Pneumothorax

Definition Presence of air in the pleural space Primary spontaneous pneumothorax Secondary spontaneous pneumothorax Tension pneumothorax Traumatic pneumothorax

Primary spontaneous pneumothorax Most common In tall thin people Rupture of tiny bleb at the apex of the lug Clinical signs: acute chest pain shortness of breath (at rest or on exertion) May be recurrent

Primary spontaneous pneumothorax Size determines management Observation and repeat X-ray Needle aspiration ICD After two pneumothoraces on the same side – surgery Pleurectomy Pleurodesis

Secondary spontaneous Pneumothorax As a result of lung disease e.g. TB, COPD or lung abscess

Traumatic pneumothorax Penetrating trauma Usually accompanied by haemothorax – haemopneumothorax Haemothorax – accumulation of blood in the pleural space Bleeding from chest wall, heart, major vessels or lungs

Traumatic pneumothorax Lung contusion – injury to lung parenchyma, oedema and blood collecting in the alveoli and an inflammatory reaction to blood components in the lung. Lung contusion affects gas exchange - ARDS

Tension pneumothorax Site of air leak acts as one-way valve – air enters pleural space during inspiration but cannot escape during expiration Volume of air and pressure in hemithorax – compression of lung Mediastinal shift away from compressed lung Possible shift of trachea and kinking of great vessels

Tension pneumothorax Clinical signs - deviation of trachea absent breath sounds acute respiratory distress ↑ jugular venous pressure hypotension Life-threatening – insert ICD

UWSD System used to drain air and fluid from thoracic cavity and regain / maintain re- expansion of lung by creating normal negative pressure Effective gas exchange only possible if lung can expand to allow ventilation

Pleural membranes Visceral and parietal pleura Between them 10ml of serous pleural fluid, produced by pleural membranes Fluid lubricates surfaces, reduces friction Negative pressure between pleura, counteracts tendency of lungs to recoil If air or fluid enter pleural space – negatve pressure lost – lung will collapse partially or fully

Chest tubes Diameter of tube depends on size of patient and what is being drained Smaller drain – air, larger drain – fluids Location of substance, determines placement of tube Pneumothorax - tube anteriorly 2nd or 3rd intercostal space or mid axillary line 3rd and 5th space Fluids - mid axillary line 6th space

UWSD Prevents air re-entering pleural space End of tube is submerged 2cm under water level Hydrostatic resistance of +2cmH2O When pressure in intrapleural space is higher than +2cmH2O, air moves from higher (intrapleural) to lower pressure (drainage chamber) Drainage chamber has a vent to allow air to escape and not build up in chamber

UWSD Fluids will drain by gravity Keep bottle below level of patient’s chest If you need to lift the bottle (with transfers), clamp it Minimize clamping time One-bottle system Two-bottle system – one for air and one for fluid Three-bottle system – suction applied to third bottle

UWSD Disposable (all-in-one) three-bottle system Waterless suction system

Patient assessment Swing Intrapleural pressure changes during inspiration and expiration transmitted to tube Inspiration (more negative), fluid moves up the tube Expiration – opposite direction Movement during normal breathing – swing Suction reduces swing

Patient assessment No swing Tube kinked or patient lying on it Lung re-expanded Dependant fluid-filled loop of tubing

Patient assessment Bubbling Bubbling in bottle – air leak from pleural space Bubbling in suction chamber – suction is applied Bubbling with cough – small air leak Bubbling on expiration – moderate air leak Bubbling during inspiration and expiration – large air leak

Patient assessment No bubbling Absence of air leak When examining UWSD – ask patient to take deep breath and observe swinging and bubbling. If no bubbling with above – ask patient to cough.

Drainage < 100ml in 24 hours – remove tube > 100ml per hour or sudden increase – tell medical staff Large amounts of blood over short time – haemorrhage Large amounts of haemoserous drainage – hypovolaemia, hypotension, low haemoglobin

suction Gentle bubbling in suction chamber Vigorous bubbling - ↑ evaporation No bubbling – insufficient suctioning

Key points Keep bottle upright – tip of tube under water Bottle below patient’s chest, clamped if held above chest Beware of occlusion of tubing If tube disconnected from bottle – clamp and reconnect as soon as possible If chest drain comes out – cover wound with gloved hand and call for help Positive pressure (CPAP, IPPB) can increase air leak, constant monitoring

Key points Patients should move around with their drains Encourage shoulder movements on side of drain and good posture Patients may be disconnected from suction, but check with staff first If patient may not be disconnected – walking on spot Disconnect tubing from suction, don’t switch suction off

Physiotherapy Localised breathing exercises Cardiovascular exercises Posture correction Shoulder - maintain ROM

Key points – pneumonectomy Positioning – check with doctor. May sometimes position on operated side or just sitting for 3-6 days Complication – pulmonary oedema. Whole CO through one lung. Report positive fluid balance with tachycardia, tachypnoea and hypoxaemia After lobectomy and pleurectomy - no absolute contra-indication to positioning in side-lying and trendellenburg

pneumonectomy

references Pryor, J.A. and Prasad, S.A. 2009. Physiotherapy for respiratory and cardiac problems. Adult and paediatrics. Edinburgh: Churchill Livingstone Images courtesy of Google search engine