by Charlotte Cooper RN, MSN, CNS

modified by Kelle Howard, RN, MSN

Respiratory Disorders: Pleural & Thoracic Injury

Thoracic Cavity

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Normal Anatomy

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Thoracic cavityChest wallPleural spaceFluid

Terminolgy Pleura

the thin serous membrane around the lungs and inner walls of the chest (2 layers)

Pleural spacethin space between the 2 layers of pleura

Pleural cavitybody cavity that surrounds the lungs

Parietal PleuraPleura 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 FluidpH 7.6 – 7.641-2g/dL proteinLess than 1000 WBC per cubic millimeterGlucose level similar to plasmaLDH less than 50% that of plasmaNa, K+, & Ca levels similar to that of

interstitial fluid

Viceral pleura –Covers surface of the lungCannot 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

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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

Categories for Traumatic Injuries

Blunt trauma

Penetrating trauma

Traumatic Chest Injuries

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Mechanism 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

Respiratory Disorders: Pleural and Thoracic Injury

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

Is it normal to have fluid in this space?Would you consider a pleural effusion a disease?

• ClassificationTransudative aka: hydorthoraces ----- systemic

causesUsually not caused by inflammatory processesMost common type

Exudative ----- localized causeUsually caused by an inflammatory processOften recurrent, difficult to treat

EmpyemaWhat is it?

What causes it?

How do we treat it?

Etiology: Pleural Effusion Identify the Class of Effusion

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Disease Process Classification of Effusion

Heart Failure

TB

Lupus/RA

Renal Disease

Lung Cancer

Trauma

Pneumonia

Liver Failure

Clinical Manifestations: Pleural Effusion

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DyspneaPleurisyDecreased breath soundsDecreased 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

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Thoracentesis Diagnostic vs. Therapeutic

Interventions: Pleural Effusion

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Interventions: Pleural EffusionChest tube placement/PleurX catheter

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Interventions: Pleural Effusion

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Treat underlying condition – CHF/Renal failurePneumoniaLiver DiseaseLupus/RAMalignancy

Pleurodesis

Chest tube insertionAllow to resolve

Complications of Pleural Effusion

Trapped Lung

Recurrent effusions

Pneumothorax

PNEUMOTHORAX3 types

Closed

Open

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

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Clinical Manifestations: Pneumothorax

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Respiratory

Cardiac

Tension Pneumothorax

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Air/blood/fluid rapidly entering the pleural space

Lung collapses

Emergency situation

Pathophysiology: Tension Pneumo

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Increase in intrapleural pressure

Compression of lung

Compresses against trachea, heart, aorta, esophagus

Ventilation and cardiac output greatly compromised

Clinical Manifestations: Tension Pneumo

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Severe dyspneaTracheal deviationDecreased cardiac outputDistended neck veinsIncreased respiratory rateIncreased heart rateDecreased blood pressureShock

Treatment Tension PneumoEmergency --- quick intervention

Needle decompressionChest tube placement

Other TypesHemothorax

Chylothorax

Intervention: Pneumothorax

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High Fowlers positionOxygen as orderedRest to decrease oxygen demand***Chest tube insertionPleurodesisSurgery

?

Clinical Manifestations: Rib Fractures

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Ribs 5-10 most commonly fracturedPainSplinting & Rapid, shallow respirationsDecreased breath soundsCrepitus Signs/symptoms of pneumothorax

Treatment: Rib FracturesReduce or minimize painDo we wrap or bind the chest?Do we use opiods?Goal?

Pathophysiology: Flail Chest

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2 or more ribs fractured

2 or more separate places

Unstable / free floating chest

Usually involves anterior or lateral fx

Paradoxical respirations

Clinical Manifestations: Flail Chest

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Dyspnea with rapid, shallow inspiration

Pain

Palpable crepitus

Decreased breath sounds

Unequal chest expansion

Tachycardia

Interventions: Flail Chest

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Oxygen as orderedElevate HOBAnalgesia SuctionSplint affected side?*Intubation*Mechanical ventilation

Pathophysiology: Pulmonary Contusion

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Abrupt chest compression then rapid decompression

Intra-alveolar hemorrhage

Interstitial/bronchial edema

Decreased surfactant production

Increase pulmonary vascular resistance

Decrease blood flow

Clinical Manifestation: Pulmonary Contusion

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Increased SOBRestlessnessAnxietyChest painCopious sputumIncreased respiratoryIncreased heart rateDyspneaCyanosis

Intervention: Pulmonary Contusion

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IntubationMechanical ventilationBronchoscopy Fluids Volume expandersPulmonary artery pressure monitoring

Chest SurgeriesLewis 593 Table 28-22; NCP 28-2Exploratory thoracotomy

Incision into thorax to look for injured or bleeding tissue

Thoracotomy not involving lungVATS

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