pneumothorax

Copyright © 2006 by Mosby, Inc.Slide 1

PneumothoraxPneumothorax

GA

DD

CL

Dr.Njia Brg Ellil


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


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


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


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


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


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


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


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


Conditions requiring chest Conditions requiring chest drainagedrainage

Air between the pleurae Air between the pleurae is a is a pneumothoraxpneumothorax


Conditions requiring chest Conditions requiring chest drainagedrainage

Blood in the pleural Blood in the pleural space is a space is a hemothoraxhemothorax


Conditions requiring chest drainageConditions requiring chest drainage

Transudate or exudate Transudate or exudate in the pleural space is a in the pleural space is a pleural effusionpleural effusion


Conditions requiring chest drainage: Conditions requiring chest drainage: pneumothoraxpneumothorax

PneumothoraxPneumothorax Occurs when there is an opening on the surface of Occurs when there is an opening on the surface of

the lung or in the airways, in the chest wall — or the lung or in the airways, in the chest wall — or bothboth

The opening allows air to enter the pleural space The opening allows air to enter the pleural space between the pleurae, creating an actual spacebetween the pleurae, creating an actual space


Conditions requiring chest drainage: Conditions requiring chest drainage: open pneumothoraxopen pneumothorax

Open pneumothoraxOpen pneumothorax Opening in the chest Opening in the chest

wall (with or without wall (with or without lung puncture)lung puncture)

Allows atmospheric air Allows atmospheric air to enter the pleural to enter the pleural spacespace

Penetrating trauma: Penetrating trauma: stab, gunshot, stab, gunshot, impalementimpalement

SurgerySurgery


Conditions requiring chest drainage: closed Conditions requiring chest drainage: closed pneumothoraxpneumothorax

Closed pneumothoraxClosed pneumothorax Chest wall is intactChest wall is intact

Rupture of the lung Rupture of the lung and visceral pleura (or and visceral pleura (or airway) allows air into airway) allows air into the pleural spacethe pleural space


Conditions requiring chest drainage: open Conditions requiring chest drainage: open pneumothoraxpneumothorax

An An open pneumothoraxopen pneumothorax is also called a “sucking is also called a “sucking chest wound”chest wound”

With the pressure changes in the chest that With the pressure changes in the chest that normally occur with breathing, air moves in and normally occur with breathing, air moves in and out of the chest through the opening in the chest out of the chest through the opening in the chest wallwall

Looks bad and sounds worse, but the opening Looks bad and sounds worse, but the opening acts as a vent so pressure from trapped air acts as a vent so pressure from trapped air cannot build up in the chestcannot build up in the chest


Conditions requiring chest drainage: closed Conditions requiring chest drainage: closed pneumothoraxpneumothorax

In a In a closed closed pneumothoraxpneumothorax, a , a patient who is breathing patient who is breathing spontaneously can spontaneously can have an equilibration of have an equilibration of pressures across the pressures across the collapsed lungcollapsed lung

The patient will have The patient will have symptoms, but this is symptoms, but this is not life-threateningnot life-threatening


Conditions requiring chest drainage: Conditions requiring chest drainage: tension pneumothoraxtension pneumothorax

A A tension pneumothoraxtension pneumothorax can kill can kill

Chest wall is intactChest wall is intact

Air enters the pleural space from the lung or Air enters the pleural space from the lung or airway, and it has no way to leaveairway, and it has no way to leave

There is no vent to the atmosphere as there is in There is no vent to the atmosphere as there is in an open pneumothoraxan open pneumothorax

Most dangerous when patient is receiving Most dangerous when patient is receiving positive pressure ventilation in which air is positive pressure ventilation in which air is forced into the chest under pressureforced into the chest under pressure


Conditions requiring chest drainage: Conditions requiring chest drainage: tension pneumothoraxtension pneumothorax

Tension pneumothoraxTension pneumothorax occurs when a occurs when a closed closed pneumothoraxpneumothorax creates creates positive pressure in the positive pressure in the pleural space that pleural space that continues to buildcontinues to build

