Chap 22, 23, 24, 25, 26, 27, and 28 Flashcards
Anatomic Alternations of the lungs of Flail Chest
- Double fracture of at least three or more adjacent ribs
- Causes chest wall to become unstable
- Affected ribs cave in during inspiration
- In a restrictive disorder
Major pathologic or structural changes of the lungs in Flail chest
- Double fracture of numerous adjacent ribs
- Ribs instability
- Lung Volume Restriction
- Atelectasis
- Lung Collapse (pneumothorax)
- Lung Contusion
- Secondary pneumonia
Etiology and Epidemiolgy of Flail Chest
- Blunt or crushing chest wall injuries
- Paradoxic movements of the chest wall
- Chest wall pain (usually intense with inspiration)
- Diminished BILATERAL breath sounds (due to small Vt’s)
- CXR
- Often accompanied with pneumothorax due to rib puncturing the pleural cavity and lung
General management of Flail chest
Mild cases: -Pain med -Lung expansion therapy a. Incentive spirometry b. IPPB -O2 therapy- maybe refractive to O2 therapy do to atelectasis and capillary shunting Severe cases: -Intubation -Volume control ventilator with PEEP -General need to be on vent. for 5-10 days for ribs to heal -Pain control
CXR flail chest
- Increased opacity
- rib fractures
- Increased density (whiter) because of atelectasis
Blunt or crushing chest wall injuries causing Flail chest
- MVA
- Falls
- Blast injuries
- Industrial accidents
Anatomic alternations of the lungs in Pneumothorax
- Exists when gas (free air) accumulates in the pleural space
- Visceral and parietal pleura separates
- Tendency for lung to recoil or collapse
- Tendency for chest wall to expand
- lung collapses with ensuing Atelectasis
- Greater veins maybe compressed causing diminished venous return to the heart and impaired cardiac output
- Is a RESTRICTIVE DISORDER
Major Pathologic and structural changes in Pneumothorax
- Gas enters pleural space
- Gas accumulation normally is in the apex and works down
- Closed pneumothorax
- Open pneumothorax
- Tension pneumothorax
- Hemothorax
- Traumatic Pneumothorax
- Spontaneous pneumothorax
- Iantrogenic pneumothorax
Closed pneumothorax
Gas is NOT in direct contact with atmosphere
Open pneumothorax
Direct contact with atmospheric gas
Tension pneumothorax
- Contact with atmosphere during inspiration, but NOT expiration
- Most potentially dangerous
- Quickly impairs cardiac funtion by squeezing the heart and major vessels
Hemothorax
- Blood accumulation in the pleural space
- Normally settles in the bases
Traumatic pneumothorax
- Penetrating wounds to the chest wall
- Sucking chest wound (open)
- One-way valve type (closed) normal leads to tension pneumothorax
Spontaneous pneumothorax
- Sudden, without obvious cause
- Tall, thin people between the age 15-35
a. Due to high negative pleural pressure
b. Normal occurs in the apex
c. can occur for pneumonia , COPD, TB
Iatrogenic pneumothorax
- Occurs during invasive procedures such as thoracentesis
- High peak airway pressures with ventilators
- High tidal volumes
Clinical Manifestations of Pneumothorax
- Absent breath sounds over affected lung
- CXR changes
- Increased translucency with pneumothorax
- Increased density with hemothorax
- Mediastinal shift to AFFECTED side in pneumothorax
- Mediastinal shift AWAY from affected side in Tension Pneumothorax
- Depressed diaphragm if pneumothorax affects entire lung
- Atelectasis
Mediastinal shift to affected side in
pneumothorax
Mediastinal shift away from affected side in
tension pneumothorax
General Management of pneumothorax
- 20% or less= Bed rest or limited activity, Reabsorption occurs within 30 days
- Larger than 20%
- One way valve (allows air to escape during inhalation)
- Chest tube
- Waterseal suction (pneuomVac)
- Use 28 to 36 Fr. Thoracostomy tube
- Usually 3rd intercostal space for pneumothorax
- 4-5th intercostals spaces for hemothorax
- O2 therapy
- Lung expansion therapy
- Pleurodesis
Waterseal suction (pneumoVac)
a. -5 to -12 cmH2O pressure (suction
b. Once lung is expanded, bubbling ceases in PneumoVac
c. Leave to just H2O seal for 24 to 48 hours then use 28 to 36 Fr thoracostomy tube
Intercostal spaces for hemothorax
4-5th
Intercostals space for pneumothorax
usually 3rd
O2 therapy in pneumothorax
Treat hypoxia
Maybe refractive to O2 because of shunting
Lung expansion therapy in pneumothorax
- Incentive spirometry
- IPPB CONTAINDICTED
- maybe on volume control ventilator with mild PEEP
- Deep breathing and ambulation
Pleurodesis
- Thoracentesis injection of drug/chemical into pleural space
- Causes inflammation
- Results in adhesion of visceral and parietal pleura
- Painful post procedure!!
