Respiratory Disorders: Pleural & Thoracic Injury by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard, RN, MSN

Thoracic Cavity http://www.google.com/imgres?imgurl=http://www.tcnj.edu/~mckinney/body.jpg&imgrefurl=http://www.tcnj.edu/~mckinney/breathing.htm&h=480&w=460&sz=60&tbnid=7I0hIqYYrrrEDM:&tbnh=129&tbnw=124&prev=/images%3Fq%3Dthoracic%2Bcavity&usg=__64_qfRrbnmkZHJsDtcpsNyD-QUk=&ei=HjqESrfvF4eosgPnloGqBw&sa=X&oi=image_result&resnum=4&ct=image

Normal Anatomy Thoracic cavity Chest wall Pleural space Fluid

Terminolgy Pleura the thin serous membrane around the lungs and inner walls of the chest (2 layers) Pleural space thin space between the 2 layers of pleura Pleural cavity body cavity that surrounds the lungs Parietal Pleura Pleura that lines the inner chest walls and covers the diaphragm Viceral Pleura Pleura that lines the lung itself Pleural Fluid pleura that lines the inner chest wall and covers the diaphragm

Pleural Fluid pH 7.6 – 7.64 1-2g/dL protein Less than 1000 WBC per cubic millimeter Glucose level similar to plasma LDH less than 50% that of plasma Na, K+, & Ca levels similar to that of interstitial fluid

Viceral pleura – Parietal pleura- Covers surface of the lung Cannot be disected away from the lung Parietal pleura- Lines the wall of the chest and covers the diaphragm Parietal ---- of or related to the formation of bone, organ or cavity. http://www.themesotheliomalibrary.com/pleural-effusions.JPG

Chest Trauma & Thoracic Injury 20-25% of trauma victims with chest trauma die 45% of trauma victims have some type of chest trauma BEWARE: External injury may appear minor

Categories for Traumatic Injuries Blunt trauma Penetrating trauma

Traumatic Chest Injuries Mechanism of Injury Common Related Injury Blunt Trauma Blunt steering wheel injury to chest Rib fractures, flail chest, pneumothorax, hemopneumothorax, myocardial contusion, pulmonary contusion, cardiac tamponade, great vessel tears Shoulder harness seat belt injury Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac tamponade Crush injury (heavy equipment, crushing the thorax) Pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood return to heart with decreased cardiac output Penetrating trauma Gunshot, stab wound to chest Open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears

Respiratory Disorders: Pleural and Thoracic Injury Pleural Effusion A collection of excess fluid in the pleural space Is it normal to have fluid in this space? Would you consider a pleural effusion a disease? Classification Transudative aka: hydorthoraces ----- systemic causes Usually not caused by inflammatory processes Most common type Exudative ----- localized cause Usually caused by an inflammatory process Often recurrent, difficult to treat

Empyema What is it? What causes it? How do we treat it?

Etiology: Pleural Effusion Identify the Class of Effusion Disease Process Classification of Effusion Heart Failure TB Lupus/RA Renal Disease Lung Cancer Trauma Pneumonia Liver Failure

Clinical Manifestations: Pleural Effusion Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement Dullness on percussion

How do we diagnosis pleural effusions?

Pleural Effusion -- Diagnositcs ____________

How do we know what type of pleural effusion it is?

Interventions: Pleural Effusion Thoracentesis Diagnostic vs. Therapeutic

Interventions: Pleural Effusion

Interventions: Pleural Effusion Chest tube placement/ PleurX catheter

Interventions: Pleural Effusion Treat underlying condition – CHF/Renal failure Pneumonia Liver Disease Lupus/RA Malignancy Pleurodesis Chest tube insertion Allow to resolve

Complications of Pleural Effusion Trapped Lung Recurrent effusions Pneumothorax

PNEUMOTHORAX 3 types Closed Open Iatrogenic

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, COPD, fractured ribs that penetrate the pleura. Occurs in stabbings, gunshot wounds, impalement injury. Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation

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Clinical Manifestations: Pneumothorax Respiratory Cardiac

Tension Pneumothorax Air/blood/fluid rapidly entering the pleural space Lung collapses Emergency situation

Pathophysiology: Tension Pneumo Increase in intrapleural pressure Compression of lung Compresses against trachea, heart, aorta, esophagus Ventilation and cardiac output greatly compromised

Clinical Manifestations: Tension Pneumo Severe dyspnea Tracheal deviation Decreased cardiac output Distended neck veins Increased respiratory rate Increased heart rate Decreased blood pressure Shock

Treatment Tension Pneumo Emergency --- quick intervention Needle decompression Chest tube placement

Other Types Hemothorax Chylothorax

Intervention: Pneumothorax High Fowlers position Oxygen as ordered Rest to decrease oxygen demand ***Chest tube insertion Pleurodesis Surgery ?

Clinical Manifestations: Rib Fractures Ribs 5-10 most commonly fractured Pain Splinting & Rapid, shallow respirations Decreased breath sounds Crepitus Signs/symptoms of pneumothorax

Treatment: Rib Fractures Reduce or minimize pain Do we wrap or bind the chest? Do we use opiods? Goal?

Pathophysiology: Flail Chest 2 or more ribs fractured 2 or more separate places Unstable / free floating chest Usually involves anterior or lateral fx Paradoxical respirations

Clinical Manifestations: Flail Chest Dyspnea with rapid, shallow inspiration Pain Palpable crepitus Decreased breath sounds Unequal chest expansion Tachycardia

Interventions: Flail Chest Oxygen as ordered Elevate HOB Analgesia Suction Splint affected side? *Intubation *Mechanical ventilation

Pathophysiology: Pulmonary Contusion Abrupt chest compression then rapid decompression Intra-alveolar hemorrhage Interstitial/bronchial edema Decreased surfactant production Increase pulmonary vascular resistance Decrease blood flow

Clinical Manifestation: Pulmonary Contusion Increased SOB Restlessness Anxiety Chest pain Copious sputum Increased respiratory Increased heart rate Dyspnea Cyanosis

Intervention: Pulmonary Contusion Intubation Mechanical ventilation Bronchoscopy Fluids Volume expanders Pulmonary artery pressure monitoring

Chest Surgeries Lewis 593 Table 28-22; NCP 28-2 Exploratory thoracotomy Incision into thorax to look for injured or bleeding tissue Thoracotomy not involving lung VATS Video-assisted thoracic surgery to do lung biopsy, lobectomy, ect