copyright © 2006 by mosby, inc. slide 1 chapter 22 pneumothorax figure 22-1. right-side...

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 22Chapter 22 Pneumothorax Pneumothorax

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

GA

DD

CL


Anatomic Alterations of the LungsAnatomic Alterations of the Lungs

Lung collapseLung collapse

AtelectasisAtelectasis

Chest wall expansionChest wall expansion

Compression of the great veins and Compression of the great veins and decreased cardiac venous returndecreased cardiac venous return


Etiology—3 WaysEtiology—3 Ways

From the lungs through a perforation of the From the lungs through a perforation of the visceral pleuravisceral pleura

From the surrounding atmosphere through a From the surrounding atmosphere through a perforation of the chest wall and parietal perforation of the chest wall and parietal pleura or, rarely, through an esophageal pleura or, rarely, through an esophageal fistula or a perforated abdominal viscusfistula or a perforated abdominal viscus

From gas-forming microorganisms in an From gas-forming microorganisms in an empyema in the pleural space (rare)empyema in the pleural space (rare)


Pneumothorax ClassificationsPneumothorax ClassificationsGeneral TermsGeneral Terms

Closed pneumothoraxClosed pneumothorax

Open pneumothoraxOpen pneumothorax

Tension pneumothoraxTension pneumothorax


Pneumothorax ClassificationsPneumothorax ClassificationsBased on OriginBased on Origin

Traumatic pneumothoraxTraumatic pneumothorax

Spontaneous pneumothoraxSpontaneous pneumothorax

Iatrogenic pneumothoraxIatrogenic pneumothorax


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


Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura that functions as a check valve.that functions as a check valve.


Spontaneous PneumothoraxSpontaneous Pneumothorax


Iatrogenic PneumothoraxIatrogenic Pneumothorax


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Associated Clinical Manifestations Associated

with PNEUMOTHORAXwith PNEUMOTHORAX

The following clinical manifestations result from The following clinical manifestations result from the pathophysiologic mechanisms caused (or the pathophysiologic mechanisms caused (or activated) by activated) by AtelectasisAtelectasis (see Figure 9-7)—the (see Figure 9-7)—the major anatomic alterations of the lungs major anatomic alterations of the lungs associated with pneumothorax (see Figure 22-1).associated with pneumothorax (see Figure 22-1).


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


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

Vital signsVital signs

Increased respiratory rateIncreased respiratory rate Stimulation of peripheral chemoreceptors Stimulation of peripheral chemoreceptors

Other possible mechanismsOther possible mechanisms

• Decreased lung complianceDecreased lung compliance

• Activation of the deflation receptorsActivation of the deflation receptors

• Activation of the irritant receptorsActivation of the irritant receptors

• Stimulation of the J receptorsStimulation of the J receptors

• Pain/anxietyPain/anxiety

Increased heart rate, cardiac output, blood pressureIncreased heart rate, cardiac output, blood pressure


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


Clinical Data Obtained at the Clinical Data Obtained at the Patient’s BedsidePatient’s Bedside

CyanosisCyanosis

Chest assessment findingsChest assessment findings Hyperresonant percussion note over the Hyperresonant percussion note over the

pneumothoraxpneumothorax

Diminished breath sounds over the pneumothoraxDiminished breath sounds over the pneumothorax

Tracheal shiftTracheal shift

Displaced heart soundsDisplaced heart sounds

Increased thoracic volume on the affected sideIncreased thoracic volume on the affected side

• Particularly in tension pneumothoraxParticularly in tension pneumothorax


Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax, hyperresonant percussion notes are produced over the affected area.pneumothorax, hyperresonant percussion notes are produced over the affected area.


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


Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter increases on the affected side in a tension pneumothorax.increases on the affected side in a tension pneumothorax.


Clinical Data Obtained from Clinical Data Obtained from Laboratory Tests and Special Laboratory Tests and Special

ProceduresProcedures


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N

VT RV FRC TLC

N or

VC IC ERV RV/TLC%

N


Arterial Blood GasesArterial Blood Gases

Small PneumothoraxSmall Pneumothorax

Acute alveolar hyperventilation with Acute alveolar hyperventilation with hypoxemiahypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of Disease Time and Progression of Disease

100100

5050

3030

8080

00

PaCO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090 Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaO2

Disease OnsetDisease OnsetP

aO2

or

PaC

O2

PaO

2 o

r P

aCO

2

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.


Arterial Blood GasesArterial Blood Gases

Large PneumothoraxLarge Pneumothorax

Acute ventilatory failure with hypoxemiaAcute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2

(Slightly)

pH PaCO2 HCO3- PaO2

(Slightly)


Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Acute Ventilatory Failure Acute Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2

Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal (severe)

O2ER SvO2

QS/QT DO2 VO2 C(a-v)O2

Normal (severe)

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Large Pneumothorax)(Large Pneumothorax)

CVP CVP RAPRAP PAPA PCWPPCWP

COCO SVSV SVISVI CICI

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Increased translucencyIncreased translucency

Mediastinal shift to unaffected side Mediastinal shift to unaffected side in tension pneumothoraxin tension pneumothorax

Depressed diaphragmDepressed diaphragm

Lung collapseLung collapse

AtelectasisAtelectasis


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


Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the right lung Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the right lung (arrow).(arrow). B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away 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 from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow).(arrow).

A B


General Management of General Management of PneumothoraxPneumothorax

>20%—gas should be evacuated >20%—gas should be evacuated

Negative pressure—5 to 12 cm HNegative pressure—5 to 12 cm H22O O

Should not exceed negative 12 cm HShould not exceed negative 12 cm H22OO



Respiratory care treatment protocolsRespiratory care treatment protocols

Oxygen therapy protocolOxygen therapy protocol

Hyperinflation therapy protocolHyperinflation therapy protocol

Mechanical ventilation protocolMechanical ventilation protocol



PLEURODESISPLEURODESIS

Chemical or medication injected into the Chemical or medication injected into the chest cavitychest cavity TalcTalc

TetracyclineTetracycline

Bleomycin sulfateBleomycin sulfate

Produces inflammatory reaction between Produces inflammatory reaction between lungs and inner chest cavitylungs and inner chest cavity Causes lung to stick to chest cavityCauses lung to stick to chest cavity


Classroom DiscussionClassroom DiscussionCase Study: PneumothoraxCase Study: Pneumothorax

copyright © 2006 by mosby, inc. slide 1 chapter 22 pneumothorax figure 22-1. right-side...

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