Respiratory Disorders: Pleural and Thoracic Injury • I. Disorders of the Pleura • A. Pleural Effusion • Definition: a collection of excess fluid in the pleural space.
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
Etiology of Pleural Effusions: • Congestive Heart Failure • Liver Disease • Renal Disease • Lupus, Rheumatoid Arthritis • Pneumonia • TB • Lung Cancer • Trauma
Answer: • Massive left sided pleural effusion in a patient presenting with lung cancer.
capillary pressure or plasma proteins capillary permeability= Exudate • Pathophysiology of Pleural Effusion Accumulation of pus in the pleural space=Empyema Formation of excess fluid= Transudate
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. Transudate vs Exudate
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
Clinical Manifestationsof Pleural Effusion • Dyspnea • Pleurisy • Decreased breath sounds • Decreased chest wall movement
Diagnostic Tests Pleural Effusion • CXR • CT scan • ABG’s/O2 Saturation
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.
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.
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.
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???
Clinical Manifestations of Spontaneous Pnemo • Abrupt onset • Pleuritic chest pain • SOB, dyspnea • respiratory rate, tachycardia • Unequal chest excursion • Decreased breath sounds on affected side
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
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
Clinical Manifestations of Pneumothorax • Dyspnea • Pleuritic Pain • RR, pulse • respiratory excursion • Absent breath sounds on affected side
D. Tension Pneumothorax • Definition: air/blood/fluid rapidly enters pleural space and unable to escape • Lung collapses Emergency situation!
Is this a right sided or left sided tension pnemothorax? Tension Pneumothorax
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
Clinical Manifestations/Complications of Tension Pneumo • Severe Dyspnea • Tracheal Deviation • Decreased Cardiac Output • Distended Neck Veins • RR, pulse, blood pressure • Shock
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)
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
Pathophysiology of Thoracic Injury • Acceleration-Deceleration Injury • Rapid change in velocity • Body stops suddenly • Chest cavity organs/tissues move forward
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
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
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
The client presents in the ED: • Chest trauma client • http://www.youtube.com/watch?v=PyDcGB-i7OQ&feature=related • What did you note in this client? What would you do 1st? 2nd?
Clinical Manifestations of Flail Chest • Dyspnea • Pain especially on inspiration • Palpable crepitus • Decreased breath sounds • Unequal Chest expansion
Flail Chest • Right lung affected
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
Internal/External fixation of ribs in Flail Chest
C. Pulmonary Contusion • Etiology/Pathophysiology • Left Pulmonary contusion
Abrupt Chest Compression then Rapid Decompression Intra-alveolar Hemorrhage Interstitial/bronchial Edema surfactant production leads to decreased lung compliance Pulmonary vascular resistance Airway obstruction, Atelectasis, Impaired O2/CO2 exchange blood flow
Clinical Manifestations of Pulmonary Contusion • SOB • Restlessness, Anxiety • Chest Pain • Copius Sputum (blood tinged) • RR, Pulse, Dyspnea, Cyanosis
Therapeutic Interventions Pulmonary Contusion • Intubation/Mechanical Ventilation • Bronchoscopy to remove secretions, cellular debris • Fluids, Volume expanders to treat shock • Pulmonary Artery pressure monitoring