Exam 5 Final Flashcards
define pneumothorax
air in the pleural space resulting in partial/complete lung collapse
define primary spontaneous pneumothorax
a pneumothorax without underlying lung disease
classically in tall, thin, young men in teens or 20s
thought to be rupture of subpleural apical blebs or bullae at unequally transmitted pressure change
define secondary spontaneous pneumothorax
a pneumothorax that results from an underlying lung disease
patients with severe COPD (FEV1 < 1L), HIV related, CF, or parenchymal disease
define iatrogenic pneumothorax
results from a medical procedure, usually involves needles
transthoracic needle, aspiration, thoracentesis, CVP placement, MV, CPR
define traumatic pneumothorax
penetrating or blunt chest trauma
define tension pneumothorax
intrapleural pressure is higher than intra-alveolar or atmospheric pressure
air continues to get into pleural space but cant exit
can cause impaired venous return, systemic hypotension, respiratory and cardiac arrest (PEA) within minutes without treatment
define bronchopleural fistula
opening between the airways and pleura that allows air to enter the pleural space
possibly by pneumonectomy, post-trauma, or infections
pathophysiology of pneumothorax
- air in pleural space
- lung collapse
- atelectasis
- chest wall expansion
- compression of great veins and decreased C.O. and venous return
etiology and epidemiology of pneumothorax
gas can enter the pleural space in 3 ways
- from lungs through perforation of visceral pleura
- from atmosphere through perforation of chest wall and parietal pleura
- from gas-forming microorganism in empyema in pleural space
classify general terms
closed pneumothorax
pleural space not in direct contact with atmosphere
classify general terms
open pneumothorax
pleural space in direct contact with atmosphere in which air moves freely in and out of opening
classify general terms
tension pneumothorax
intrapleural pressure exceeds intra-alveolar (atmospheric) pressure
what is the clinical manifestations of awake patient with traumatic pneumothorax
chest wound is painful
respiratory distress
air typically makes sucking sound
diagnosis of tension pneumothorax
clinical evaluation
requires inspecting the entire chest wall surface
treatment of traumatic pneumothorax
partially occlusive dressing followed by tube thoracostomy
immediate management to cover wound with gauze taped on 3 sides to allow air to exit
how does tension pneumothorax form
- air accumulates and compresses lung
- eventually shifts mediastinum
- compress the contralateral lung
- increases intrathoracic pressure enough to decrease venous return causing shock
this happens rapidly, typically in patients on PPV
signs and symptoms of pneumothorax
- increased intrathoracic pressure
- hypotension
- tracheal deviation
- JVD
- affected hemithorax is hyperresonant
- unilateral chest movement
- absent breath sounds
treatment for tension pneumothorax
- needle decompression (14 or 16g) into 2nd intercostal space midclavicular line
- tube thoracostomy immediately after
classification based on origin
traumatic pneumothorax
from penetrating wounds (knife, bullet, impaling object, crush chest injury)
pleural space in contact with atmosphere
AKA: sucking chest wound
may result in tension or closed pneumothorax
signs and symptoms of traumatic pneumothorax
- pleuritic chest pain
- dyspnea
- tachypnea
- tachycardia
- subcutaneous emphysema
diagnosis of traumatic pneumothorax
- chest x-ray
- ultrasonography
- CT
treatment for traumatic pneumothorax
- thoracostomy tube into 5th or 6th intercostal space anterior to midaxillary line
- bronchoscopy
describe pendeluft effect traumatic pneumothorax
on inspiration the air enters pleural space and shunts to the good lung
on expiration the air exits pleural space partially and shunts from good lung to bad lung
describe pendeluft effect tension pneumothorax
on inspiration air enters pleural space and shunts air to good lung
on expiration a flap closes exit from pleural space and air is exhaled normally
classification based on origin
spontaneous pneumothorax
sudden onset without underlying cause
secondary to underlying process (pneumonia, TB, COPD)
bleb or bulla rupture
often occurs in tall, thin males 15-35
acts as both a closed and tension pneumothorax
classifications based on origin
iatrogenic penumothorax
sometimes occurs during diagnostic or therapeutic procedures (biopsy, thoracentesis, intercostal nerve block, cannulation of subclavian vein, tracheostomy)
during PPMV
always a hazard
physical assessment findings of a pneumothorax
vital signs
tachypnea
tachycardia
hypertension
cyanosis
physical assessment findings of a pneumothorax
chest assessment
sharp chest pain
