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Respiratory Disorders: Pleural and Thoracic Injury I. Disorders of the Pleura A. Pleural Effusion Definition: a collection of excess fluid in the pleural space. 5/24/2017 1 5/24/2017 2 5/24/2017 Pleural effusion Chest x-ray of a pleural effusion. The arrow A shows fluid layering in the right pleural cavity. The B arrow shows the normal width of the lung in the cavity 3 Etiology of Pleural Effusions: 5/24/2017 Congestive Heart Failure Liver Disease Renal Disease Lupus, Rheumatoid Arthritis Pneumonia TB Lung Cancer Trauma 4 What would you think is happening in this client? 5/24/2017 5 Answer: 5/24/2017 Massive left sided pleural effusion in a patient presenting with lung cancer. 6 Pathophysiology of Pleural Effusion capillary pressure or plasma proteins Formation of excess fluid= Transudate 5/24/2017 capillary permeability= Exudate Accumulation of pus in the pleural space=Empyema 7 Transudate Non-inflammatory Trans means movement of fluid due to changes in pressure gradients What do you remember about oncotic pressure and serum albumin levels??? What is hydrostatic pressure? 5/24/2017 vs Exudate Inflammatory in nature Exudate means there is a release of fluid. Exudative pleural effusion are due to changes in capillary permeability. The capillaries are inflammed and are not as selective and allow fluid to leak into the pleural space. 8 Let’s try to classify Transudative or Exudative Pleural Effusion…. Etiology of Pleural Effusions: 5/24/2017 Congestive Heart Failure Liver Disease Renal Disease Lupus, Rheumatoid Arthritis Pneumonia TB Lung Cancer Trauma ARDS 9 Clinical Manifestations of Pleural Effusion 5/24/2017 Dyspnea Pleurisy Decreased breath sounds Decreased chest wall movement 10 Diagnostic Tests Pleural Effusion 5/24/2017 CXR CT scan ABG’s/O2 Saturation 11 Therapeutic Interventions 5/24/2017 Thoracentesis-needle aspiration of fluid in pleural space. Usually 1200-1500ml /time. Antibiotics if due to infectious process. Chest tube to drain fluid/air. Pleurodesis-instillation of chemical agent (doxycycline) into pleural space to create inflammatory response (scar tissue) to adhese the visceral and parietal pleura. Treat underlying condition that is causing the effusion. 12 Nursing Diagnosis #1 Ineffective breathing pattern related to decreased lung expansion of left lung secondary to accumulation of fluid in the pleural space, pain and discomfort of breathing deeply secondary to inflammation and irritation of pleural space, and poor positioning in bed secondary to inability to reposition self without assistance. Nursing Diagnosis #2 Impaired gas exchange related to ineffective capillary – alveolar gas exchange secondary to presence of atelectasis in lower left lung and respiratory fatigue caused by presence of pleural effusion in left lung compromising ability to inspire deeply and causing pain. PleurX® Pleural Catheter System B. Spontaneous Pneumothorax Definition-accumulation of air in the pleural space Pathophysiology Rupture of bleb on the lung surface allows air into the pleural space • Primary pneumothorax- affects previously healthy individuals • Secondary pneumothorax-affects individuals with preexisting lung disease – Which diseases can you think of??? 5/24/2017 17 Clinical Manifestations of Spontaneous Pnemo 5/24/2017 Abrupt onset Pleuritic chest pain SOB, dyspnea respiratory rate, tachycardia Unequal chest excursion Decreased breath sounds on affected side 18 C. Traumatic Pneumothorax Definition/Pathophysiology: Accumulation of air into pleural space due to blunt or penetrating trauma of chest wall/lungs. Types of Traumatic Pneumothorax • Closed Pneumo • Open Pneumo • Iatrogenic Pneumo 5/24/2017 19 Closed Pneumothorax No opening from external chest. Open Pneumothorax Opening from external chest wall into pleura. Iatrogenic Pneumothorax Puncture or laceration of visceral pleura during medical tx Occurs in crashes, falls, MVAs, CPR, fractured ribs that penetrate the pleura. Occurs in stabbings, gunshot wounds, impalement injury. Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation 5/24/2017 20 I’m just asking…. The client has a spontaneous pneumothorax….which type of pneumothorax is this: A- Iatrogenic B- Open C- Closed D- Intermediate 5/24/2017 21 Clinical Manifestations of Pneumothorax 5/24/2017 Dyspnea Pleuritic Pain RR, pulse respiratory excursion Absent breath sounds on affected side 22 D. Tension Pneumothorax Definition: air/blood/fluid rapidly enters pleural space and unable to escape Lung collapses Emergency situation! 5/24/2017 23 Tension Pneumothorax Is this a right sided or left sided tension pnemothorax? 5/24/2017 24 Pathophysiology of Tension Pnemothorax Compression of lung to other side Compresses against trachea, heart, aorta, esophagus 5/24/2017 Increase in Intrapleural pressure Ventilation and Cardiac Output greatly compromised 25 Clinical Manifestations/Complications of Tension Pneumo Severe Dyspnea Tracheal Deviation Decreased Cardiac Output Distended Neck Veins RR, pulse, blood pressure Shock 5/24/2017 26 Therapeutic Interventions for Pneumothorax 5/24/2017 High Fowlers position O2 as ordered Rest to decrease O2 demand Chest tube insertion Pleurodesis Surgery: Thoracotomy to remove blebs, partial excision of parietal pleura done using VATS (video assisted thorascopic surgery) 27 II. Trauma of the Chest/Lung Chest injury is the leading cause of death from trauma May involve chest wall, lungs, heart, great vessels, esophagus Life threatening chest injuries include: Airway obstruction Tension pneumo, open pneumo, massive hemothorax Flail chest with pulmonary contusion 5/24/2017 28 A. Rib Fracture 5/24/2017 Simple rib fracture in an at risk client may lead to pneumonia, atelectasis, respiratory failure Displaced rib fractures can result in pnemo/hemothorax, intrathoracic vessel tears, liver or spleen injury 29 Clinical Manifestations of Rib Fractures 5/24/2017 Pain on inspiration/coughing Voluntary splinting Rapid, shallow respirations Decreased breath sounds Crepitus on palpation Signs/symptoms of pneumo/hemothorax 30 B. Flail Chest 5/24/2017 Etiology/Pathophysiology Occurs when 2+ consecutive ribs are fractured in multiple places Segment of chest wall becomes “freefloating” or flail Flail segment of chest wall is sucked in during inspiration and moves outward with expiration 31 The client presents in the ED: 5/24/2017 Chest trauma client http://www.youtube.com/watch?v=PyDcGBi7OQ&feature=related What did you note in this client? What would you do 1st? 2nd? 32 Clinical Manifestations of Flail Chest 5/24/2017 Dyspnea Pain especially on inspiration Palpable crepitus Decreased breath sounds Unequal Chest expansion 33 What assessment finding is present??? 5/24/2017 34 Flail Chest 5/24/2017 Right lung affected 35 Therapeutic Interventions Flail Chest 5/24/2017 O2 as ordered Elevate HOB Intercostal nerve block or epidural analgesia to decrease pain Suction as ordered Splint affected area Preferred treatment= Intubation and positive pressure ventilation 36 5/24/2017 Internal/External fixation of ribs in Flail Chest 37 Judet Plates for Fractured Ribs/Flail Chest 5/24/2017 38 Sanchez Plates for Fractured Ribs/Flail Chest 5/24/2017 39