1. Pneumothorax

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

3. 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

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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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.

20. 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

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

22. 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

23. 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

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

25. 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

26. pneumonectomy

27. references
Pryor, J.A. and Prasad, S.A Physiotherapy for respiratory and cardiac problems. Adult and paediatrics. Edinburgh: Churchill Livingstone
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