That pressure is then That pressure is then transmitted to the transmitted to the mediastinum (heart and mediastinum (heart and great vessels)great vessels)


Conditions requiring chest drainage: Conditions requiring chest drainage: mediastinal shiftmediastinal shift

Mediastinal shift

Mediastinal shiftMediastinal shift occurs occurs when the pressure gets when the pressure gets so high that it pushes the so high that it pushes the heart and great vessels heart and great vessels into the unaffected side into the unaffected side of the chestof the chest

These structures are These structures are compressed from compressed from external pressure and external pressure and cannot expand to accept cannot expand to accept blood flowblood flow


Conditions requiring chest drainage: Conditions requiring chest drainage: mediastinal shiftmediastinal shift

Mediastinal shiftMediastinal shift can quickly lead to can quickly lead to cardiovascular collapsecardiovascular collapse

The vena cava and the right side of the heart The vena cava and the right side of the heart cannot accept venous returncannot accept venous return

With no venous return, there is no cardiac outputWith no venous return, there is no cardiac output

No cardiac output = not able to sustain lifeNo cardiac output = not able to sustain life


Conditions requiring chest drainage:Conditions requiring chest drainage:tension pneumothoraxtension pneumothorax

When the pressure is When the pressure is external, CPR will not external, CPR will not help – the heart will still help – the heart will still not accept venous returnnot accept venous return

Immediate, live-saving Immediate, live-saving treatment is placing a treatment is placing a

needle to needle to relieve pressure relieve pressure followed by followed by chest tubechest tube


Conditions requiring chest drainage: Conditions requiring chest drainage: hemothoraxhemothorax

HemothoraxHemothorax occurs after thoracic surgery and occurs after thoracic surgery and many traumatic injuriesmany traumatic injuries

As with pneumothorax, the negative pressure As with pneumothorax, the negative pressure between the pleurae is disrupted, and the lung will between the pleurae is disrupted, and the lung will collapse to some degree, depending on the collapse to some degree, depending on the amount of bloodamount of blood

The risk of mediastinal shift is insignificant, as the The risk of mediastinal shift is insignificant, as the amount of blood needed to cause the shift would amount of blood needed to cause the shift would result in a life-threatening intravascular lossresult in a life-threatening intravascular loss


Remove fluid & airRemove fluid & air

ThoracostomyThoracostomy creates an opening in the chest wall creates an opening in the chest wall through which a chest tube (also called thoracic through which a chest tube (also called thoracic catheter) is placed, which allows air and fluid to catheter) is placed, which allows air and fluid to flow out of the chestflow out of the chest


Remove fluid and airRemove fluid and air


Remove fluid & airRemove fluid & air

Choose site

Explore with finger

Place tube with clamp

Suture tube to chest


Remove fluid & air through chest tubeRemove fluid & air through chest tube


Remove fluid and air after thoracic Remove fluid and air after thoracic surgerysurgery

At the end of the At the end of the procedure, the procedure, the surgeon makes a surgeon makes a stab wound in the stab wound in the chest wall through chest wall through which the chest which the chest tube is placed into tube is placed into the pleural spacethe pleural space


Prevent air & fluid from returning to Prevent air & fluid from returning to the pleural spacethe pleural space

Chest tube is attached to a Chest tube is attached to a drainage devicedrainage device Allows air and fluid to leave the chestAllows air and fluid to leave the chest

Contains a one-way valve to prevent air & fluid Contains a one-way valve to prevent air & fluid returning to the chestreturning to the chest

Designed so that the device is below the level of the Designed so that the device is below the level of the chest tube for gravity drainagechest tube for gravity drainage



How does a chest drainage system work?How does a chest drainage system work?

