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Exam 5 Final Flashcards

1
Q

define pneumothorax

A

air in the pleural space resulting in partial/complete lung collapse

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2
Q

define primary spontaneous pneumothorax

A

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

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3
Q

define secondary spontaneous pneumothorax

A

a pneumothorax that results from an underlying lung disease

patients with severe COPD (FEV1 < 1L), HIV related, CF, or parenchymal disease

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4
Q

define iatrogenic pneumothorax

A

results from a medical procedure, usually involves needles

transthoracic needle, aspiration, thoracentesis, CVP placement, MV, CPR

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5
Q

define traumatic pneumothorax

A

penetrating or blunt chest trauma

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6
Q

define tension pneumothorax

A

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

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7
Q

define bronchopleural fistula

A

opening between the airways and pleura that allows air to enter the pleural space

possibly by pneumonectomy, post-trauma, or infections

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8
Q

pathophysiology of pneumothorax

A
  1. air in pleural space
  2. lung collapse
  3. atelectasis
  4. chest wall expansion
  5. compression of great veins and decreased C.O. and venous return
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9
Q

etiology and epidemiology of pneumothorax

A

gas can enter the pleural space in 3 ways

  1. from lungs through perforation of visceral pleura
  2. from atmosphere through perforation of chest wall and parietal pleura
  3. from gas-forming microorganism in empyema in pleural space
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10
Q

classify general terms

closed pneumothorax

A

pleural space not in direct contact with atmosphere

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11
Q

classify general terms

open pneumothorax

A

pleural space in direct contact with atmosphere in which air moves freely in and out of opening

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12
Q

classify general terms

tension pneumothorax

A

intrapleural pressure exceeds intra-alveolar (atmospheric) pressure

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13
Q

what is the clinical manifestations of awake patient with traumatic pneumothorax

A

chest wound is painful

respiratory distress

air typically makes sucking sound

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14
Q

diagnosis of tension pneumothorax

A

clinical evaluation

requires inspecting the entire chest wall surface

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15
Q

treatment of traumatic pneumothorax

A

partially occlusive dressing followed by tube thoracostomy

immediate management to cover wound with gauze taped on 3 sides to allow air to exit

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16
Q

how does tension pneumothorax form

A
  1. air accumulates and compresses lung
  2. eventually shifts mediastinum
  3. compress the contralateral lung
  4. increases intrathoracic pressure enough to decrease venous return causing shock

this happens rapidly, typically in patients on PPV

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17
Q

signs and symptoms of pneumothorax

A
  1. increased intrathoracic pressure
  2. hypotension
  3. tracheal deviation
  4. JVD
  5. affected hemithorax is hyperresonant
  6. unilateral chest movement
  7. absent breath sounds
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18
Q

treatment for tension pneumothorax

A
  1. needle decompression (14 or 16g) into 2nd intercostal space midclavicular line
  2. tube thoracostomy immediately after
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19
Q

classification based on origin

traumatic pneumothorax

A

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

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20
Q

signs and symptoms of traumatic pneumothorax

A
  1. pleuritic chest pain
  2. dyspnea
  3. tachypnea
  4. tachycardia
  5. subcutaneous emphysema
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21
Q

diagnosis of traumatic pneumothorax

A
  1. chest x-ray
  2. ultrasonography
  3. CT
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22
Q

treatment for traumatic pneumothorax

A
  1. thoracostomy tube into 5th or 6th intercostal space anterior to midaxillary line
  2. bronchoscopy
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23
Q

