Plural effusion

plueral effusion due to an empyema

(pus) in the pleural cavity,

Closed pneumothorax

A closed pneumothorax occurs when the visceral (inner) lining of the pleura is disrupted, allowing air to enter the pleural space from the lung. There is no external wound.

Flutter valve

A flutter valve (also called the Heimlich valve after its inventor) is used to evacuate air from the pleural space. • This device consists of a one-way rubber valve within a rigid plastic tube. It is attached to the external end of the chest tube. • During inspiration, when pressure in the chest is greater than atmospheric pressure, the valve opens. During expiration, when intrathoracic pressure is less than atmospheric pressure, the valve closes. • The flutter valve can be used for small- to moderate-sized pneumothorax. • It also allows for mobility of the patient, as the smaller drainage bag can be hidden under the clothes while the patient ambulates.

Manifestations of a pleural effusion

A large pleural effusion will compress or put pressure on the adjacent lung tissue. This causes the patient to become short of breath. The patient may also complain of pleural pain, usually from the friction between the visceral and parietal pleura. This pain usually lessens as the pleural effusion increases because the fluid decreases the friction. As the nurse auscultates, breath sounds are diminished. Chest wall movement may be limited. If the nurse were to percuss over the area, there would be a dull percussion tone due to the fluid.

Pneumothorax

A pneumothorax is caused by air entering the pleural cavity. • Normally, negative subatmospheric pressure exists between the visceral pleura (surrounding the lung) and the parietal pleura (lining the thoracic cavity), known as the pleural space. This space contains a few milliliters of lubricating fluid to reduce friction when the tissues move. • When air enters this space, the change to positive pressure causes a partial or complete lung collapse. As the volume of air in the pleural space increases, the lung volume decreases. • This condition should be suspected after any trauma to the chest wall. In an open pneumothorax, air enters through an opening in the chest wall and parietal (outer) lining of the pleura.

Spontaneous pneumothorax

A spontaneous pneumothorax typically occurs due to the rupture of small blebs (air-filled sacs) located on the surface of the lung. • These blebs can occur in healthy, young individuals or as a result of lung disease such as COPD, asthma, cystic fibrosis, and pneumonia. • Smoking increases the risk for bleb formation. Other risk factors include being tall and thin, male gender, family history, and previous spontaneous pneumothorax.

Thoracentesis proceedure

A thoracentesis involves insertion of a needle into the intercostal space. The placement of the needle is confirmed by x-ray and percussion of dullness at the location. Fluid is then aspirated with a needle or allowed to drain into a sterile container.

Amount of fluid taken during thoracentesis

After removing the fluid, (usually not more than 1200 mL of pleural fluid is removed at one time to avoid hypotension, hypoxemia, or pulmonary edema), the needle is removed, and a bandage applied. The patient is then sent for an x-ray to detect a possible pneumothorax.

Care after a thoracentesis

After the procedure usually just a band aid is put over the insertion site and the patient is positioned on the unaffected side for an hour. After the hour, the patient should be able to resume normal activity. The nurse will continue to monitor vital signs and respiratory status for the first several hours and a chest x-ray is usually completed after the procedure.

Other causes of a pnuemothorax

Barotrauma from excessive ventilatory pressure during manual or mechanical ventilation can rupture alveoli or bronchioles. • Esophageal procedures may also be involved in the development of a pneumothorax. • Tearing during insertion of a gastric tube can allow air from the esophagus to enter the mediastinum and pleural space.

Cardiac tamponade

Blood rapidly collects in pericardial sac, compresses myocardium because the pericardium does not stretch, and prevents ventricles from filling. • Muffled, distant heart sounds, hypotension, neck vein distention, increased central venous pressure • Medical emergency: pericardiocentesis with surgical repair as appropriate

Blunt trauma

Blunt trauma occurs when the chest strikes or is struck by an object. • The resultant impact can cause shearing and compression of thoracic structures. • The external injury may appear minor, but internally the organs may have severe injuries. • Rib and sternal fractures can lacerate lung tissue. • In a high-velocity impact, shearing forces can result in laceration or tearing of the aorta. Compression of the chest may result in contusion, crush injury, and organ rupture.

Chest tube system

Brisk bubbling of air often occurs in this chamber when a pneumothorax is initially evacuated. • Intermittent bubbling during exhalation, coughing, or sneezing (when the patient's intrathoracic pressure is increased) may be observed as long as air is in the pleural space. • Eventually, as the air leak resolves and the lung becomes more fully expanded, bubbling ceases. • Normal fluctuation of the water within the water-seal chamber is called tidaling. • This up-and-down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration. • Investigate any sudden cessation of tidaling, as this may signify an occluded chest tube. • Gradual reduction and eventual cessation of tidaling is expected as the lung reexpands.

