Respiratory Disorders:

Pleural and Thoracic

Injury

I. Disorders of the Pleura

A.

Pleural Effusion
Definition: a collection of
excess fluid in the pleural
space.

07/16/16

07/16/16

07/16/16

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
3

Etiology of Pleural Effusions:

07/16/16

Congestive Heart Failure

Liver Disease
Renal Disease
Lupus, Rheumatoid Arthritis
Pneumonia
TB
Lung Cancer
Trauma

What would you think is

happening in this client?

07/16/16

Answer:

07/16/16

Massive left sided pleural

effusion in a patient presenting
with lung cancer.

Pathophysiology of Pleural
Effusion

capillary pressure
or
plasma proteins

Formation of excess fluid=

Transudate
07/16/16

capillary permeability=
Exudate

Accumulation of pus
in the pleural space=Empyema
7

Transudate

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?

07/16/16

vs Exudate

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.
8

Lets try to classify Transudative or

Exudative Pleural Effusion.
Etiology of Pleural Effusions:

07/16/16

Congestive Heart Failure

Liver Disease
Renal Disease
Lupus, Rheumatoid Arthritis
Pneumonia
TB
Lung Cancer
Trauma
ARDS
9

Clinical Manifestations
of Pleural Effusion

07/16/16

Dyspnea
Pleurisy
Decreased breath sounds
Decreased chest wall movement

10

Diagnostic Tests Pleural

Effusion

07/16/16

CXR
CT scan
ABGs/O2 Saturation

11

Therapeutic Interventions

07/16/16

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.
12

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???

07/16/16

17

Clinical Manifestations
of Spontaneous Pnemo

07/16/16

Abrupt onset
Pleuritic chest pain
SOB, dyspnea
respiratory rate, tachycardia
Unequal chest excursion
Decreased breath sounds on
affected side

18

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

07/16/16

19

07/16/16

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
20

Im just asking.

The client has a spontaneous

pneumothorax.which type of
pneumothorax is this:

A- Iatrogenic
B- Open
C- Closed
D- Intermediate

07/16/16

21

Clinical Manifestations
of Pneumothorax

07/16/16

Dyspnea
Pleuritic Pain
RR, pulse
respiratory excursion
Absent breath sounds on
affected side
22

D. Tension Pneumothorax

Definition: air/blood/fluid rapidly

enters pleural space and unable
to escape

Lung collapses
Emergency situation!

07/16/16

23

Tension
Pneumothorax

Is this a right sided or left sided tension pnemothorax?

07/16/16

24

Pathophysiology of
Tension Pnemothorax

Compression of lung to other side

Compresses against trachea, heart, aorta,

esophagus

07/16/16

Increase in Intrapleural pressure

Ventilation and Cardiac Output greatly

compromised
25

Clinical
Manifestations/Complications of
Tension Pneumo

07/16/16

Severe Dyspnea
Tracheal Deviation
Decreased Cardiac Output
Distended Neck Veins
RR, pulse,
blood pressure
Shock
26

Therapeutic Interventions
for Pneumothorax

07/16/16

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)
27

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

07/16/16

28

A. Rib Fracture

07/16/16

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
29

Clinical Manifestations
of Rib Fractures

07/16/16

Pain on inspiration/coughing
Voluntary splinting
Rapid, shallow respirations
Decreased breath sounds
Crepitus on palpation
Signs/symptoms of
pneumo/hemothorax

30

B. Flail Chest

07/16/16

Etiology/Pathophysiology

Occurs when 2+ consecutive ribs are

fractured in multiple places

Segment of chest wall becomes freefloating or flail

Flail segment of chest wall is sucked in

during inspiration and moves outward with
expiration
31

The client presents in

the ED:

07/16/16

Chest trauma client

http://www.youtube.com/watch?v=PyDcGBi7OQ&feature=related

What did you note in this client? What

would you do 1st? 2nd?

32

Clinical Manifestations
of Flail Chest

07/16/16

Dyspnea
Pain especially on
inspiration
Palpable crepitus
Decreased breath sounds
Unequal Chest expansion
33

What assessment
finding is present???

07/16/16

34

Flail Chest

07/16/16

Right lung
affected

35

Therapeutic Interventions
Flail Chest

07/16/16

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
36

07/16/16

Internal/External fixation of ribs in

Flail Chest

37

Judet Plates for Fractured

Ribs/Flail Chest

07/16/16

38

Sanchez Plates for Fractured

Ribs/Flail Chest

07/16/16

39