It’s all about It’s all about bottles and bottles and

strawsstraws



Tube from patient

Tube open to atmosphere vents air

Most basic conceptMost basic concept

Straw attached to Straw attached to chest tube from patient chest tube from patient is placed under 2cm of is placed under 2cm of fluid (water seal)fluid (water seal)

Just like a straw in a Just like a straw in a drink, air can push drink, air can push through the straw, but through the straw, but air can’t be drawn back air can’t be drawn back up the strawup the straw



This system works if only air is leaving the chestThis system works if only air is leaving the chest

If fluid is draining, it will add to the fluid in the If fluid is draining, it will add to the fluid in the water seal, and increase the depthwater seal, and increase the depth

As the depth increases, it becomes harder for As the depth increases, it becomes harder for the air to push through a higher level of water, the air to push through a higher level of water, and could result in air staying in the chestand could result in air staying in the chest



Tube open to atmosphere vents air Tube from patient

Fluid drainage

2cm fluid

For drainage, a second For drainage, a second bottle was addedbottle was added

The The first bottlefirst bottle collects collects the the drainagedrainage

The The second bottlesecond bottle is is the the water sealwater seal

With an extra bottle for With an extra bottle for drainage, the water drainage, the water seal will then remain at seal will then remain at 2cm 2cm



The two-bottle system is the key for chest The two-bottle system is the key for chest drainagedrainage A place for drainage to collectA place for drainage to collect

A one-way valve that prevents air or fluid from A one-way valve that prevents air or fluid from returning to the chestreturning to the chest


Restore negative pressure in the pleural Restore negative pressure in the pleural spacespace

Many years ago, it was believed that suction was Many years ago, it was believed that suction was always required to pull air and fluid out of the always required to pull air and fluid out of the pleural space and pull the lung up against the pleural space and pull the lung up against the parietal pleuraparietal pleura

However, recent research has shown that suction However, recent research has shown that suction may actually prolong air leaks from the lung by may actually prolong air leaks from the lung by pulling air through the opening that would pulling air through the opening that would otherwise close on its ownotherwise close on its own

If If suctionsuction is required, a is required, a third bottlethird bottle is added is added


Restore negative pressure in the Restore negative pressure in the pleural spacepleural space

Tube to vacuum source

Tube open to atmosphere vents air

Tube from patient

Fluid drainage

Straw under 20 cmH2O



The straw submerged in the suction control bottle The straw submerged in the suction control bottle (typically to 20cmH(typically to 20cmH22O) limits the amount of O) limits the amount of negative pressure that can be applied to the negative pressure that can be applied to the pleural space – in this case -20cmHpleural space – in this case -20cmH22OO

The submerged straw is open at the topThe submerged straw is open at the top

As the vacuum source is increased, once bubbling As the vacuum source is increased, once bubbling begins in this bottle, it means atmospheric begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction levelpressure is being drawn in to limit the suction level


Restore negative pressure in the Restore negative pressure in the pleural spacepleural space

The The depth of the waterdepth of the water in the suction bottle in the suction bottle determines the amount determines the amount of negative pressure of negative pressure that can be transmitted that can be transmitted to the chest, to the chest, NOT the NOT the reading on the reading on the vacuum regulatorvacuum regulator



There is no research to support this number of -There is no research to support this number of -20cmH20cmH22O, just conventionO, just convention

Higher negative pressure can increase the flow Higher negative pressure can increase the flow rate out of the chest, but it can also damage rate out of the chest, but it can also damage tissuetissue


How a chest drainage system How a chest drainage system worksworks

Expiratory positive pressureExpiratory positive pressure from the patient from the patient helps push air and fluid out of the chest (cough, helps push air and fluid out of the chest (cough, Valsalva)Valsalva)

GravityGravity helps fluid drainage as long as the chest helps fluid drainage as long as the chest drainage system is below the level of the chestdrainage system is below the level of the chest

SuctionSuction can improve the speed at which air and can improve the speed at which air and fluid are pulled from the chestfluid are pulled from the chest


From bottles to a boxFrom bottles to a box

The bottle system worked, but it was bulky at the The bottle system worked, but it was bulky at the bedside and with 16 pieces and 17 connections, bedside and with 16 pieces and 17 connections, it was difficult to set up correctly while it was difficult to set up correctly while maintaining sterility of all of the partsmaintaining sterility of all of the parts

