). Slide 27 Copyright © 2006 by Mosby. Note the shift of the heart and mediastinum to the right away from the tension pneumothorax. Inc. The same pneumothorax 30 minutes later. Development of a small tension pneumothorax in the lower part of the right lung (arrow).A B Figure 22-10. . Slide 28 Copyright © 2006 by Mosby. B. A. Also note the depression of the right hemidiaphragm (arrow). Inc. Note the shift of the heart and mediastinum to the left away from the tension pneumothorax. General Management of Pneumothorax   >20%—gas should be evacuated Negative pressure—5 to 12 cm H2O  Should not exceed negative 12 cm H2O Slide 29 Copyright © 2006 by Mosby. Inc. . . Inc.General Management of Pneumothorax Respiratory care treatment protocols    Oxygen therapy protocol Hyperinflation therapy protocol Mechanical ventilation protocol Slide 30 Copyright © 2006 by Mosby. 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 Copyright © 2006 by Mosby. Inc. Slide 31 . .Classroom Discussion Case Study: Pneumothorax Slide 32 Copyright © 2006 by Mosby. Inc.