Pleural Effusion, Pneumothorax, Chest tubes

Question 1

Types of Pleural Space

Answer 1

Parietal Pleura- Lines the chest wall

Visceral Pleura- Covers the lungs

Question 2

What is Pleural Effusion?

Answer 2

A collection of fluid in the pleural space.

- it’s not a disease but a sign of serious disease.

Question 3

What is Transudate Effusion?

Answer 3

Occurs primarily in non-inflammatory conditions- an accumulation of protein-poor, cell-poor fluid

caused by:

1. increased hydrostatic pressure from the heart failure.
2. decreased oncotic pressure found in chronic liver or renal disease(from hypoalbuminemia.

pressure causes the fluid to move out of the capillaries and into the pleural space.

Question 4

What is Exudate Effusion?

Answer 4

An accumulation of fluid and cells in an area of inflammation.
- results from increased capillary permeability characteristics of the inflammatory reaction.
Caused by:
1. Pulmonary malignancies
2. Pulmonary infections
3. Pulmonary embolization
4. GI diseases

Question 5

What is Pneumothorax and types?

Answer 5

Air in the pleural space.

• Partial or complete collapse of the lungs as a result of the air in the pleural space; may be:
  1. Closed
  2. Open

Question 6

What is Closed Pneumothorax?

Answer 6

Closed Pneumothorax has no associated external wound.
SPONTANEOUS PNEUMOTHORAX
-most common
-accumulation of air in the pleural space without an apparent antecedent event.
-CAUSED by rupture of small blebs on the visceral pleural space.
- Occurs most commonly in underweight male cigarette smokers 20-40 yrs of age.
- Recurrent
other Causes of pneumothorax:
1. Injury to the lungs caused by mechanical ventilation.
2. injury to the lungs caused by insertion of a subclavian catheter(TLC)
3. Perforation of the esophagus
4. Injury to the lungs from broken ribs
5. Ruptured blebs or bullae in a patient with COPD.

Question 7

What is Open Pneumothorax?

Answer 7

An Open Pneumothorax occurs when air enters the pleural space through an opening in the chest wall.

• Stab Wounds
• Gunshot Wounds
• Surgical thoracotomy
• AKA Sucking chest wound- should be covered with a Vented Dressing=>secured on 3 sides & left untaped, allowing air to escape from the vent.
• –Decreases the likelihood of a Tension Pneumothorax.
• If the object that caused the open chest wound is still in place, it should be left there and removed by the physician.

Question 8

What is Tension Pneumothorax?

Answer 8

A Tension Pneumothorax is a pneumothorax with a rapid accumulation of air in the pleural space causing severely high intrapleural pressures with resultant tension on the heart and great vessels.
intrathoracic pressure increases=> the lung collapses=> MEDIASTINUM SHIFTS TOWARDS THE UNAFFECTED SIDE, causing compression
- as the pressure increases, cardiac output is altered because of decrease venous return & compression of the vena cava & aorta.
- tension pneumothorax is a Medical Emergency
- both respiratory & circulatory systems affected
- if tension in the pleural space is not relieved, patient like to die: inadequate cardiac output, severe HYPOXEMIA

Question 9

What is Hemothorax?

Answer 9

A hemothorax is an accumulation of blood in the intrapleural space.
Frequently associated with open pneumothorax
-Chest trauma
-Lung Malignancy
- Anticoagulant Therapy
- Pulmonary Embolism
-Pleural adhesion tears

Question 10

What id the purpose of Chest Tubes & Pleural Drainage

Answer 10

To remove air & fluid from the pleural space and to restore normal intrapleural pressure so that the lungs can re-expand.
intrapleural pressure=negative pressure.

If the intrapleural pressure= atmospheric pressure: the lungs will collapse(Pneumothorax)

Question 11

in Pneumothorax Air can enter to the lungs

Answer 11

• Traumatic injury
• Gunshot wound
• Fractured rib
• Thoracotomy
• Mechanical ventilation
• Spontaneous pneumothorax

A tube can be inserted to help drain the air out.

Question 12

in Pneumothorax Fluid can enter to the lungs

Answer 12

Fluid can accumulate in the pleural space

• Impaired Lymphatic Drainage (malignancy)
• Changes in Osmotic Pressure (heart failure)
• Empyema (Lung Abscess)

A tube can be inserted to help drain the fluid out.

Question 13

Chest tubes/drainage maintenance

Answer 13

• Tubes sutured to Chest Wall

- Puncture site covered with dressing- petroleum Gauze

Question 14

3 Basic Compartments of Pleural Drainage Systems

Answer 14

1. Collection Chamber: receives fluid & air from the chest cavity- the fluid stays in this chamber while the air vents to the second compartment.
2. Water Seal Chamber: contains 2cm H2O which acts as one-way valve.
   - the incoming air enters from the collection chamber and bubbles up through the water.
   - Air/water cannot go back the other way, hence the ‘underwater seal’.
3. The Suction Control Chamber: Applies controlled suction to the chest drainage system.
   - attached to wall suction
   - filled with water with top end vented
   - typically filled with 20cm water
   - excess pressure relieved via vented top when it exceeds the set 20cm of air.

Question 15

Nursing management of pleural drainage

Answer 15

• monitor fluid output
• no milking/stripping
• clamping: only when changing a ‘full’ pleuravac
• drainage must below of the pt’s chest level
• follow facility protocol if chest tube becomes disconnected
• petroleum gauze
• pain management

Question 16

What are the Complications of Chest Drainage?

Answer 16

1. Chest Tube Malposition
   - make sure that patient not lying on it
   - monitor for tidaling in the Water Seal Chamber
   - kinked tubing
2. Disconnection
   - follow facility’s protocol
   - usually immediate chest x-ray(check placement)
   - Vaseline Gauze
3. Skin (Puncture) Site Infection
4. Re-expansion Pulmonary Edema with evacuation of large volumes of pleural fluid
   - can cause a vasovegal hypotensive response..
5. Pain
6. Pneumonia- from patient positioning
7. Shoulder Disuse, AKA Frozen Shoulder- from lack of range of motion exercise
8. Subcutaneous Emphysema, AKA Crepitus- the collection of air in the tissues just under the skin.

Question 17

Chest Tube removal

Answer 17

• Underwater Seal only(disconnected from the wall suction)
• When drainage tapers off
• To monitor any additional drainage
• once Chest tubes removed:
  1. Q days chest x-rays
  2. Monitor respirations, oxygenation
  3. covers with Petroleum Gauze