CT scans and pleural effusions

CT scans and ultrasounds are also used to determine different pleural effusions. If the cause of the pleural effusion is not apparent, a thoracentesis may be done.

Chest X Ray and pleural effusion

Chest x-ray is the choice diagnostic that will show pleural effusion. The fluid typically collects in dependent regions of the pleural cavity. The pleural effusion is usually seen at the base of the affected lung on an upright chest xray and lateral if the patient is on their side.

Chlyothorax

Chylothorax is the presence of lymphatic fluid in the pleural space. The thoracic duct is disrupted either traumatically or from a malignancy, and the lymphatic fluid fills the pleural space. This milky white fluid is high in lipids. Normal lymphatic flow through the thoracic duct is 1500 to 2500 mL/day. This amount can be increased up to tenfold after ingestion of fats. • Some cases heal with conservative treatment (chest drainage, bowel rest, and dietary modifications). • Octreotide has been used to reduce the flow of lymphatic fluid with some success. • Surgery (thoracic duct ligation) and pleurodesis (the artificial production of adhesions between the parietal and visceral pleura), may be considered for refractory cases.

Care during a thoracentesis

During the procedure the nurse will monitor the patient's pulse, color, oxygen saturation. Usually the patient is placed on a monitor. The nurse also needs to support the patient during the procedure.

Signs of respiratory distress from chest trauma

Dyspnea, respiratory distress • Cough with or without hemoptysis • Cyanosis of mouth, face, nail beds, mucous membranes • Tracheal deviation • Audible air escaping from chest wound • Decreased breath sounds on side of injury • Decreased O2 saturation • Frothy secretions

occlusive dressing

Emergency treatment consists of covering the wound with an occlusive dressing that is secured on three sides (vent dressing). • During inspiration, as negative pressure is created in the chest, the dressing pulls against the wound, preventing air from entering the pleural space. • During expiration, as the pressure rises in the pleural space, the dressing is pushed out and air escapes through the wound and from under the dressing. • If the object that caused the open chest wound is still in place, do not remove it until a HCP is present. Stabilize the impaled object with a bulky dressing.

pleural effusion due to exudate

Exudate, a protein rich fluid is seen with inflammatory processes such as infections, systemic inflammations such as lupus, pulmonary infarction and malignancy. The result of increased capillary permeability

Hemothorax

Hemothorax is an accumulation of blood in the pleural space resulting from injury to the chest wall, diaphragm, lung, blood vessels, or mediastinum. • The patient with a traumatic hemothorax requires immediate insertion of a chest tube for evacuation of the blood, which can be recovered and reinfused for a short period of time after the injury. • When it occurs with pneumothorax, it is called a hemopneumothorax.

Latogenic pneumothorax

Iatrogenic pneumothorax can occur due to laceration or puncture of the lung during medical procedures. • For example, transthoracic needle aspiration, subclavian catheter insertion, pleural biopsy, and transbronchial lung biopsy all have the potential to injure the lung.

Pneumothorax symptoms

If a pneumothorax is small, mild tachycardia and dyspnea may be the only manifestations. • If the pneumothorax occupies a large area, respiratory distress may be present, including shallow, rapid respirations; dyspnea; air hunger; and oxygen desaturation. • On auscultation, there are no breath sounds over the affected area. • A chest x-ray shows the presence of air or fluid in the pleural space and reduction in lung volume.

Chest tubes and pleural dranage

If enough fluid or air accumulates in the pleural space, the negative pressure becomes positive and the lungs collapse. • As a result, chest tubes are inserted to drain the pleural space, reestablish negative pressure, and allow for proper lung expansion. • They may also be inserted in the mediastinal space to drain air and fluid postoperatively. • Chest tubes are approximately 20 inches (51 cm) long and vary in size from 12F to 40F. The size inserted is determined by the patient's condition. Large (36F to 40F) tubes are used to drain blood, medium (24F to 36F) tubes are used to drain fluid, and small (12F to 24F) tubes are used to drain air. • Pigtail tubes are very small (10F to 14F) tubes with a curly end designed to keep them in place. They are a safe and effective alternative to larger bore chest tubes for treatment of pneumothorax

Initial interventions for any patient with chest trauma

If unresponsive, assess circulation, airway, and breathing. • If responsive, monitor airway, breathing, and circulation. • Ensure patent airway. • Administer high flow O2 to keep SpO2 >90%. • Establish IV access with two large-bore catheters. Begin fluid resuscitation as appropriate. • Remove clothing to assess injury. • Cover sucking chest wound with nonporous dressing taped on three sides. •

Ongoing monitoring of chest trauma

Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status, and urinary output. • Anticipate intubation for respiratory distress. • Release dressing if tension pneumothorax develops after sucking chest wound is covered.