In flail chest, which of the following occurs?
- Tidal volume increases
- Atelectasis often occurs
- Intrapulmonary shunting occurs
- Pneumothorax is rare
- Atelectasis often occurs
- Intrapulmonary shunting occurs
(tidal volume decreases)
When a patient has a severe fail chest which of the following occurs
cardiac output decreased
central venous pressure increases
A flail chest consists of a double fracture of at least
three adjacent ribs
Which of the following resp care techniques is/ are commonly used in the tx of severe flail chest
Intubation with continuous mandatory ventilation
Postitive end-expiratory pressure/continuous positive airway pressure (PEEP/CPAP)
When mechanical ventilation is used to stabilize a flail chest, how much time generally is needed for adequate bone healing to occur
5-10 days
When gas moves between the pleural space and the atmosphere during a ventilatory cycle, the patient is said to have a(n)
Closed pneumothorax
When gas enters the pleural space during inspiration but is unable to leave during expiration, the patient is said to have a(n)
Valvular pneumothorax
Tension pneumothorax
Which of the following may cause a pneumothorax?
- pneumonia
- tuberculosis
- COPD
- Blebs
When a patient has a pneumothorax because of a sucking chest wound, which of the following occurs?
- The mediastinum often moved to the unaffected side
- Intrapleural pressure on the affected side often rises above the atmospheric pressure during expiration
- The mediastinum often moves to the affected side during expiration
The increased ventilatory rate commonly manifested in patients with pneumothorax may result from which of the following?
- Stimulation of the J receptors
- Increased lung compliance
- Increased stimulation of the Hering-Breuer reflex
- Stimulation of the irritant reflex
- Stimulation of the J receptor
4. Stimulation of the irritant reflex
The physician usually elects to evacuate the intrathoracic gas when the pneumothorax is greater than:
20%
During treatment of a pneumothorax with a chest tube and suction, the negative (suction) pressure usually need not exceed:
-12cmH2O
A patient with a severe tension pneumothorax demonstrates which of the following on the affected side?
- Diminished breath sounds
- Hyperresonant percussion note
- Dull percussion not
- Whispered perctoriloqy
- Diminished breath sounds
2. Hyperresonant percussion note
When a patient has a large tension pneumothorax, which of the following occurs?
PA increases
Which of the following is or are associated with exudative effusion
- Inflammation
- Disease of the pleural surfaces
Which of the following is probably the most common cause of a transudative pleural effusion
CHF
A hemothorax is said to be present when the hematocrit of the pleural fluid is at least
50%
What percentage of patients with pulmonary emboli develop pleural effusion
30-50%
Which of the following is or are associated with pleural effusion?
- Decreased FRC
- Decreased VC
Pleural effusion and empyema will produce what kind of lung disorder?
Restrictive lung disorder
Major pathologic or structural changes associated with pleural effusion are:
- Lung compression
- Atelectasis
- Compression of the great veins and decreased cardiac venous return
Transudate effusion:
- Fluid from pulmonary capillaries moves into the pleural space
- Fluid is thin and watery, containing few blood cells and protein
- Pleural surfaces are not involved
Exudate effusion
- Pleural surfaces are diseased
- Fluid has high protein count and cellular debris
- Usually caused by inflammation, infection, or malignancy
What kind of curvature of the spine is manifested in kyphosis
Posterior
Kyphoscoliosis affects approximately what percentage of the U.S. population
2%
Which of the following is/are associated with kyphoscoliosis? 1. Diminished breath sounds 2. Dull percussion note 3. Decreased tactile fremitus 4. Bronchial breath sounds A. 1 B. 2 C. 1, 3 D. 2, 4
D. 2, 4
Patients with kyphoscoliosis will exhibit a dull percussion note and bronchial breath sounds because of atelectasis. They will also have increased tactile fremitus.
What do ABG look like in advanced kyphoscoliosis?
normal pH, +HCO, +PaCO2
Which of the following is another name for hypersensitivity pneumonitis
pg 373
Which of the following is commonly located near a central bronchus or hilus and projects into the large bronchi?
Squamous cell carcinoma
Which of the following arises from the mucous glands of the tracheobronchial tree?
Adenocarcinoma
Which of the following carcinomas has the strongrst correlation with cig smoking
Small cell carcinoma(oat cell)
Which of the following has the fastest growth (doubling) rate
Small cell carcinoma
Which of the following is or are associated with bronchogenic carcinoma?
- Alveolar consolidation
- Pleural effusion
- Alveolar hyperinflation
- Atelectasis
Alveolar Consolidation
Pleural Effusion
Atelectasis
Which of the following is another name for hypersensitivity pneumonitis?
Extrinsic Allergic Alveolitis
Which of the following is or are considered pulmonary vasculitides?
- Rheumatoid arthritis
- Wegeners granulomatosis
- Lymphomatoid granulomatosis
- Churg-Strauss Syndrom
Wegener’s Granulomatosis
Lymphomatoid Granulomatosis
Churg-Strauss Syndrome