In 1967, a one-piece, disposable plastic box was In 1967, a one-piece, disposable plastic box was introducedintroduced

The box did everything the bottles did – and The box did everything the bottles did – and moremore


At the bedsideAt the bedside

Keep drain below the chest Keep drain below the chest for gravity drainagefor gravity drainage

This will cause a This will cause a pressure pressure gradientgradient with relatively with relatively higher pressure in the chesthigher pressure in the chest

Fluid, like air, moves from Fluid, like air, moves from an area of higher pressure an area of higher pressure to an area of lower pressureto an area of lower pressure

Same principle as raising an Same principle as raising an IV bottle to increase flow IV bottle to increase flow raterate


Monitoring intrathoracic pressureMonitoring intrathoracic pressure

The water seal chamber and suction control The water seal chamber and suction control chamber provide intrathoracic pressure monitoringchamber provide intrathoracic pressure monitoring

Gravity drainage without suctionGravity drainage without suction: Level of water in : Level of water in the the water seal chamber = intrathoracic pressurewater seal chamber = intrathoracic pressure (chamber is calibrated manometer)(chamber is calibrated manometer)

Slow, gradual rise in water level over time means more Slow, gradual rise in water level over time means more negative pressure in pleural space and signals healingnegative pressure in pleural space and signals healing

Goal is to return to -8cmHGoal is to return to -8cmH2200

With suctionWith suction: Level of water in : Level of water in suction control +suction control + level of water in level of water in water sealwater seal chamber chamber = = intrathoracic pressureintrathoracic pressure


Monitoring air leakMonitoring air leak

Water seal is a window into Water seal is a window into the pleural spacethe pleural space

Not only for pressureNot only for pressure

If air is leaving the chest, If air is leaving the chest, bubbling will be seen herebubbling will be seen here

Air leak meter (1-5) provides a Air leak meter (1-5) provides a way to “measure” the leak and way to “measure” the leak and monitor over time – getting monitor over time – getting better or worse?better or worse?


Setting up the drainSetting up the drain

Follow the manufacturer’s instructions for adding Follow the manufacturer’s instructions for adding water to the 2cm level in the water seal chamber, water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control and to the 20cm level in the suction control chamber (unless a different level is ordered)chamber (unless a different level is ordered)

Connect 6' patient tube to thoracic catheterConnect 6' patient tube to thoracic catheter

Connect the drain to vacuum, and slowly increase Connect the drain to vacuum, and slowly increase vacuum until vacuum until gentle bubblinggentle bubbling appears in the appears in the suction control chambersuction control chamber


Setting up suctionSetting up suction

You don’t need to boil spaghetti!You don’t need to boil spaghetti!

Vigorous bubbling is Vigorous bubbling is loudloud and and disturbing to most patientsdisturbing to most patients

Will also cause Will also cause rapid evaporationrapid evaporation in the in the chamber, which will chamber, which will lower suction levellower suction level

Too much bubbling is Too much bubbling is not needed clinicallynot needed clinically in in 98% of patients – more is not better98% of patients – more is not better

If too much, turn down vacuum source until If too much, turn down vacuum source until bubbles go away, then slowly increase until they bubbles go away, then slowly increase until they reappear, then stopreappear, then stop


Disposable chest drainsDisposable chest drains

Collection chamberCollection chamber Fluids drain directly into chamber, calibrated in mL fluid, Fluids drain directly into chamber, calibrated in mL fluid,

write-on surface to note level and timewrite-on surface to note level and time

Water sealWater seal One way valve, U-tube design, can monitor air leaks & One way valve, U-tube design, can monitor air leaks &

changes in intrathoracic pressurechanges in intrathoracic pressure

Suction control chamberSuction control chamber U-tube, narrow arm is the atmospheric vent, large arm is U-tube, narrow arm is the atmospheric vent, large arm is

the fluid reservoir, system is regulated, easy to control the fluid reservoir, system is regulated, easy to control negative pressurenegative pressure

pneumothorax

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