Pneumothorax & Hemothorax

Tension pneumothorax: Manifestations

Air hunger Violent agitation Tracheal deviation away from affected side Subcutaneous emphysema Neck vein distention Hyperresonance to percussion Dyspnea Marked tachycardia Decreased or absent breath sounds on the affected side Cyanosis Profuse diaphoresis Medical emergency: needle decompression followed by chest tube insertion with chest drainage system.

Tension pneumothorax

Air in pleural space that does not escape. The increased air in the pleural space shifts organs and increases intrathoracic pressure This results in 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.

Pneumothorax

Air the in pleural space When air enters the pleural space, the change to positive pressure causes a partial or complete lung collapse

Purpose of a Chest Tube

Are inserted to drain the pleural space and reestablish negative pressure, allowing for proper lung expansion 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.

Nursing Assessment of Pt w Chest Tube drainage unit:

Assess for manifestations of reaccumulation of air and fluid in the chest: ↓ or absent breath sounds Monitor pulse oximetry & ABGs Administer O2 as ordered Administer analgesia Significant bleeding (>100 mL/hr) Chest drainage site infection (drainage, erythema, fever, ↑ WBC) Poor wound healing Notify physician for management plan Monitor for leaks Report any change in the quantity or characteristics of drainage (e.g., clear yellow to bloody) to the physician and record the change Mark the time of measurement and the fluid level on the drainage unit according to the unit standards Evaluate for subcutaneous emphysema at chest tube site. Encourage the patient to breathe deeply periodically to facilitate lung expansion and encourage range-of-motion exercises to the shoulder on the affected side. Encourage use of incentive spirometry every hour while awake to prevent atelectasis or pneumonia.

Hemothorax

Blood in the pleural space, may or may not occur in conjunction with pneumothorax. Due to Injury to the chest wall, diaphragm, lung, blood vessels, or mediastinum

Iatrogenic Pneumothorax

Can occur due to laceration or puncture of the lung during medical procedures, such as: Transthoracic needle aspiration Subclavian catheter insertion Thoracentesis Pleural biopsy Transbronchial lung biopsy. Barotrauma from excessive ventilatory pressure during manual or mechanical ventilation

Traumatic Pneumothorax

Can occur from either penetrating (open) or nonpenetrating (closed) chest trauma Open/Penetrating trauma allows air to enter the pleural space through an opening in the chest wall, can be from: Stab or gunshot wounds Surgical thoracotomy Referred to as a sucking chest wound, since air enters the pleural space through the chest wall during inspiration. Emergency treatment Consists of covering the wound with an occlusive dressing that is secured on three sides (vent dressing). If the object that caused the open chest wound is still in place, do not remove it until a physician is present. Stabilize the impaled object with a bulky dressing. Closed/Nonpenetrating chest trauma, such as rib fractures, can lacerate the lung and cause air to enter the pleural space. Blunt trauma can also cause alveolar rupture secondary to sudden chest compression.

Pneumothorax: Manifestations

Dyspnea, decreased movement of involved chest wall, hyperresonance to percussion 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. Chest pain and a cough with or without hemoptysis may be present. On auscultation, no breath sounds are detected over the affected area. A chest x-ray shows air or fluid in the pleural space and reduction in lung volume. Chest tube insertion with flutter valve or chest drainage system (water-seal drainage ) Thoracentesis can be done-chest tube is definitive treatment

Hemothorax: Manifestations

Dyspnea, diminished or absent breath sounds, dullness to percussion, decreased Hgb, shock depending on blood volume lost Mental status changes-signify internal blood loss Chest tube insertion with chest drainage system. Autotransfusion of collected blood, treatment of hypovolemia as necessary.

Potential Complications of Chest Tube drainage units

If volumes from 1 to 1.5 L of pleural fluid are removed rapidly, reexpansion pulmonary edema or a vasovagal response with symptomatic hypotension can occur. Subcutaneous emphysema can occur from air leaking into the tissue surrounding the chest tube insertion site. A small amount of subcutaneous air is harmless and will be reabsorbed. Severe subcutaneous emphysema can cause drastic swelling of the head and the neck with potential airway compromise. Clamping the chest tube can cause rapid accumulation of air in the pleural space, causing tension pneumothorax

Spontaneous Pneumothorax

Occurs due to the rupture of small blebs (air-filled blisters) located on the apex of the lung Primary spontaneous pneumothorax: can occur in healthy, young individuals Secondary spontaneous pneumothorax: occurs due to lung disease such as COPD, asthma, cystic fibrosis, and pneumonia Smoking increases the risk for bleb formation Risk factors include being tall and thin, male gender, family history, and previous spontaneous pneumothorax

Chylothorax

Presence of lymphatic fluid in the pleural space Fifty percent of cases heal with conservative treatment (chest drainage, bowel rest, and parenteral nutrition). Octreotide has been used with some success to reduce the flow of lymphatic fluid. Surgery and pleurodesis are options if conservative therapy fails. Pleurodesis is the artificial production of adhesions between the parietal and visceral pleura, usually done with a chemical sclerosing agent, such as talc or doxycycline.

Nursing Management of Chest Tube drainage units

When disconnection occurs, the chest tube is immersed in sterile water (about 2 cm) until the system can be reestablished Minimize the risk of atelectasis and shoulder stiffness. Encourage coughing, deep breathing, incentive spirometer use, and range-of-motion exercises. Meticulous sterile technique during dressing changes can reduce the incidence of infected sites. Chest tubes may be momentarily clamped to change the drainage apparatus or to check for air leaks. Appearance of a new air leak warrants assessment of the drainage system to identify whether the air leak is coming from the patient or the system Never elevate the drainage system to the level of the patient's chest because this will cause fluid to drain back into the lungs. Water-Seal Chamber: Observe for air fluctuations (tidaling) and intermittent bubbling in the water-seal chamber If tidaling (during expiration) is not observed, the drainage system is blocked, the lungs are reexpanded, or the system is attached to suction. If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak) Suspect a system leak when bubbling is continuous Ensure that dressing is air-occlusive