Pneumothorax, and then, Pulmonary Edema

Bryan AbadillaSRTACC, ONT RT-13

What is a Pneumothorax? • Definition:

• A Pneumothorax can be defined as a collapsed lung due to excess air in the pleural space which is between your lung and the chest wall. The excess air causes pressure against your lungs which causes it to collapse.

• Symptoms:• Sudden chest pain• Shortness of breath

• Causes:• Chest injury• Lung disease• Blebs (surgery?) • Mechanical ventilation ? How ?

Ref: Mayoclinic.org

What is a Pneumothorax contd. • Diagnosis:• CXR/CT for confirmation

• Treatment:• Small pneumothorax? • Needle aspiration• Chest tube• Surgery

• Prognosis:• Small pneumothorax will heal on it’s own. • If previous pneumothorax has occurred the more

likely it can occur again.

Ref: Mayoclinic.org

http://www.unboundedmedicine.com/images/Tension%20type%20Pneumothorax.jpg

What is Pulmonary Edema?• Definition:

• Fluid retention in the alveoli causing swelling of the lungs.

• Symptoms:• Shortness of breath• Pink frothy secretions• Tachypnea• Peripheral Edema (pitting)• Hypoxemia• Auscultation – rails/crackles

• Causes:• ARDS• Pneumothorax (Re-expansion

pulmonary edema)*• CHF• Kidney Failure

Ref: medicinenet.com

What is Pulmonary Edema contd. • Diagnosis:• Cardiogenic vs Noncardiogenic• CXR: Significant opacification (white)• Bat wing

• Treatment:• Diuretics• Mild edema: Oral medication• Severe edema: Hospitalization +

diuretics via IV. • Oxygen therapy• Positive pressure• Bipap/Cpap

Ref: medicinenet.com

http://medicalpicturesinfo.com/pulmonary-edema/

Patient Data

• 58 yr, 5’8” 230lb Latino Male arrives in ER• Complains of chest discomfort and SOB. • Hx:• States no hx of hospitalization or pulmonary issues.• First time ever being in a hospital with lung

problems. • Used to work construction with roofing (tar?)• Non-smoker• Works as a painter

Initial Assessment• Shortness of breath• Peripheral edema• Skin is cool & dry• Alert• Breath sounds: • Right = diminished, Left = wheeze

• HR: 96, RR: 24, BP: 128/84, SpO2: 92% RA• Placed Pt on 2L NC, SpO2 improved to 97%

Lab findings

• Na: 139 K+: 4.2 Cl: 103• BUN: 34 WBC: 14.4

• pH: 7.50• PaCO2: 31mmHg• PaO2: 90mmHg• Hco-3: 23.4 mEq/L• Interpretation: Uncompensated Respiratory

Alkalosis

Day 1• Doctor’s orders:

• CXR• Pneumothorax on the right

• ABG• Admitted to hospital• TX: Chest tube thoracotomy placement• Monitor patient during and after procedure is finished• Duoneb 2.5mg Q4 • LevoFloxacin drip 500mg/hr• Feratab 324 mg Tab PO

• Assessment• Pt is recovering from chest tube thoracotomy• Semi-fowler• HR: 94, BP: 126/88, RR: 26, SpO2: 98% 3L NC• Breath sounds: Right = Diminished Left = wheezing• Shortness of breath

Ref: rxlist.com

Day 2• Doctors Orders

• CXR• Bilateral haziness. Indication for?

• BiPap: Ipap 12 Epap 8 PS 4• Lasix 20mg tab Qd• Norvasc 5mg tab QD• Continue Duoneb tx Q4• Metronidazole 7.5 mg Q6• Magnesium Sulfate 2g continuous IV

• Assessment• Pt is in semi-fowler position on 3L NC• HR: 90, BP: 128/86, RR: 24, SpO2 95%• Breath sounds: Late inspiratory crackles• Non-productive strong cough

• BiPaP Trial• Placed pt on BiPap w/ IPAP 12 and EPAP 8. • Doctor ordered for pt to wear as long as he could• Pt only tolerated for 15 mins• c/o too hot

• Turned off humidifier• Still “too hot”

Ref: rxlist.com

Day 3• Doctor’s orders

• Continue Duoneb Q4• Continue Lasix QD• Continue Norvasc QD• BiPap QHS/NOC• Monitor patient

• Assessment • Pt in semi-fowler position• HR: 92, BP: 130/87, RR: 24, SpO2 98% 3L NC• Breath sounds: Diminished/clear • Refuses to wear bipap

Medication List

Ref: rxlist.com

Name Class Dosage Indication

Feratab Iron Supplement 324mg Tab p.c. Iron deficiency

Lasix Diuretic 20mg Tab QD Pulmonary edema, fluid retention

Norvasc Dihydropyridine 5mg Tab QD Hypertension

LevoFloxacin Fluoroquinolones (antibiotic)

500mg/hr IV Tx infection

Metronidazole Nitroimidazoles (antibiotic)

7.5 mg Q6 Tx infection

Magnesium Sulfate Antidysrhythmic 2g continuous IV Tx arrhythmias

Duoneb Beta-2 adrenergic bronchodilator

2.5mg Albuterol/0.5mg Ipratropium Bromide in 3ml Q4

Bronchospasm. Help keep patent airway

Overall summary and conclusion• Pt arrives c/o chest pain and SOB• Assessment revealed wheezing and diminished breath sounds• CXR ordered revealing pneumothorax on right side• Doctor orders chest tube thoracotomy• Pt is now receiving Duoneb Tx Q4• Later findings reveal inspiratory crackles• Doctor orders another CXR revealing bilateral haziness; pulmonary edema• Patient is given Lasix and ordered to be put on Bipap to help flush out fluid in alveoli• Bipap settings of IPAP 12 EPAP 8• Patient can only tolerate BiPap for 15 minutes c/o: Can’t breath it’s too hot• Tried removing humidifier but still same results• Doctor orders BiPap NOC/QHS but patient refuses• Continue to monitor patient with Duoneb tx Q4 and Lasix • Monitor patient

• Reocurring pneumothorax• Keep SpO2 > 92%• Monitor WBC

Resources• Web:

• http://www.mayoclinic.org/diseases-conditions/pneumothorax/home/ovc-20179880 • http://www.medicinenet.com/pulmonary_edema/article.htm• http://www.rxlist.com (for medication classifications)

• Photos: • http://www.unboundedmedicine.com/images/Tension%20type%20Pneumothorax.jpg • http://medicalpicturesinfo.com/pulmonary-edema/ • http://

www.doctortipster.com/3895-cardiogenic-acute-pulmonary-edema-causes-symptoms-diagnosis-and-treatment.html

• https://upload.wikimedia.org/wikipedia/commons/4/46/Blausen_0742_Pneumothorax.png