Respiratory Disorders: Pleural and Thoracic Injury

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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.

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• Etiology of Pleural Effusions
• Heart Failure
• Liver Disease
• Renal Disease
• Lupus, Rheumatoid Arthritis
• Pneumonia
• TB
• Lung Cancer
• Trauma

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• Pathophysiology of Pleural Effusion

capillary pressure or plasma proteins
capillary permeability Exudate
Accumulation of pus in the pleural spaceEmpyema
Formation of excess fluid Transudate
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Clinical Manifestationsof Pleural Effusion

• Dyspnea
• Pleurisy
• Decreased breath sounds
• Decreased chest wall movement

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Diagnostic Tests Pleural Effusion

• CXR
• CT scan
• ABGs/O2 Saturation

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Therapeutic Interventions

• 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.

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• 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???

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Clinical Manifestations of Spontaneous Pnemo

• Abrupt onset
• Pleuritic chest pain
• SOB, dyspnea
• respiratory rate, tachycardia
• Unequal chest excursion
• Decreased breath sounds on affected side

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• 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

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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
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Clinical Manifestations of Pneumothorax

• Dyspnea
• Pleuritic Pain
• RR, pulse
• respiratory excursion
• Absent breath sounds on affected side

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D. Tension Pneumothorax

• Definition air/blood/fluid rapidly enters
  pleural space and unable to escape
• Lung collapses
• Emergency situation!

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Tension Pneumothorax
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Pathophysiology of Tension Pnemothorax

• Increase in Intrapleural pressure
• Compression of lung to other side
• Compresses against trachea, heart, aorta,
  esophagus
• Ventilation and Cardiac Output greatly
  compromised

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Clinical Manifestations/Complications of Tension
Pneumo

• Severe Dyspnea
• Tracheal Deviation
• Decreased Cardiac Output
• Distended Neck Veins
• RR, pulse, blood pressure
• Shock

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Therapeutic Interventions for Pneumothorax

• 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 thoracoscopic surgery)

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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

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• Crash Test

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Pathophysiology of Thoracic Injury

• Acceleration-Deceleration Injury
• Rapid change in velocity
• Body stops suddenly
• Chest cavity organs/tissues move forward

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A. Rib Fracture

• 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

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Clinical Manifestations of Rib Fractures

• Pain on inspiration/coughing
• Voluntary splinting
• Rapid, shallow respirations
• Decreased breath sounds
• Crepitus on palpation
• Signs/symptoms of pneumo/hemothorax

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B. Flail Chest

• Etiology/Pathophysiology
• Occurs when 2 consecutive ribs are fractured in
  multiple places
• Segment of chest wall becomes free-floating or
  flail
• Flail segment of chest wall is sucked in during
  inspiration and moves outward with expiration

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The client presents in the ED

• Chest trauma client
• Flail chest trauma client
• What did you note in this client? What would you
  do 1st? 2nd?
• \

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Clinical Manifestations of Flail Chest

• Dyspnea
• Pain especially on inspiration
• Palpable crepitus
• Decreased breath sounds
• Unequal Chest expansion

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What assessment finding is present???

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Flail Chest

• Right lung affected

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Therapeutic Interventions Flail Chest

• 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

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• Internal/External fixation of ribs in
• Flail Chest

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Judet Plates for Fractured Ribs/Flail Chest
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Sanchez Plates for Fractured Ribs/Flail Chest
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C. Pulmonary Contusion

• Etiology/Pathophysiology
• Left Pulmonary contusion

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Abrupt Chest Compression then Rapid Decompression
Intra-alveolar Hemorrhage
Interstitial/bronchial Edema
surfactant production leads to
decreased lung compliance
Pulmonary vascular resistance
Airway obstruction, Atelectasis,
Impaired O2/CO2 exchange
blood flow
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Clinical Manifestations of Pulmonary Contusion

• SOB
• Restlessness, Anxiety
• Chest Pain
• Copius Sputum (blood tinged)
• RR, Pulse, Dyspnea, Cyanosis

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Therapeutic Interventions Pulmonary Contusion

• Intubation/Mechanical Ventilation
• Bronchoscopy to remove secretions, cellular
  debris
• Fluids, Volume expanders to treat shock
• Pulmonary Artery pressure monitoring