Respiratory Disorders: Pleural & Thoracic Injury

by Charlotte Cooper RN, MSN, CNS

modified by Kelle Howard, RN, MSN

Thoracic Cavity

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Normal Anatomy

• Thoracic cavity• Chest wall• Pleural space• Fluid

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Terminolgy

• Pleura– the thin serous membrane around the lungs and inner walls of the

chest (2 layers)• Pleural space

– thin space between the 2 layers of pleura• Pleural cavity

– body cavity that surrounds the lungs• Parietal Pleura

– Pleura that lines the inner chest walls and covers the diaphragm• Viceral Pleura

– Pleura that lines the lung itself

• Pleural Fluid– pleura that lines the inner chest wall and covers the diaphragm

Pleural Fluid

• pH 7.6 – 7.64• 1-2g/dL protein• Less than 1000 WBC per cubic millimeter• Glucose level similar to plasma• LDH less than 50% that of plasma• Na, K+, & Ca levels similar to that of interstitial

fluid

• Viceral pleura –– Covers surface of the lung– Cannot be disected away from the lung

• Parietal pleura-– Lines the wall of the chest and covers the diaphragm

http://www.themesotheliomalibrary.com/pleural-effusions.JPG

Chest Trauma & Thoracic Injury

• 20-25% of trauma victims with chest trauma die

• 45% of trauma victims have some type of chest trauma

• BEWARE: External injury may appear minor

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Categories for Traumatic Injuries

• Blunt trauma

• Penetrating trauma

Traumatic Chest InjuriesMechanism of Injury Common Related Injury

Blunt TraumaBlunt steering wheel injury to chest Rib fractures, flail chest, pneumothorax,

hemopneumothorax, myocardial contusion, pulmonary contusion, cardiac tamponade, great vessel tears

Shoulder harness seat belt injury Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, pericardial contusion, cardiac tamponade

Crush injury (heavy equipment, crushing the thorax)

Pneumothorax and hemopneumothorax, flail chest, great vessel tears and rupture, decreased blood return to heart with decreased cardiac output

Penetrating traumaGunshot, stab wound to chest Open pneumothorax, tension pneumothorax,

hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears 9

Respiratory Disorders: Pleural and Thoracic Injury

• Pleural Effusion• A collection of excess fluid in the pleural space

• Classification• Transudative aka: hydorthoraces ----- systemic causes

– Usually not caused by inflammatory processes– Most common type

• Exudative ----- localized cause– Usually caused by an inflammatory process– Often recurrent, difficult to treat

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Empyema

• What is it?

• What causes it?

• How do we treat it?

Etiology: Pleural Effusion Identify the Class of Effusion

Disease Process Classification of Effusion

Heart Failure

TB

Lupus/RA

Renal Disease

Lung Cancer

Trauma

Pneumonia

Liver Failure

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Other Types

• Hemothorax

• Chylothorax

Clinical Manifestations: Pleural Effusion

• Dyspnea• Pleurisy• Decreased breath sounds• Decreased chest wall movement • Dullness on percussion

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How do we diagnosis pleural effusions?

Pleural Effusion -- Diagnositcs

• ____________• ____________• ____________• ____________

How do we know what type of

pleural effusion it is?

Interventions: Pleural Effusion

• Thoracentesis Diagnostic vs. Therapeutic

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Interventions: Pleural Effusion

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Thoracentesis

• What are your nursing responsibilities pre & post thoracentesis?– ______________– ______________– ______________– ______________– ______________– ______________

Interventions: Pleural EffusionChest tube placement/

PleurX catheter

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Interventions: Pleural Effusion

Treat underlying condition CHF/Renal failurePneumoniaLiver DiseaseLupus/RAMalignancyPleurodesis

Chest tube insertionAllow to resolve

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Complications of Pleural Effusion

• Trapped Lung

• Recurrent effusions

• Pneumothorax

PNEUMOTHORAX

• 3 types– Closed

– Open• aka? __________________

– Iatrogenic

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, COPD, fractured ribs that penetrate the pleura.

Occurs in stabbings, gunshot wounds, impalement injury.

Occurs in central line placement, thoracentesis, lung biopsy, bronchoscopy, & mechanical ventilation, central line placement 26

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Clinical Manifestations: Pneumothorax

• Describe what you would see:– Respiratory

– Cardiac

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Tension Pneumothorax

• Air/blood/fluid rapidly entering the pleural space

• Lung collapses

• Emergency situation

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Pathophysiology: Tension PneumoIncrease in intrapleural pressure

Compression of lung

Compresses against trachea, heart, aorta, esophagusWhat is this called?

Ventilation and cardiac output greatly compromised

__________________________

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Clinical Manifestations: Tension Pneumo

• Severe dyspnea• Tracheal deviation• Decreased cardiac output• Distended neck veins• Increased respiratory rate• Increased heart rate• Decreased blood pressure• Shock

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Treatment Tension Pneumo

• Emergency --- quick intervention– Needle decompression– Chest tube placement

Intervention: Pneumothorax

• High Fowlers position• Oxygen as ordered• Rest to decrease oxygen demand• ***Chest tube insertion• Pleurodesis• Surgery

?

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Clinical Manifestations: Rib Fractures

• Ribs 5-10 most commonly fractured• Pain• Splinting & rapid, shallow respirations• Decreased breath sounds• Crepitus • Signs/symptoms of pneumothorax

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Treatment: Rib Fractures

• Reduce or minimize pain• Do we wrap or bind the chest?• Do we use opiods?• Goal?

Pathophysiology: Flail Chest• 2 or more ribs fractured

• 2 or more separate places

• Unstable / free floating chest

• Usually involves anterior or lateral fx

• Paradoxical respirations

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Clinical Manifestations: Flail Chest• Dyspnea with rapid, shallow inspiration

• Pain

• Palpable crepitus

• Decreased breath sounds

• Unequal chest expansion

• Tachycardia

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Interventions: Flail Chest

• Oxygen as ordered• Elevate HOB• Analgesia • Suction• Splint affected side?• *Intubation• *Mechanical ventilation

• What do you think the major goals are?

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Pathophysiology: Pulmonary Contusion

Abrupt chest compression then rapid decompression

Intra-alveolar hemorrhage

Interstitial/bronchial edema

Decreased surfactant production

Increase pulmonary vascular resistance

Decrease blood flow

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Clinical Manifestation: Pulmonary Contusion

• Increased SOB• Restlessness• Anxiety• Chest pain• Copious sputum• Increased respiratory• Increased heart rate• Dyspnea• Cyanosis

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Intervention: Pulmonary Contusion

• Intubation• Mechanical ventilation• Bronchoscopy • Fluids • Volume expanders• Pulmonary artery pressure monitoring

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Chest SurgeriesLewis 573 Table 28-24; NCP 28-2

• Exploratory thoracotomy– Incision into thorax to look for injured or bleeding

tissue

• Thoracotomy not involving lung• VATS

– Video-assisted thoracic surgery to do lung biopsy, lobectomy, ect