describe pendeluft effect traumatic pneumothorax

A

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

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24
Q

describe pendeluft effect tension pneumothorax

A

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

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25
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
26
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
27
physical assessment findings of a pneumothorax vital signs
tachypnea tachycardia hypertension cyanosis
28
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
29
physical assessment findings tension pneumothorax
tracheal shift, mediastinal shift away displaced heart sounds increased thoracic volume on affected side hypotension and JVD
30
what occurs in a tension pneumothorax to cause hypotension
compression of great veins and decreased C.O. and venous return
31
why would you see JVD with a tension pneumothorax
a build up in chest wall pressure decreases blood return to heart and causes JVD
32
ABG with small pneumothorax
acute respiratory alkalosis (alveolar hyperventilation) with hypoxemia
33
ABG with large pneumothorax
acute respiratory acidosis (ventilatory failure) with hypoxemia
34
how does a pneumothorax affect oxygen indicies
``` QS/QT - increases DO2 - decreases VO2 - normal C(a-v)O2 - increases O2ER - increases SvO2 - decreases ```
35
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 ```
36
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
37
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
38
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
39
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)
40
where do you place a chest tube
anterior - 2nd intercostal space, midclavicular line directed at apex lateral - midaxillary line between 5-7 intercostal space
41
define flail chest
double rib fracture of at least 3 adjacent ribs, resulting in an unstable thoracic cage
42
what happens on inspiration and exhalation of a flail chest
inspiration ribs cave in expiration ribs balloon out
43
anatomic alteration of flail chest
1. double fracture of numerous adjacent ribs 2. rib instability (tx: PEEP) 3. lung restriction 4. atelectasis 5. lung collapse (pneumothorax) 6. lung contusion (bruise) 7. secondary pneumonia
44
a flailing chest wall will result in what type respiratory failure
type 2 (ventilatory) due to pendeluft effect
45
a lung contusion will result in what type respiratory failure
type 1 (oxygenation) due to diffusion defect
46
etiology of flail chest
crush chest injury result of 1. MVA or blunt trauma 2. falls 3. blast injury 4. direct compression 5. occupational and industrial accident
47
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
48
physical exam findings of flail chest
vitals - tachypnea, tachycardia, HTN chest wall paradoxical movement cyanosis breath sounds diminished on effected and unaffected side
49
ABG findings mild to moderate flail chest
acute respiratory alkalosis
50
ABG findings severe flail chest
acute respiratory acidosis
51
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 ```
52
radiologic findings flail chest
increased opacity rib fractures increased density on affected side
53
treatment in mild case of flail chest
pain management routine bronchial hygiene
54
treatment in severe cases of flail chest
VC MV with PEEP take 5-10 days form bone to start healing
55
define pleural effusion
any abnormal accumulation of fluid in pleura
56
anatomic alterations of lung with pleural effusion
lung compression atelectasis compression of great veins and decreased C.O. and venous return
57
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
58
define transudate pleural effusion
increased hydrostatic pressure move fluid from parietal pleura capillaries into pleural space pleural surface not involved in production of transudate
59
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
60
Etiology of transudate PE
CHT (most common) hepatic hydrothorax (Ascites) peritoneal dialysis pulmonary embolus hypoalbuminemia lymphatic obstruction nephrotic syndrome
61
what are the primary causes of transudative PE
abnormal hydrostatic pressure abnormal oncotic pressure
62
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
63
etiology pathologic pE
emphyema chylothorax - ruptured thoracic duct hemothorax - trauma or blood vessel hemorrhage
64
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
65
Complications from a parapneumatic pleural effusion may often lead to the formation of:
empyema
66
physical assessment of PE
tachycardia tachypnea HTN chest pain/decresed excursion cyanosis dry nonproductive cough
67
chest assessment of PE
tracheal shift decreased tactile/vocal fremitis dispalced heart sounds/PMI plueral friction rub breath sounds diminished, fine crackles
68
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
69
diagnostic testing for PE
thoracoscopy - visualize thoracentesis - drainage
70
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
71
describe thoracentesis
percutaneous needle aspiration of effusion sample drainage for lung reexpansion involves placement of chest tube
72
risk of thoracentesis
artery laceration infection pneumothorax
73
Which of the following is considered the most sensitive procedure to assess size and location of a pleural effusion?
CT scan of chest
74
general management of PE
must be individualized exam of pleural fluid for transudate or exudate assessment pleurodesis chest thoracotomy tube pleuroperitoneal shunt & pleurex catheter
75
describe pleurodesis
chemical or medication injected into chest cavity adhereing lung to chest wall
76
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
77
indications of pleural chest tube
tension pneumothorax pneumothorax (>10-20%) hemothorax emphyema pleural effusion chylothorax
78
indication for mediastinal chest tube
free air or blood
79
indication for pericardial chest tube
cardiac tamponade or pneumopericardium open-heart surgery
80
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)
81
components of chest tube
CT tubing flexible tubing connecting CT to drainage system 1-4 compartment drainage system (1-4 bottle, disposable drainage system)
82
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
83
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
84
describe 3 bottle drain system
collection water seal suction chamber can be for air or fluid
85
chest tube placement for pneumothorax
2-3 intercostal space midcalvicular or midaxilarry directed at apex
86
chest tube placement for hemothorax or pleural effusion
5-7 intercostal space midaxillary directed inferior and posterior
87
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
88
troubleshooting patient with CT
deterioration of condition indicated tension pneumothorax notify physician immediately bag on 100 Fio2 if on MV
89
troubleshooting drain system of CT tidalling and bubbling present
indicates patient has air leak (pneumothorax)
90
troubleshooting drain system of CT no tidalling or bubbling present
indicates lung re-expansion or obstruction by kinks or clots
91
troubleshooting drain system of CT no tidalling bubbling present
indicates possble connection or system air leak
92
troubleshooting drain system of CT tidalling present no bubbling
observed with peumonectomy or decreased lung compliance

Critical Care (4 decks)

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