acute dyspnea
hyperresonant percussion note over unaffected
diminished over affected
tracheal shift “away” from affected
displaced heart sounds (PMI)
increased thoracic volume on affected side
physical assessment findings
tension pneumothorax
tracheal shift, mediastinal shift away
displaced heart sounds
increased thoracic volume on affected side
hypotension and JVD
what occurs in a tension pneumothorax to cause hypotension
compression of great veins and decreased C.O. and venous return
why would you see JVD with a tension pneumothorax
a build up in chest wall pressure decreases blood return to heart and causes JVD
ABG with small pneumothorax
acute respiratory alkalosis (alveolar hyperventilation) with hypoxemia
ABG with large pneumothorax
acute respiratory acidosis (ventilatory failure) with hypoxemia
how does a pneumothorax affect oxygen indicies
QS/QT - increases DO2 - decreases VO2 - normal C(a-v)O2 - increases O2ER - increases SvO2 - decreases
how does pneumothorax affect hemodynamics
CVP - increase RAP - increase PAP - increase PCWP - decrease CO - decrease SV - decrease SVI - decrease CI - decrease RVSWI - increase LVSWI - decrease PVR - increase SVR - decrease
radiologic findings of pneumothorax
increase translucency (hyperlucency) and loss of vascular markings on affected side
atelectasis
mediastinal shift to unaffected side in tension pneumothorax
depressed diaphragm
general management of small pneumothorax (15-20%)
patient may only need bed rest or limited physical activity
resorption of intrapleural gas occurs within 30 days
general management of large pneumothorax (>20%)
evacuate
suction used: negative pressure used -5 to -12 cmH2O
after re-expansion and bubbling in suction chamber ceases; CT clamped and left for 24-48 hours without suction
general management of pneumothorax
pleurodesis
chemical or medication injected into chest cavity (Talc, tetracycline, bleomycin sulfate)
produces inflammatory reaction between lungs and inner chest cavity (lung adhere to chest cavity)
where do you place a chest tube
anterior - 2nd intercostal space, midclavicular line directed at apex
lateral - midaxillary line between 5-7 intercostal space
define flail chest
double rib fracture of at least 3 adjacent ribs, resulting in an unstable thoracic cage
what happens on inspiration and exhalation of a flail chest
inspiration ribs cave in
expiration ribs balloon out
anatomic alteration of flail chest
- double fracture of numerous adjacent ribs
- rib instability (tx: PEEP)
- lung restriction
- atelectasis
- lung collapse (pneumothorax)
- lung contusion (bruise)
- secondary pneumonia
a flailing chest wall will result in what type respiratory failure
type 2 (ventilatory) due to pendeluft effect
a lung contusion will result in what type respiratory failure
type 1 (oxygenation) due to diffusion defect
etiology of flail chest
crush chest injury result of
- MVA or blunt trauma
- falls
- blast injury
- direct compression
- occupational and industrial accident
physical assessment of flail chest
paradoxical movement of chest wall
paradoxical movement may not be present if patient is tense
crepitation from ends of ribs moving against each other
signs and symptoms of pneumothorax
physical exam findings of flail chest
vitals - tachypnea, tachycardia, HTN
chest wall paradoxical movement
cyanosis
breath sounds diminished on effected and unaffected side
ABG findings mild to moderate flail chest
acute respiratory alkalosis
ABG findings severe flail chest
acute respiratory acidosis
how does flail chest affect hemodynamics
CVP - increase RAP - increase PAP - increase PCWP - decrease CO - decrease SV - decrease SVI - decrease CI - decrease RVSWI - increase LVSWI - decrease PVR - increase SVR - decrease
radiologic findings flail chest
increased opacity
rib fractures
increased density on affected side
treatment in mild case of flail chest
pain management
routine bronchial hygiene
treatment in severe cases of flail chest
VC MV with PEEP
take 5-10 days form bone to start healing
define pleural effusion
any abnormal accumulation of fluid in pleura
anatomic alterations of lung with pleural effusion
lung compression
atelectasis
compression of great veins and decreased C.O. and venous return
mechanics of ventilation in pleural effusion
effusion causes atelectasis due to limited thoracic space resulting in restrictive PFTs
commonly dyspneic
rare to cause fibrothorax
hypoxemia causes increased P(A-a)O2
define transudate pleural effusion
increased hydrostatic pressure move fluid from parietal pleura capillaries into pleural space
pleural surface not involved in production of transudate
define exudate PE
fluid has high protein count and cellular debris
usually caused by inflammation and the pleural surface is diseased