Penetrating trauma

Penetrating trauma is an injury in which a foreign object impales or passes through the body tissues, creating an open wound. • Examples include knife wounds, gunshot wounds, and injuries with other sharp objects. • Severity depends on location of penetration and affected organs/vessels.

Risk factors of a pleural effusion

Pleural effusion can result from either a systemic or local disease process. Some systemic disorders include: Heart Failure Liver/Renal disease Connective tissue disorders Pneumonia Atelectasis Tuberculosis Lung cancer Trauma

Treatment of pleural effusion

Pleural effusion usually occurs secondary to another disorder, the underlying cause should be treated to prevent further fluid accumulation. An empyema may require repeated drainage as well as parenteral antibiotics. Occasionally, a thoracotomy or surgical excision may be necessary. Recurrent pleural effusions, usually due to cancer may be prevented by creating a pleurodesis - adhering the parietal and visceral pleura. This is done by instilling doxycycline or talc into the area.

Signs of cardiovascular compromise from chest trauma

Rapid, thready pulse • Decreased BP • Narrowed pulse pressure • Asymmetric BP values in arms • Distended neck veins • Muffled heart sounds • Chest pain • Dysrhythmias

Rib fractures

Rib fractures are the most common type of chest injury resulting from blunt trauma. • Ribs 5 through 9 are most commonly fractured because they are the least protected by chest muscles. • If the fractured rib is splintered or displaced, it may damage the pleura, lungs, and other internal organs. • Clinical manifestations of fractured ribs include pain at the site of injury, especially during inspiration and with coughing. The patient splints the affected area and takes shallow breaths to try to decrease the pain. Atelectasis and pneumonia may develop because of decreased chest wall movement and retained secretions. • •

Additional interventions for chest trauma

Stabilize impaled objects with bulky dressings. Do not remove object. • Assess for other significant injuries and treat appropriately. • Place patient in a semi-Fowler's position or position patient on the injured side if breathing is easier after cervical spine injury has been ruled out. Administer small amounts of analgesia as necessary for pain and to help with breathing. • Prepare for emergency needle decompression if tension pneumothorax or cardiac tamponade present. • Ongoing Monitoring • Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, respiratory status, and urinary output. • Anticipate intubation for respiratory distress. • Release dressing if tension pneumothorax develops after sucking chest wound is covered.

Symptoms of a tension pneumothorax

Tension pneumothorax is a medical emergency, with both the respiratory and cardiovascular systems affected. • Manifestations include dyspnea, marked tachycardia, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, cyanosis, and profuse diaphoresis. • If the tension in the pleural space is not relieved, the patient is likely to die from inadequate cardiac output or severe hypoxemia. • Treat with needle decompression and chest tube insertion

Causes of a tension pneumothorax

Tension pneumothorax may result from either an open or a closed pneumothorax. In an open chest wound, a flap may act as a one-way valve. Thus, air can enter on inspiration but cannot escape. • Tension pneumothorax can occur with mechanical ventilation and resuscitative efforts. It can also occur if chest tubes are clamped or become blocked in a patient with a pneumothorax. Unclamping the tube or relief of the obstruction may correct this situation.

Tension pneumothorax

Tension pneumothorax occurs when air enters the pleural space but cannot escape. • The continued accumulation of air in the pleural space causes compression of the lung on the affected side and pressure on the heart and great vessels, pushing them away from the affected side. • The mediastinum shifts toward the unaffected side, compressing the good' lung, which further compromises oxygenation. • As the pressure increases, venous return is decreased, and cardiac output falls.

Flail chest presentation

The affected (flail) area will move in the opposite direction with respect to the intact portion of the chest. • During inspiration, the affected portion is sucked in, and during expiration, it bulges out. • This paradoxical chest movement not only prevents adequate ventilation but also increases the work of breathing.

