Respiratory Disorders: Pleural and Thoracic Injury

1. Respiratory Disorders: Pleural and Thoracic Injury by Charlotte Cooper RN, MSN, CNS modified by Kelle Howard RN, MSN Modified by Darlene “Cookie” Wilson, RN, MSN

2. Thoracic Cavity http://www.google.com/imgres?imgurl=http://www.tcnj.edu/~mckinney/body.jpg&imgrefurl=http://www.tcnj.edu/~mckinney/breathing.htm&h=480&w=460&sz=60&tbnid=7I0hIqYYrrrEDM:&tbnh=129&tbnw=124&prev=/images%3Fq%3Dthoracic%2Bcavity&usg=__64_qfRrbnmkZHJsDtcpsNyD-QUk=&ei=HjqESrfvF4eosgPnloGqBw&sa=X&oi=image_result&resnum=4&ct=image

3. Normal Anatomy • Thoracic cavity • aka? • Chest wall • Pleural space • aka? • Fluid What is this fluid called?

4. Terminology • 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 • Visceral Pleura • Pleura that lines the lung itself • Pleural Fluid • pleura that lines the inner chest wall and covers the diaphragm

5. 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 • How much pleural fluid is in the pleural space?

6. Visceral pleura –(Pulmonary Pleura) • Covers surface of the lung • Cannot be dissected away from the lung • Parietal pleura- • Lines the wall of the chest and covers the diaphragm http://www.themesotheliomalibrary.com/pleural-effusions.JPG

7. Cross-section of Chest

8. 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

9. Categories for Traumatic Injuries • Blunt trauma • Penetrating trauma Give some examples?

10. Traumatic Chest Injuries

12. Respiratory Disorders: Pleural and Thoracic Injury • 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? • Classification • Transudative ----- 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

13. Empyema • What is it? • What causes it? • How do we treat it?

14. Etiology: Pleural EffusionIdentify the Class of Effusion

15. Etiology: Pleural EffusionIdentify the Class of Effusion

16. Clinical Manifestations: Pleural Effusion • Dyspnea • O2 sats? • Pleurisy • What is this? • Decreased breath sounds • Why? • Decreased chest wall movement • Why? • Dullness on percussion • Why?

18. How do we diagnosis pleural effusions?

19. Pleural Effusion -- Diagnositcs • CXR --- how will the order be written? • Thoracic CT • Chest Ultrasound – why would we need to do this? • Thoracentesis • For the CHF pt – what do you think his CXR will show?

20. http://emedicine.medscape.com/article/807375-media

22. How do we know what type of pleural effusion it is?

23. Interventions: Pleural Effusion • Thoracentesis Diagnostic vs. Therapeutic

24. Interventions: Pleural Effusion What are your nursing responsibilities post thoracentesis?

25. Interventions: Pleural EffusionChest tube placement/PleurX catheter

26. Interventions: Pleural Effusion • Treat underlying condition – especially in transudative • CHF/Renal failure • Pneumonia • Liver Disease • Lupus/RA • Malignancy • Pleurodesis (what is this?) • Parietal Pleurectomy • Chest tube/indwelling catheter insertion • Allow to resolve • when would this be an option?

27. Complications of Pleural Effusion • Trapped Lung • What is this? • Recurrent effusions • Why does this happen? • Pneumothorax

28. Empyema causing trapped lung

29. PNEUMOTHORAX • 3 types • Closed • Open • aka? • What nursing interventions do we implement? • Iatrogenic • What does this mean?

31. What type of pneumo would this trauma cause?

32. ww What is a bleb? What type of pneumo would this cause? http://images.google.com/imgres?imgurl=http://graphics8.nytimes.com/images/2007/08/01/health/adam/15210.jpg&imgrefurl=http://www.nytimes.com/slideshow/2007/08/01/health/100150Pneumothoraxseries_4.html&usg=__VZn79dHtqdr7izJf1jBM0r5R4ig=&h=320&w=400&sz=44&hl=en&start=3&sig2=06HaoI7v1pH1SPxnpU_4Vg&um=1&tbnid=l0LTfAdhVxUVSM:&tbnh=99&tbnw=124&prev=/images%3Fq%3Dblebs%2Bon%2Blungs%2Bcausing%2Bpneumothorax%26hl%3Den%26rlz%3D1T4DMUS_enUS282US282%26sa%3DN%26um%3D1&ei=lGWJSvXaGIawtAOVxtidBw

33. Clinical Manifestations: Pneumothorax • Respiratory • Describe these manifestations • Cardiac • Describe these manifestations Manifestations are dependent upon what?

34. Tension Pneumothorax • Air/blood/fluid rapidly entering the pleural space • Lung collapses • Emergency situation What is the emergency here? Does it occur in open or closed pneumos?

35. Pathophysiology: Tension Pneumo • Increase in intrapleural pressure • Compression of lung • Compresses against trachea, heart, aorta, esophagus • Ventilation and cardiac output greatly compromised Medical EMERGENCY

36. Clinical Manifestations: Tension Pneumothorax • Severe dyspnea • Tracheal deviation • Decreased cardiac output • Distended neck veins • Increased respiratory rate • Increased heart rate • Decreased blood pressure • Shock

37. Treatment Tension Pneumothorax • Emergency --- quick intervention • Needle decompression • Chest tube placement

38. Other Types • Hemothorax • Chylothorax

39. Intervention: Pneumothorax • High Fowlers position • Oxygen as ordered • Rest to decrease oxygen demand • ***Chest tube insertion • Pleurodesis • Surgery What about open pneumo? How do we resolve tension pneumos?

40. Review - Patho • http://www.youtube.com/watch?v=Hn0SHGuUVak&NR=1

41. Clinical Manifestations: Rib Fractures • Ribs 5-10 most commonly fractured • Why? • Pain • On inspiration or expiration? • Splinting & Rapid, shallow respirations • What is a complication of this? • Decreased breath sounds • Crepitus • Signs/symptoms of pneumothorax

42. Treatment: Rib Fractures • Reduce or minimize pain • Do we wrap or bind the chest? • Do we use opiods? • Goal?

43. 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

44. Free floating Rib Fractures may result in a Flail chest with paradoxic respirations

45. Rib fractures http://www.youtube.com/watch?v=snqrcB30ZXQ

46. Clinical Manifestations: Flail Chest • Dyspnea with rapid, shallow inspiration • Pain • Palpable crepitus • Decreased breath sounds • Unequal chest expansion • Tachycardia Is flail chest always apparent in all patients?

47. Interventions: Flail Chest • Oxygen as ordered • Elevate HOB • *Analgesia • Suction • Splint affected side? • *Intubation • *Mechanical ventilation GOAL?

48. 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

49. Pulmonary Contusion

50. Clinical Manifestation: Pulmonary Contusion • Increased SOB • Restlessness • Anxiety • Chest pain • Copious sputum • Increased respiratory • Increased heart rate • Dyspnea • Cyanosis