Chapter 22 Pneumothorax Mosby items and derived items
![Chapter 22 Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. Chapter 22 Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc.](https://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-1.jpg)
Chapter 22 Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 1
![CL GA DD Figure 22 -1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm; CL GA DD Figure 22 -1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm;](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-2.jpg)
CL GA DD Figure 22 -1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm; CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 2
![Anatomic Alterations of the Lungs Lung collapse Atelectasis Chest wall expansion Compression of the Anatomic Alterations of the Lungs Lung collapse Atelectasis Chest wall expansion Compression of the](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-3.jpg)
Anatomic Alterations of the Lungs Lung collapse Atelectasis Chest wall expansion Compression of the great veins and decreased cardiac venous return Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 3
![Etiology Gas can gain entrance to the pleural space in three ways: 1. From Etiology Gas can gain entrance to the pleural space in three ways: 1. From](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-4.jpg)
Etiology Gas can gain entrance to the pleural space in three ways: 1. From the lungs through a perforation of the visceral pleura 2. From the surrounding atmosphere through a perforation of the chest wall and parietal pleura or, rarely, through an esophageal fistula or a perforated abdominal viscus 3. From gas-forming microorganisms in an empyema in the pleural space (rare) Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 4
![Pneumothorax Classifications General Terms Closed pneumothorax Open pneumothorax Tension pneumothorax Mosby items and derived Pneumothorax Classifications General Terms Closed pneumothorax Open pneumothorax Tension pneumothorax Mosby items and derived](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-5.jpg)
Pneumothorax Classifications General Terms Closed pneumothorax Open pneumothorax Tension pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 5
![Pneumothorax Classifications Based on Origin Traumatic pneumothorax Spontaneous pneumothorax Iatrogenic pneumothorax Mosby items and Pneumothorax Classifications Based on Origin Traumatic pneumothorax Spontaneous pneumothorax Iatrogenic pneumothorax Mosby items and](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-6.jpg)
Pneumothorax Classifications Based on Origin Traumatic pneumothorax Spontaneous pneumothorax Iatrogenic pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 6
![Traumatic Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , Traumatic Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. ,](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-7.jpg)
Traumatic Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 7
![Figure 22 -2. Sucking chest wound with accompanying pendelluft in an open pneumothorax. The Figure 22 -2. Sucking chest wound with accompanying pendelluft in an open pneumothorax. The](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-8.jpg)
Figure 22 -2. Sucking chest wound with accompanying pendelluft in an open pneumothorax. The large arrow illustrates the chest wall injury. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 8
![Figure 22 -3. Closed (tension) pneumothorax produced by a chest wall wound. The large Figure 22 -3. Closed (tension) pneumothorax produced by a chest wall wound. The large](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-9.jpg)
Figure 22 -3. Closed (tension) pneumothorax produced by a chest wall wound. The large arrow illustrates the chest wall injury. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 9
![Spontaneous Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , Spontaneous Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. ,](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-10.jpg)
Spontaneous Pneumothorax Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 10
![Figure 22 -4. Right pneumothorax produced by a rupture in the visceral pleura that Figure 22 -4. Right pneumothorax produced by a rupture in the visceral pleura that](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-11.jpg)
Figure 22 -4. Right pneumothorax produced by a rupture in the visceral pleura that functions as a check valve. Progressive enlargement of the pneumothorax occurs, producing atelectasis on the affected side. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 11
![Iatrogenic Pneumothorax An iatrogenic pneumothorax sometimes occurs during specific diagnostic or therapeutic procedures—for example Iatrogenic Pneumothorax An iatrogenic pneumothorax sometimes occurs during specific diagnostic or therapeutic procedures—for example](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-12.jpg)
Iatrogenic Pneumothorax An iatrogenic pneumothorax sometimes occurs during specific diagnostic or therapeutic procedures—for example Ø Ø Ø Pleural or liver biopsy Thoracentesis Intercostal nerve block Cannulation of a subclavian vein Tracheostomy An iatrogenic pneumothorax is always a hazard during positive-pressure mechanical ventilation! Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 12
![Overview of the Cardiopulmonary Clinical Manifestations Associated with Pneumothorax The following clinical manifestations result Overview of the Cardiopulmonary Clinical Manifestations Associated with Pneumothorax The following clinical manifestations result](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-13.jpg)
Overview of the Cardiopulmonary Clinical Manifestations Associated with Pneumothorax The following clinical manifestations result from the pathophysiologic mechanisms caused (or activated) by Ø Atelectasis Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 13
![Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-14.jpg)
Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 14
![Clinical Data Obtained at the Patient’s Bedside Mosby items and derived items © 2011, Clinical Data Obtained at the Patient’s Bedside Mosby items and derived items © 2011,](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-15.jpg)
Clinical Data Obtained at the Patient’s Bedside Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 15
![The Physical Examination Vital Signs Ø Increased respiratory rate (tachynea) • Tachypnea occurs because The Physical Examination Vital Signs Ø Increased respiratory rate (tachynea) • Tachypnea occurs because](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-16.jpg)
The Physical Examination Vital Signs Ø Increased respiratory rate (tachynea) • Tachypnea occurs because of the following: Stimulation of peripheral chemoreceptors (hypoxemia) Pendelluft−see Figure 22 -2 Decreased lung Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 16
![The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Decreased lung compliance/increased ventilatory rate relationship Activation The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Decreased lung compliance/increased ventilatory rate relationship Activation](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-17.jpg)
The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Decreased lung compliance/increased ventilatory rate relationship Activation of the deflation receptors Activation of the irritant receptors Stimulation of the J receptors Pain/anxiety Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 17
![Figure 22 -5. Venous admixture in pneumothorax. Mosby items and derived items © 2011, Figure 22 -5. Venous admixture in pneumothorax. Mosby items and derived items © 2011,](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-18.jpg)
Figure 22 -5. Venous admixture in pneumothorax. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 18
![The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Ø Increased • Heart rate (pulse) • The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Ø Increased • Heart rate (pulse) •](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-19.jpg)
The Physical Examination, (Cont’d) Vital Signs, (Cont’d) Ø Increased • Heart rate (pulse) • Blood pressure Cyanosis Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 19
![The Physical Examination, (Cont’d) Chest Assessment Findings Hyperresonant percussion note over the pneumothorax Ø The Physical Examination, (Cont’d) Chest Assessment Findings Hyperresonant percussion note over the pneumothorax Ø](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-20.jpg)
The Physical Examination, (Cont’d) Chest Assessment Findings Hyperresonant percussion note over the pneumothorax Ø Diminished breath sounds over the pneumothorax Ø Tracheal shift Ø Displaced heart sounds Ø Increased thoracic volume on the affected side (particularly in tension pneumothorax) Ø Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 20
![Figure 22 -6. Because the ratio of extrapulmonary gas to solid tissue increases in Figure 22 -6. Because the ratio of extrapulmonary gas to solid tissue increases in](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-21.jpg)
Figure 22 -6. Because the ratio of extrapulmonary gas to solid tissue increases in a pneumothorax, hyperresonant percussion notes are produced over the affected area. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 21
![Figure 22 -7. Breath sounds diminish as gas accumulates in the intrapleural space. Mosby Figure 22 -7. Breath sounds diminish as gas accumulates in the intrapleural space. Mosby](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-22.jpg)
Figure 22 -7. Breath sounds diminish as gas accumulates in the intrapleural space. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 22
![Figure 22 -8. As gas accumulates in the intrapleural space, the chest diameter increases Figure 22 -8. As gas accumulates in the intrapleural space, the chest diameter increases](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-23.jpg)
Figure 22 -8. As gas accumulates in the intrapleural space, the chest diameter increases on the affected side in a tension pneumothorax. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 23
![Clinical Data Obtained from Laboratory Tests and Special Procedures Mosby items and derived items Clinical Data Obtained from Laboratory Tests and Special Procedures Mosby items and derived items](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-24.jpg)
Clinical Data Obtained from Laboratory Tests and Special Procedures Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 24
![Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-25.jpg)
Pulmonary Function Test Findings Moderate to Severe (Restrictive Lung Pathophysiology) Lung Volume & Capacity Findings VT N or IRV ERV IC FRC TLC RV VC RV/TLC ratio Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. N 25
![Arterial Blood Gases (Small Pneumothorax) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) p. Arterial Blood Gases (Small Pneumothorax) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) p.](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-26.jpg)
Arterial Blood Gases (Small Pneumothorax) Acute Alveolar Hyperventilation with Hypoxemia (Acute Respiratory Alkalosis) p. H Pa. CO 2 HCO 3 (slightly) Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. Pa. O 2 26
![Pa. O 2 and Pa. CO 2 trends during acute alveolar hyperventilation. Mosby items Pa. O 2 and Pa. CO 2 trends during acute alveolar hyperventilation. Mosby items](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-27.jpg)
