NURS 312: Pneumothorax

Sub Q emphysema

Air gets into the tissue under the skin in the chest or neck Usually appears as bulging skin Feels crunchy on palpation, like rice krispies under the skin The crackling is produced by gas being pushed through the tissue on palpation Monitor that it can be a normal occurrence after a chest tube or that the chest tube is not placed properly.

Nursing priorities: Pneumothorax

Airway Oxygenation- may be on continuous 02- higher flow Ensure patency and function of chest tubes Assessment: Auscultation Pain/ comfort Measure amount of drainage Troubleshoot for problems

Trouble shooting chest tubes, Problem: Air Leak

Briefly clamp chest tube between pt. and drainage system, closer to insertion site If water seal chamber is bubbling, the leak is in the tubing (lower down) If water seal chamber stops bubbling, the leak is at the insertion site Secure all connections with tape Change tubing if needed ( check with MD) Apply sterile petroleum gauze around chest tube insertion site if leak is present there When looking for suction, look at "E", when adequate suction, the bevel would pop all the way out. Water lower on inspiration, higher on expiration. No movement of water = tubing occlusion or lung may be rexpanded. Refilling water. Assess output and comment on any output greater than 70-100 ml Keep lowering the suction to find the leak. How would you know that there is an air leak? Continuous bubbling,

Chest Tubes

Chest tubes and pleural drainage systems: Remove air and fluid from the pleural space Restore normal intrapleural pressure so that the lungs can re-expand When we take out the air or fluid, allows pressure to go make to negative and for the lung to re-expand

Pnemothorax Diagnostics

CXR: Absent vascular markings (normal vasculature wont be visible) Air - air will be sisle - may be so much air that you cant see the lung Lobe of lung may appear shrunken Diaphragm that is hyperexpanded Tracheal deviation Mediastinal shift

Trouble shooting chest tubes, Problem: Pt. develops sudden mediastinal shift Tracheal deviation; paradoxical pulse; decreased CO; increased JVD

Call for help immediately Check drainage tubes for patency Prepare for CODE

Trouble shooting chest tubes, Problem: Chest tube becomes disconnected from drainage system

Clamp chest tube nearest to insertion site Replace tubing leading from chest tube and create temporary underwater seal system to maintain negative pressure Unclamp chest tube as soon as either: Tubing is placed underwater Connection is secured to a new system Secure connections with tape Assess patient for signs of distress Put in 2 cm in sterile water

Pleural effusion

Collection of fluid in the pleural space = Indication of another problem Normally only ~ 25 ml of pleural fluid in the pleural space Increase of normal amount of fluid in that space Transudative (CHF, obstruction in normal circulation), exudative (pneumonia) Need to understand why it is happening.

Air Leak Disorders

Consist of those conditions that result in extra-alveolar air accumulation Two categories are Pneumothorax and Barotrauma Two main causes are --Disruption of the parietal or visceral pleura, which allows air to enter the pleural space; and --Rupture of alveoli, which allows air to enter the interstitial space = b.c a shift

Trouble shooting chest tubes, Problem: Obstruction in Drainage system

Look for kinks in tubing Loop tubing on bed to allow for strait drainage Obtain physicians order to milk or strip tubing Start at tube in chest, work all the way down to canister. Stripping = pull the whole tubing Milking = roll between thumb and forefinger.

Signs and Symptoms of Pnemothorax

Dyspnea Decreased chest wall movement of affected side Diminished or absent breath sounds Hyper- resonance on percussion Tension: Air hunger Cyanosis Panic Hemothorax = accumulation of blood that causes the collapse. Shocky Dull to percussion

Different types of Pnemothoraxes

Hemothorax: Accumulation of blood in the intrapleural space Found in association with open pneumothorax and is therefore called a hemopneumothorax. Chylothorax ( Chylopneumothorax) Lymphatic fluid (and possible air) in the pleural space due to a leak in the thoracic duct. Causes include trauma, surgical procedures, and malignancy.

Chest tube insertion for pneumothorax

Initial therapy consists of adequate ventilation, administration of humidified O2, careful administration of IV solutions, and pain control. The goal of therapy is to re-expand the lung and ensure adequate oxygenation Pain is important because they won't be breathing as well. So use an incentive spirometer, providing pain control, ect.

Trouble shooting chest tubes, Problem: Chest tube falls out

Notify MD immediately. Instruct patient to exhale force fully- apply sterile occlusive dressing to site quickly. Why a 3 sided dressing? So a one way valve can be created.

Traumatic Pneumothorax

Open - laceration in the parietal pleura that allows atmospheric air to enter the pleural space; occurs as a result of penetrating chest trauma Closed - laceration in the visceral pleura that allows air from the lung to enter the pleural space; occurs as a result of blunt chest trauma Iatrogenic - laceration in the visceral pleura that allows air from the lung to enter the pleural space; occurs as a result of therapeutic or diagnostic procedures, such as central line insertion, thoracentesis, and needle aspiration Tension - occurs when air is allowed to enter the pleural space but not to exit it; as pressure increases inside the pleural space, the lung collapses and the mediastinum shifts to the unaffected side; may result from a spontaneous or traumatic pneumothorax. rush of air into the lung. Tracheal deviation. Can put pressure on the heart. Medical emergency. Wound to chest has created a one way valve. Air can rush in on inhalation but cant get out on exhalation.

Pneumothorax- defined

Presence of air in the pleural space Complete or partial collapse of lung = can be major vs minor Suspect with trauma or blunt injury to chest wall Suspect with chronic airflow limitation diseases May occur with Infection May occur in lung cancers Post operative thoracic sx.

Spontaneous Pnemothorax

Primary - disruption of the visceral pleura that allows air from the lung to enter the pleural space; occurs spontaneously in patients without underlying lung disease Secondary - disruption of the visceral pleura that allows air from the lung to enter the pleural space; occurs spontaneously in patients with underlying lung disease

Flail Chest

Results from multiple rib fractures causing an unstable chest wall. The affected (flail) area will move paradoxically to the intact portion of the chest during respiration. During inspiration, the affected portion is sucked in, and during expiration, it bulges out. This paradoxical chest movement prevents adequate ventilation of the lung in the injured area.

Chest tubes: Nursing role

Routine monitoring to evaluate if chest drainage is successful by: Observing for tidalling in the water-seal chamber, Listening for breath sounds over the lung fields, Measuring the amount of fluid drainage. Chest tube malposition/misplacement is the most common complication! Where does it get inserted for a pneumothorax? Higher (2nd intercostal space midclavicular line) a tube might be lower to collect fluid Base of lung to collect fluid as the fluid would pool down there. Do all require a chest tube? No. if they are small enough, the lung can reabsorb it (would be monitored quite closely) Heimlich valve. Allows air to exist but not enter. Small size.

Restrictive air flow disorders

These disorders are characterized by a restriction in lung volume (caused by decreased compliance of the lungs or chest wall). Example? Muscular dystrophy, obesity This is in contrast to obstructive disorders, which are characterized by increased resistance to airflow. Example? COPD, asthma, CF