Respiratory Disorders: Pleural and Thoracic Injury I. Disorders of the Pleura A. Pleural Effusion Definition: a collection of excess fluid in the pleural space. 4/19/2017

4/19/2017

Pleural effusion Chest x-ray of a pleural effusion 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 4/19/2017

Etiology of Pleural Effusions: Congestive Heart Failure Liver Disease Renal Disease Lupus, Rheumatoid Arthritis Pneumonia TB Lung Cancer Trauma 4/19/2017

What would you think is happening in this client? 4/19/2017

Answer: Massive left sided pleural effusion in a patient presenting with lung cancer. 4/19/2017

in the pleural space=Empyema Pathophysiology of Pleural Effusion capillary pressure or plasma proteins capillary permeability= Exudate Accumulation of pus in the pleural space=Empyema Formation of excess fluid= Transudate 4/19/2017

Transudate vs Exudate 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. 4/19/2017

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 4/19/2017

Clinical Manifestations of Pleural Effusion Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement 4/19/2017

Diagnostic Tests Pleural Effusion CXR CT scan ABG’s/O2 Saturation 4/19/2017

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. 4/19/2017

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.

PleurX® Pleural Catheter System

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??? 4/19/2017

Clinical Manifestations of Spontaneous Pnemo Abrupt onset Pleuritic chest pain SOB, dyspnea respiratory rate, tachycardia Unequal chest excursion Decreased breath sounds on affected side 4/19/2017

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 4/19/2017

No opening from external chest. Open Pneumothorax Closed Pneumothorax No opening from external chest. Open Pneumothorax Opening from external chest wall into pleura. Iatrogenic Pneumothorax Puncture or laceration of visceral pleura during medical tx Occurs in crashes, falls, MVAs, CPR, fractured ribs that penetrate the pleura. Occurs in stabbings, gunshot wounds, impalement injury. Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation 4/19/2017

I’m just asking…. The client has a spontaneous pneumothorax….which type of pneumothorax is this: A- Iatrogenic B- Open C- Closed D- Intermediate 4/19/2017

Clinical Manifestations of Pneumothorax Dyspnea Pleuritic Pain RR, pulse respiratory excursion Absent breath sounds on affected side 4/19/2017

D. Tension Pneumothorax Definition: air/blood/fluid rapidly enters pleural space and unable to escape Lung collapses Emergency situation! 4/19/2017

Is this a right sided or left sided tension pnemothorax? Tension Pneumothorax                             Is this a right sided or left sided tension pnemothorax? 4/19/2017

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 4/19/2017

Clinical Manifestations/Complications of Tension Pneumo Severe Dyspnea Tracheal Deviation Decreased Cardiac Output Distended Neck Veins RR, pulse, blood pressure Shock 4/19/2017

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) 4/19/2017

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 4/19/2017

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 4/19/2017

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 4/19/2017

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 4/19/2017

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? 4/19/2017

Clinical Manifestations of Flail Chest Dyspnea Pain especially on inspiration Palpable crepitus Decreased breath sounds Unequal Chest expansion 4/19/2017

What assessment finding is present???                             4/19/2017

Flail Chest Right lung affected 4/19/2017

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 4/19/2017

Internal/External fixation of ribs in Flail Chest 4/19/2017

Judet Plates for Fractured Ribs/Flail Chest 4/19/2017

Sanchez Plates for Fractured Ribs/Flail Chest 4/19/2017