1. 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

2. 4/19/2017

3. 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
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4. Etiology of Pleural Effusions:
Congestive Heart Failure
Liver Disease
Renal Disease
Lupus, Rheumatoid Arthritis
Pneumonia TB
Lung Cancer
Trauma
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5. What would you think is happening in this client?
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6. Answer:
Massive left sided pleural effusion in a patient presenting with lung cancer.
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7. 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

8. 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

9. 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
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10. Clinical Manifestations of Pleural Effusion
Dyspnea
Pleurisy
Decreased breath sounds
Decreased chest wall movement
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11. Diagnostic Tests Pleural Effusion
CXR
CT scan
ABG’s/O2 Saturation
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12. Therapeutic Interventions
Thoracentesis-needle aspiration of fluid in pleural space. Usually ml /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

14. 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.

15. 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.

16. PleurX® Pleural Catheter System

17. 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

18. Clinical Manifestations of Spontaneous Pnemo
Abrupt onset
Pleuritic chest pain
SOB, dyspnea
respiratory rate, tachycardia
Unequal chest excursion
Decreased breath sounds on affected side
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19. 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
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20. 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
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21. I’m just asking….
The client has a spontaneous pneumothorax….which type of pneumothorax is this:
A- Iatrogenic
B- Open
C- Closed
D- Intermediate
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22. Clinical Manifestations of Pneumothorax
Dyspnea
Pleuritic Pain
RR, pulse
respiratory excursion
Absent breath sounds on affected side
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23. D. Tension Pneumothorax
Definition: air/blood/fluid rapidly enters pleural space and unable to escape
Lung collapses
Emergency situation!
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24. Is this a right sided or left sided tension pnemothorax?
Tension Pneumothorax
                           
Is this a right sided or left sided tension pnemothorax?
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25. 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
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26. Clinical Manifestations/Complications of Tension Pneumo
Severe Dyspnea
Tracheal Deviation
Decreased Cardiac Output
Distended Neck Veins
RR, pulse, blood pressure
Shock
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27. 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

28. 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

29. 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

30. 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

31. 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

32. The client presents in the ED:
Chest trauma client
What did you note in this client? What would you do 1st? 2nd?
4/19/2017

33. Clinical Manifestations of Flail Chest
Dyspnea
Pain especially on inspiration
Palpable crepitus
Decreased breath sounds
Unequal Chest expansion
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34. What assessment finding is present???
                           
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35. Flail Chest
Right lung affected
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36. 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
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37. Internal/External fixation of ribs in Flail Chest
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38. Judet Plates for Fractured Ribs/Flail Chest
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39. Sanchez Plates for Fractured Ribs/Flail Chest
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