Pneumothorax

Introduction

Pneumothorax is a collection of air or gas in the chest or pleural space that

causes part or all of a lung to collapse.
Normally, the pressure in the lungs is greater than the pressure in the pleural
space surrounding the lungs. However, if air enters the pleural space, the
pressure in the pleura then becomes greater than the pressure in the lungs,
causing the lung to collapse partially or completely. Pneumothorax can be either
spontaneous or due to trauma.
If a pneumothorax occurs suddenly or for no known reason, it is called a
spontaneous pneumothorax. This condition most often strikes tall, thin men
between the ages of 20 to 40. In addition, people with lung disorders, such as
emphysema, cystic fibrosis, and tuberculosis, are at higher risk for spontaneous
pneumothorax. Traumatic pneumothorax is the result of accident or injury due to
medical procedures performed to the chest cavity, such as thoracentesis or
mechanical ventilation. Tension pneumothorax is a serious and potentially life-
threatening condition that may be caused by traumatic injury, chronic lung
disease, or as a complication of a medical procedure. In this type of
pneumothorax, air enters the chest cavity, but cannot escape. This greatly
increased pressure in the pleural space causes the lung to collapse completely,
compresses the heart, and pushes the heart and associated blood vessels
toward the unaffected side.

Pathophysiology:
• “Accumulation of air or gas in the
pleural cavity”

• Left-sided pneumothorax (on the right

side of the image) on CT scan of the
chest with chest tube in place.
Anatomy Review- Pleural cavity
• Visceral pleura
– Encases lungs
• Pleural space/cavity
– Area between pleura
– Contains fluid (4ml)
– Fluid prevents friction
– Fluid circulated by…
• lymph system
• Parietal pleura
– Lines chest wall

Anatomy review - Breathing

• Diaphragm i & accessory muscles
move outward ◊
• Negative pressure in the thoracic cavity ◊
• Negative pressure pulls air into the lungs via the nose and
mouth
• Diaphragm & accessory muscle relax (h) ◊
• air exhaled
• If the visceral pleural is perforated or the chest wall &
parietal pleural are perforated
• air enters the pleural space ◊
• negative pressure is lost ◊
• Lung on the affected side collapses
• An abnormal chest x-ray shows the presence of an air pocket
(arrows) in the pleural sac surrounding one lung, which has
collapsed. This finding is typical of a severe pneumothorax. A
normal chest x-ray is shown on the right for comparison; the
heart (H), lungs (L), vertebrae (v), and
collarbone (C) can be seen.

Classifications of pneumothorax
 • Spontaneous pneumothorax
– with out injury
– Air enters the pleural cavity via the airway
– Farther classified as:
• Primary
• Secondary

Spontaneous (Primary) Pneumothorax

• Pt. with no known lung disease.
• D/T a rupture of a bulla in the lung.
• Most often tall, thin men between 20 and 40 years
old.

Spontaneous Secondary Pneumothorax

• occurs in pt. with known lung disease
– most often COPD
• Other lung diseases commonly assoc. with
– Tuberculosis
– Pneumonia
– Asthma
– lung cancer
• Often severe & life threatening
• Traumatic Pneumothorax
– D/T injury to the chest wall
– Further classified as Open or closed

Open Pneumothorax
• Air enters pleural cavity via outside
• A free communication between the exterior and
the pleural space as through an open wound
– blowing wound
– sucking wound
• may be caused by a penetrating injury
– stab wound,
– gunshot wound
– impaled object

Closed pneumothorax
• Air enters the pleural cavity via lungs
• D/t/ blunt chest trauma
– Car crash
– Fall
– Crushing chest injury

Tension Peumothorax
 • air accumulates in the pleural space with each breath.
• The remorseless increase in intrathoracic
pressure à

• • massive shifts of the

mediastinum away from
the affected lung à
• compressing
intrathoracic vessels à
• cardiovascular collapse

• a piece of tissue forms a one-way valve that allows air to enter the pleural cavity
but not to escape, overpressure can build up with every breath

Etiology / Contributing factors

• Spontaneous
– Lung disease - COPD
– Tall, thin men
• Traumatic
– A penetrating chest wound
– Barotrauma
• scuba divers
• Iatrogenic Pneumothorax
– * insertion of a central line
– * thoracic surgery
– * thoracentesis
– * pleural or transbronchial
biopsy.

Clinical Manifestations (all types)

• Sudden sharp chest pain
 • Asymmetrical chest expansion
• dyspnea
• Cyanosis
• Percussion
– Hyper resonance or tympany
• Breath sounds
– diminished
– Absent

Clinical Manifestations (all types)

• Respiratory distress
• O2 Sats
– decreased
• Tachypnea
• Tachycardia
• Restlessness/ Anxiety

S&S of open pneumothorax

• Crepitus
– (subcutaneous emphysema)
• Sucking chest wound”

S&S Tension pneumothorax

 i cardiac output
• Hypotension
• Tachycardia (compensatory)
• Tachypnea
• Mediastinal shift and tracheal deviation
– To the unaffected side
• Cardiac arrest
• Distended neck veins

Dx exam and tests

• HX & PE
• Chest x-ray
• ABG’s
– Initial PaCO2
• Decreased
• respiratory alkalosis
– Later ABG’s
• Hypoxemia
• Hypercapnia
• Acidosis

Treatment - First aid: Open pneumothorax

 • Cover immediately with an occlusive dressing, made air-tight with petroleum
jelly or clean plastic sheeting.

Tx: Small pneumothorax

• Spontaneous recovery
– Bed rest
– resolve on its own in 1 to 2 weeks
• Remove with small bore needle inserted into the pleural space

Tx: Larger pneumothorax

• Chest tube
• Surgery repair
• Pleurodesis
– “glue”
– Very painful
– Prep with analgesic
• O2
• Surgery

Nursing interventions
• Closely monitor resp status
• Frequent assess
– LOC
– Color
– VS
– Chest pain?
– Restlessness?
• Chest Tube
• Rest/Activity Balance
• Sedation
• Provide a means for communicate
• Educate patient & family

• Notify MD for:
– SpO2 < 90% or Change Greater
Than 5%
– Respiratory Distress
– Inadequate Sedation
– h Peak Airway Pressure (Especially with Pressure Control Mode)
Complications
• Recurrent pneumothorax
– D/C
• smoking
• high altitudes
• scuba diving
• flying in unpressurized aircrafts
• Cardiac damage
 DISTURBANCE IN OXYGENATION

PNEUMOTHORAX

PREPAERD BY;
ALINGAN, M.
TOMADA, S.