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

2. Thoracic Cavity

3. Normal Anatomy
Thoracic cavity
Chest wall
Pleural space
Fluid

4. 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

5. 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

6. 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.

7. 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

8. Categories for Traumatic Injuries
Blunt trauma
Penetrating trauma

9. 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

10. 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

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

12. 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

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

15. How do we diagnosis pleural effusions?

16. Pleural Effusion -- Diagnositcs
____________

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

20. Interventions: Pleural Effusion
Thoracentesis
Diagnostic
vs.
Therapeutic

21. Interventions: Pleural Effusion

22. Interventions: Pleural Effusion Chest tube placement/ PleurX catheter

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

24. Complications of Pleural Effusion
Trapped Lung
Recurrent effusions
Pneumothorax

25. PNEUMOTHORAX
3 types
Closed
Open
Iatrogenic

26. 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

27. ww

28. Clinical Manifestations: Pneumothorax
Respiratory
Cardiac

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

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

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

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

33. Other Types
Hemothorax
Chylothorax

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

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

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

37. 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

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

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

40. 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

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

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

43. 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