Pa. O 2 and Pa. CO 2 trends during acute alveolar hyperventilation. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 27
![Arterial Blood Gases (Large Pneumothorax) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) p. Arterial Blood Gases (Large Pneumothorax) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) p.](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-28.jpg)
Arterial Blood Gases (Large Pneumothorax) Acute Ventilatory Failure with Hypoxemia (Acute Respiratory Acidosis) p. H Pa. CO 2 HCO 3 (Slightly) Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. Pa. O 2 28
![Pa. O 2 and Pa. CO 2 trends during acute or chronic ventilatory failure. Pa. O 2 and Pa. CO 2 trends during acute or chronic ventilatory failure.](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-29.jpg)
Pa. O 2 and Pa. CO 2 trends during acute or chronic ventilatory failure. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 29
![Oxygenation Indices QS/QT DO 2 VO 2 N C(a-v)O 2 (Severe) O 2 ER Oxygenation Indices QS/QT DO 2 VO 2 N C(a-v)O 2 (Severe) O 2 ER](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-30.jpg)
Oxygenation Indices QS/QT DO 2 VO 2 N C(a-v)O 2 (Severe) O 2 ER Sv. O 2 Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 30
![Hemodynamic Indices Large Pneumothorax CVP RAP PA PCWP CO SVI CI RVSWI LVSWI PVR Hemodynamic Indices Large Pneumothorax CVP RAP PA PCWP CO SVI CI RVSWI LVSWI PVR](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-31.jpg)
Hemodynamic Indices Large Pneumothorax CVP RAP PA PCWP CO SVI CI RVSWI LVSWI PVR SVR Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 31
![Radiologic Findings Chest radiograph Increased translucency on the side of pneumothorax Ø Mediastinal shift Radiologic Findings Chest radiograph Increased translucency on the side of pneumothorax Ø Mediastinal shift](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-32.jpg)
Radiologic Findings Chest radiograph Increased translucency on the side of pneumothorax Ø Mediastinal shift to unaffected side in tension pneumothorax Ø Depressed diaphragm Ø Atelectasis Ø Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 32
![A B Figure 22 -9. A, Development of a small tension pneumothorax in the A B Figure 22 -9. A, Development of a small tension pneumothorax in the](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-33.jpg)
A B Figure 22 -9. A, Development of a small tension pneumothorax in the lower part of the right lung (arrow). B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow). Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 33
![A B Figure 22 -10. A, A 19 -year-old male patient, 6 feet 5 A B Figure 22 -10. A, A 19 -year-old male patient, 6 feet 5](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-34.jpg)
A B Figure 22 -10. A, A 19 -year-old male patient, 6 feet 5 inches tall, who experienced a sudden spontaneous left-sided pneumothorax while playing a round of golf. A spontaneous pneumothorax is not uncommon in people who are tall and thin. B, Chest radiograph of the same patient 45 minutes later in the emergency room. Note the shift of the heart and mediastinum to the right (toward the affected side), away from the tension pneumothrorax, and the depressed diaphragm on the patient’s left side. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 34
![General Management of Pneumothorax The management of pneumothorax depends on the degree of lung General Management of Pneumothorax The management of pneumothorax depends on the degree of lung](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-35.jpg)
General Management of Pneumothorax The management of pneumothorax depends on the degree of lung collapse. When the pneumothorax is relatively small (15% to 20%), the patient may need only bed rest or limited physical activity. Ø In such cases, resorption of intrapleural gas usually occurs within 30 days. Ø When the pneumothorax is larger than 20%, it should be evacuated. Ø Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 35
![General Management of Pneumothorax, (Cont’d) When suction is used, the negative pressure need not General Management of Pneumothorax, (Cont’d) When suction is used, the negative pressure need not](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-36.jpg)
General Management of Pneumothorax, (Cont’d) When suction is used, the negative pressure need not exceed -12 cm H 2 O; -5 cm H 2 O is generally all that is needed. After the lung has reexpanded and bubbling from the chest tube has ceased, the tube is left in place without suction for another 24 to 48 hours. Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 36
![General Management of Pneumothorax, (Cont’d) PLEURODESIS Chemical or medication injected into the chest cavity General Management of Pneumothorax, (Cont’d) PLEURODESIS Chemical or medication injected into the chest cavity](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-37.jpg)
General Management of Pneumothorax, (Cont’d) PLEURODESIS Chemical or medication injected into the chest cavity Ø Ø Ø Talc Tetracycline Bleomycin sulfate Produces inflammatory reaction between lungs and inner chest cavity Ø Causes lung to stick to chest cavity Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 37
![Respiratory Care Treatment Protocols Oxygen Therapy Protocol Lung Expansion Therapy Protocol Mechanical Ventilation Protocol Respiratory Care Treatment Protocols Oxygen Therapy Protocol Lung Expansion Therapy Protocol Mechanical Ventilation Protocol](http://slidetodoc.com/presentation_image_h2/5db7a558f5bedd3ca400fad92c39b2ce/image-38.jpg)
Respiratory Care Treatment Protocols Oxygen Therapy Protocol Lung Expansion Therapy Protocol Mechanical Ventilation Protocol Mosby items and derived items © 2011, 2006 by Mosby, Inc. , an affiliate of Elsevier Inc. 38
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