roughly 70% of all PE
Etiology of transudate PE
CHT (most common)
hepatic hydrothorax (Ascites)
peritoneal dialysis
pulmonary embolus
hypoalbuminemia
lymphatic obstruction
nephrotic syndrome
what are the primary causes of transudative PE
abnormal hydrostatic pressure
abnormal oncotic pressure
etiology exudative PE
malignant PE and mesotheliomas
bacterial pneumonias
tuberculosis
fungal disease
PE result from disease in GI tract
PE result from collagen vascular disease
postoperative
etiology pathologic pE
emphyema
chylothorax - ruptured thoracic duct
hemothorax - trauma or blood vessel hemorrhage
A lab report shows a pleura effusion protein level of 10 g/dL together with the presence of malignant cells on the cytology report. You would classify this effusion as a:
exudate
Complications from a parapneumatic pleural effusion may often lead to the formation of:
empyema
physical assessment of PE
tachycardia
tachypnea
HTN
chest pain/decresed excursion
cyanosis
dry nonproductive cough
chest assessment of PE
tracheal shift
decreased tactile/vocal fremitis
dispalced heart sounds/PMI
plueral friction rub
breath sounds diminished, fine crackles
radiologic findings of PE
upright PA or lateral decubitus
blunted costophrenic angles (meniscus)
depressed diaphragm
mediastinal shift - unaffected side
atelectasis
excessive pleural fluid - affected side, radiopaque
diagnostic testing for PE
thoracoscopy - visualize
thoracentesis - drainage
describe thoracoscopy
ideally desgined for diagnostic and therapeutic pleural procedures
allows visualization of surfaces, drainage of effusion, biopsy, and pleurodesis
perform under local anesthesia and conscious sedation
describe thoracentesis
percutaneous needle aspiration of effusion sample
drainage for lung reexpansion involves placement of chest tube
risk of thoracentesis
artery laceration
infection
pneumothorax
Which of the following is considered the most sensitive procedure to assess size and location of a pleural effusion?
CT scan of chest
general management of PE
must be individualized
exam of pleural fluid for transudate or exudate assessment
pleurodesis
chest thoracotomy tube
pleuroperitoneal shunt & pleurex catheter
describe pleurodesis
chemical or medication injected into chest cavity adhereing lung to chest wall
describe pleuroperitoneal shunt and pleurex catheter
for effusions refractory to all other treatments
small pump moves fluid from pleura to peritoneal cavity
pleurex catheter connects to suction at home to drain persistant effustion
indications of pleural chest tube
tension pneumothorax
pneumothorax (>10-20%)
hemothorax
emphyema
pleural effusion
chylothorax
indication for mediastinal chest tube
free air or blood
indication for pericardial chest tube
cardiac tamponade or pneumopericardium
open-heart surgery
goals of a chest tube
removal or air/fluid from space (pleural, mediastinum, pericardial)
prevent fluid/air from gaining reentry to cavity
lung re-expansion (primary goal)
components of chest tube
CT tubing
flexible tubing connecting CT to drainage system
1-4 compartment drainage system (1-4 bottle, disposable drainage system)
describe 1 bottle drain system
tube from patient submerged 2cm into sterile H2O (PPV +2)
tube on top allows vent to atmosphere
water-seal - air leaves and not reenter
tidalling - result of pressure change
combined water seal and collection bottle
only for air
describe 2 bottle drain system
collection bottle and water seal chamber
rate and amount of drain can be measured
gravity dependent
disadvantage cant drain large leak
air and fluid
describe 3 bottle drain system
collection
water seal
suction chamber
can be for air or fluid
chest tube placement for pneumothorax
2-3 intercostal space midcalvicular or midaxilarry
directed at apex
chest tube placement for hemothorax or pleural effusion
5-7 intercostal space midaxillary
directed inferior and posterior
CT insertion procedure
instruct patient
gather equipment
set up drain system
prepare site
insert CT proper location
cover with sterile occlusive dressing
place drain system below CT
attach suction
confirm placement
troubleshooting patient with CT
deterioration of condition indicated tension pneumothorax
notify physician immediately
bag on 100 Fio2 if on MV
troubleshooting drain system of CT
tidalling and bubbling present
indicates patient has air leak (pneumothorax)
troubleshooting drain system of CT
no tidalling or bubbling present
indicates lung re-expansion or obstruction by kinks or clots
troubleshooting drain system of CT
no tidalling
bubbling present
indicates possble connection or system air leak
troubleshooting drain system of CT
tidalling present
no bubbling
observed with peumonectomy or decreased lung compliance