Treatment of flail chest

The goal is to facilitate lung expansion and ensure adequate oxygenation. Analgesia is necessary to help promote adequate respiration. Although many patients can be managed without the use of mechanical ventilation, intubation and ventilation may be necessary. • Surgical fixation of the flail segment may be used. The lung parenchyma and fractured ribs will heal with time. Some patients continue to experience intercostal pain after the flail chest has resolved.

Treatment of rib fractures

The goal of treatment is to decrease pain so that the patient can breathe adequately and clear secretions. • Strapping the chest with tape or using a thoracic binder is not recommended, as it limits chest expansion and predisposes the individual to atelectasis. Nonsteroidal antiinflammatory drugs, opioids, and thoracic nerve blocks can be used to reduce pain and aid with deep breathing and coughing. • Patient teaching should emphasize deep breathing, coughing, use of incentive spirometry, and appropriate use of pain medications

Pathophysiology of a pleural effusion

The pathophysiology of a pleural effusion is determined by the underlying condition.

Assessments after thoracentesis

The patient's vital signs, including pulse oximetry and respiratory status should be monitored during and after the procedure. Respiratory distress and diminished or absent breath sounds on the side of the thoracentesis could indicate a pneumothorax.

The pleural cavity

The pleural cavity is the fluid filled space surrounding the lungs. It lies between the two pulmonary pleurae - visceral and parietal pleura. The pleura is a serous membrane which forms the pleural sac. The outer pleura - parietal pleura is attached to the chest wall and the inner pleura - visceral pleura covers the lungs and adjoining structures.

How much fluid is in the pleural space

The pleural space normally contains 5-15 ml of serous fluid. Pleural effusion is a collection of excess fluid in the pleural space as seen in this picture.

Thoracentesis

This can be performed at the bedside under local anesthesia and usually requires less than 30 minutes to complete. This is the standard position you would like the patient to be in during the procedure. However, if the patient is unable to move to a sitting position, a side lying position can be used also.

Treatment of a pneumothorax

Treatment of a pneumothorax depends on its severity and the nature of the underlying cause. • If the patient is stable and has minimal air and/or fluid accumulated in the intrapleural space, no treatment may be necessary as the condition may resolve spontaneously. • The most definitive and common form of treatment of pneumothorax and hemothorax is to insert a chest tube and connect it to water-seal drainage. • Repeated spontaneous pneumothorax may need to be treated surgically by a partial pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another. • Tension pneumothorax is a medical emergency, requiring urgent needle decompression followed by chest tube insertion to water-seal drainage.

pleural effusion due to a hemothorax

blood in the pleural cavity, hemorrhagic pleural effusion - blood and pleural fluid

Mechanisms of injury for chest trauma

blunt trauma and penetrating trauma.

Pleural effusion due to transudate

formed when capillary pressure is high, or plasma protein is low Heart failure is the most common precipitating factor in transudate formation.

Insertion of a chest tube

insertion of a chest tube can take place in the emergency department (ED), in the operating room, or at the patient's bedside. • The patient is positioned with the arm raised above the head on the affected side to expose the midaxillary area, the standard site for insertion. Elevate the patient's head 30 to 60 degrees, when possible, to lower the diaphragm and reduce the risk of injury. • Time permitting, a chest x-ray is used to confirm the affected side. • The area is cleansed with an antiseptic solution. The chest wall is infiltrated with a local anesthetic, and a small incision is made over a rib. • The area is first probed digitally to avoid injury with a sharp instrument. • A clamp is used to hold the chest tube and guide it into place. The tube is advanced up and over the top of the rib to avoid the intercostal nerves and blood vessels that are behind the rib inferiorly. • Once inserted, the tube is secured (sutured) in place, the incision is closed with sutures, and the tube is connected to a pleural drainage system (will discuss in next few slides). • The wound is covered with an occlusive dressing. Most clinicians prefer to seal the wound around the chest tube with petroleum gauze. • Proper tube placement is confirmed by chest x-ray. • The insertion of a chest tube and its presence in the pleural space is painful. Monitor the patient's comfort at frequent intervals and use the appropriate pain-relieving interventions. • • •

The most deffinitive and common form of treatment of pneumothorax and hemothorax

is to insert a chest tube and connect it to water-seal drainage. • Repeated spontaneous pneumothorax may need to be treated surgically by a partial pleurectomy, stapling, or pleurodesis to promote adherence of the pleurae to one another. • Tension pneumothorax is a medical emergency, requiring urgent needle decompression followed by chest tube insertion to water-seal drainage.

pleural effusion due to chylothorax

lymph in the pleural space