Pneumothorax

Pleural Cavity

Pleura

 The thin serous membrane around the lungs

Parietal Pleura

and inner walls of the chest.  Pleura that lines the inner chest walls and

Pleural Cavity

covers the diaphragm. (Outer pleura)  Has 5 – 15 mL. Acts as lubricant that allows the pleural surfaces to move without

Visceral Pleura Mediastinum

friction.  Pleura that covers the lungs. (Inner pleura)  The space in the thoracic cavity behind the sternum and in between the two pleural sacs (containing the lungs).

Definition Pneumothorax, or collapsed lung, is a potential medical emergency caused by accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or spontaneously.

Pathophysiology The lungs are located inside the chest cavity, which is a hollow space. Air is drawn into the lungs by the diaphragm. The pleural cavity is the region between the chest wall and the lungs. If air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes mechanically impossible for the injured person to breathe, even with an open airway. If a piece of tissue forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape, overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe shortness of breath as well as circulatory collapse, both life-threatening conditions. This condition requires urgent intervention. Motor vehicular accident Gun or Knife wound in Chest wall or Diaphragm

Puncture / tear in an internal respiratory structure Alveoli, Bronchus, Bronchioles (e.g. alveolar collapse)

Open Pneumothorax

Closed Pneumothorax

Air enter pleural space a with every inhalation; and cannot escape during expiration Air enters the Pleural Space

Pneumothorax

Kinds of Pneumothorax Open Pneumothorax

Closed Pneumothorax

 Air enters pleural space to the hole  Air escapes in pleural space from a in chest wall or diaphragm. puncture or tear in an internal respiratory structure such as bronchus, bronchioles, and alveoli.  Cause of surgery on the chest or trauma to the chest wall. (e.g. stab  This condition over time results in a wound) gradual accumulation of air to the degree that it begins to put pressure (it allows air to enter the pleural space) on the Mediastinum, compressing the heart and decreasing cardiac output due to the reduced amount of diastolic filling of the ventricles, leading to circulatory problems.

Classification of Pneumothorax Spontaneous  Cause is “Unknown”

Tension

Traumatic

 Site of Pleural rapture  May lead to lung acts as one way valve, collapse resulting permitting air to enter from either blunt form  Could be result of on inspiration but trauma to chest wall another disease such preventing its escape creating of an open as COPD, PTB and by closing up during sucking chest wound Cancer expiration. cause either gun or knife wound, motor  Chest wall is intact; vehicle accident. blebs/bulla is rapture causing collapse lungs. (a bladder-like structure more than 5 mm in diameter with thin walls that may be full of fluid)

Clinical Manifestation  Sudden shortness of breath  Dry coughs  Cyanosis (turning blue)  Pain felt in the chest, back and/or arms are the main symptoms.  In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound.  If untreated hypoxia may lead to loss of consciousness and coma. 

In addition, shifting of the Mediastinum away from the site of the injury can obstruct the superior and inferior vena cava resulting in reduced cardiac preload and decreased cardiac output.

 Untreated, a severe pneumothorax can lead to death within several minutes.

Spontaneous    

Tension

Pleural pain  Severe hypoxemia Tachypnea  Dyspnea Mild Dyspnea  Hypotension P.E.  Venous return is decreased (result of o Reveal Absent / decreased breath compression by the increasing pressure) sound o Hyperesonance (percussion) on the  Shock affected side.  Bradycardia

Assessment and Diagnostic findings  Dyspnea

To diagnose pneumothorax, it is

 Tachycardia

necessary for the health care provider

 Tachypnea

to:

 Sharp chest pain

 Pleural Pain  Absent of breath sound  Decreased expansion unilaterally  Cyanosis  Hypotension  Sucking Wound

 Auscultation

Note the one part of the chest that doesn’t transmit the normal sounds of breathing.  Chest X-Ray

Will show the air pocket and the collapsed lung and show that the

 Tracheal deviation to the unaffected trachea is being pushed to one side side with tension pneumothorax because of a collapsed lung.  Electrocardiogram (ECG) Will be performed to record the electrical impulses that control the heart's activity.  Arterial Blood Gases (ABGs)

Blood samples may be taken to check for the level of O2 and CO2 level

Treatment  A small pneumothorax may resolve on its own, but most require medical treatment. The object of treatment is to remove air from the chest and allow the lung to reexpand. This is done by inserting a needle and syringe (if the pneumothorax is small) or chest tube through the chest wall. This allows the air to escape without allowing any air back in. The lung will then re-expand itself within a few days. Surgery may be needed for repeat occurrences.  A chest tube is placed quickly or a large-bore needle is inserted into the pleural space to decompress it until a chest tube can be placed  An outward gush of air as the needle or chest tube is inserted confirms the presence of tension pneumothorax  The chest tube is connected to water seal drainage and suction until the damage pleura is healed.  After the pneumothorax is evacuated and the pleural rupture is healed, the chest tube is removed.

Chest Tube Thoracostomy  Returns (-) pressure to the internal pleural space  Remove abnormal accumulation of air  Serves as lung while healing is ongoing.

The insertion of chest tube permits removal of the air or bloody fluid and allows reexpansion of the lungs and restoration of the normal negative pressure in the pleural space. Because air rises, a chest tube inserted to remove air is usually placed anteriorly through the 2nd ICS. A chest tube inserted to remove fluids is placed posteriorly in the 8th and 9th ICS because fluid tends to flow to the bottom of the pleural space.

Chest Drainage Container A waterseal at the end of a chest tube is essential to allow air to escape through the tube but prevent air from traveling back up the tube and into the pleural space. The waterseal drainage system is placed below the level of the patient’s chest, taking

advantage of the force or gravity to promote drainage and prevent backflow of bottle contents into the pleural space.