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Respiratory Pleural and Thoracic Injury


Respiratory Pleural and Thoracic Injury Marnie Quick, RN, MSN, CNRN Thoracic cavity Lungs Mediastinum Heart Aorta and great vessels Esophagus Trachea Breathing ... – PowerPoint PPT presentation

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Title: Respiratory Pleural and Thoracic Injury

Respiratory Pleural and Thoracic Injury
  • Marnie Quick, RN, MSN, CNRN

Thoracic cavity
  • Lungs
  • Mediastinum
  • Heart
  • Aorta and great vessels
  • Esophagus
  • Trachea

Breathing inspiration
  • When the diaphragm contracts, it moves down,
    increasing the volume of the thoracic cavity When
    the volume increases, the pressure inside
  • Air moves from an area of higher pressure, the
    atmosphere, to an area of lower pressure, the
  • Pressure within the lungs is called
    intrapulmonary pressure

Breathing exhalation
  • Exhalation occurs when the phrenic nerve stimulus
  • The diaphragm relaxes and moves up in the chest
  • This reduces the volume of the thoracic cavity
  • When volume decreases, intrapulmonary pressure
  • Air flows out of the lungs to the lower
    atmospheric pressure

  • This is normally an unconscious process
  • Lungs naturally recoil, so exhalation restores
    the lungs to their resting position
  • However, in respiratory distress, particularly
    with airway obstruction, exhalation can create
    increased work of breathing as the abdominal
    muscles try to force air out of the lungs

Physics of Gases
  • If two areas of different pressure communicate,
    gas will move from the area of higher pressure to
    the area of lower pressure

Respiratory airways and unit
Pleural anatomy
  • Lungs are surrounded by thin tissue called the
    pleura, a continuous membrane that folds over
  • Parietal pleura lines the chest wall
  • Visceral pleura (pulmonary) covers the lung

Pleural anatomy
Visceral pleura
  • Normally, the two membranes are separated only by
    the lubricating pleural fluid
  • Fluid reduces friction, allowing the pleura to
    slide easily during breathing

Parietal pleura
Intercostal muscles
Normal Pleural Fluid Quantity Approx. 25mL per
Pleural physiology
  • The area between the pleura is called the pleural
    space (sometimes referred to as potential
  • Normally, vacuum (negative pressure) in the
    pleural space keeps the two pleura together and
    allows the lung to expand and contract
  • During inspiration, the intrapleural pressure is
    approximately -8cmH20 (below atmosphere)
  • During exhalation, intrapleural pressure is
    approximately -4cmH20

When pressures are disrupted
Intrapleural pressure -8cmH20
  • If air or fluid enters the pleural space between
    the parietal and visceral pleura, the -4cmH20
    pressure gradient that normally keeps the lung
    against the chest wall disappears and the lung

Intrapulmonary pressure -4cmH20
Pleural injury Pneumothorax
  • Etiology/Patho- air in pleural space
  • Closed
  • Open
  • Tension
  • Clinical manifestations Emergency manag
  • Lewis 586 Table 28-20

Closed Pneumothorax
  • Chest wall is intact
  • Rupture of the lung and visceral pleura allows
    air into the pleural space
  • Spontaneous- no apparent cause (thin individual)
  • Blunt trauma-CPR/fall
  • Penetrating from fractured ribs

Open Pneumothorax
  • Opening in the chest wall
  • Allows atmospheric air to enter/exit the pleural
    space during respiration
  • Penetrating trauma stab, gunshot, impalement

Tension pneumothorax
  • Tension pneumothorax occurs when a closed
    pneumothorax creates positive pressure in the
    pleural space that continues to build
  • That pressure is then transmitted to the
    mediastinum (heart and great vessels)

Mediastinal shift
  • Mediastinal shift occurs when the pressure gets
    so high that it pushes the heart and great
    vessels into the unaffected side of the chest
  • These structures are compressed from external
    pressure and cannot expand to accept blood flow

Conditions requiring chest drainage mediastinal
  • Mediastinal shift can quickly lead to
    cardiovascular collapse
  • The vena cava and the right side of the heart
    cannot accept venous return
  • With no venous return, there is no cardiac output
  • No cardiac output not able to sustain life

Which is more life threatening?
Pleural injury hemothorax
  • Blood in pleural space
  • Caused by trauma lung
  • malignancy pulmonary embolus complication
    anticoagulant therapy
  • Like pneumothorax- lung can collapse
  • Manifestations similar to pneumothorax blood
    loss symptoms dull percussion over blood

Rib fractures
Free floating Rib Fractures may result in a Flail
chest with paradoxic respirations
Pleural effusion
  • Fluid in the pleural space is pleural effusion
  • Transudate is a clear fluid that collects in the
    pleural space when there are fluid shifts in the
    body from conditions such as CHF, malnutrition,
    renal and liver failure
  • Exudate is a cloudy fluid with cells and proteins
    that collects when the pleura are affected by
    malignancy or diseases such as tuberculosis and
    pneumonia. Pus-empyema

Thoracentesis- needle to remove fluid
Collaborative care for pleural/thoracic Injuries
  • Diagnostic tests- chest X-ray CT O2 sats
    ABGs/CBC analysis of aspirated fluid pulmonary
    function studies
  • High Fowlers O2 rest to dec O2 demand
  • Treatment depends on severity
  • Treatment- chest tube
  • Treatment- Heimlich valve on chest tube

Treatment goal for pleural conditions
  • 1. Remove fluid air as promptly as possible
  • 2. Prevent drained air fluid from returning to
    the pleural space
  • 3. Restore negative pressure in the pleural space
    to re-expand the lung

Collaborative Care Treatment of Chest and
thoracic injuries
  • Emergency management chest trauma (Lewis p 586
    Table 28-19)
  • Etiology
  • Assessment
  • Interventions
  • Emergency management thoracic injury (Lewis p 586
    Table 28-20)
  • Clinical manifestations
  • Emergency management

Chest SurgeriesLewis 593 Table 28-22 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

Pleural effusion- common manifestations and
collaborative care
  • Common manifestations
  • Dyspnea, pleuritic pain, dec/absent breath
    sounds, limited chest wall movement
  • Diagnostic tests- Chest X-ray CT analysis of
    aspirated fluid from thoracentesis
  • Treatment-
  • Thoracentesis- insert needle into space to drain
  • Treat underlying cause
  • administer O2

Chest Tubes to remove air fluid
  • Also called thoracic catheters
  • Different sizes
  • From infants to adults
  • Small for air, larger for fluid
  • Different configurations
  • Curved or straight
  • Types of plastic
  • PVC
  • Silicone
  • Coated/Non-Coated
  • Heparin
  • Decrease friction

Chest tube insertion
Choose site
Suture tube to chest
Explore with finger
Place tube with clamp
Photos courtesy
Different placement of chest tubes to remove air
to remove fluid
Chest tubes in place
Prevent air fluid from returning to the pleural
  • Chest tube is attached to a drainage device
  • Allows air and fluid to leave the chest
  • Contains a one-way valve to prevent air fluid
    returning to the chest
  • Designed so that the device is below the level of
    the chest tube for gravity drainage
  • What happens if you clamp the chest tube?

Water suction on left Dry suction rightLewis p.
589 Fig 28-8
Prevent air fluid from returning to the pleural
  • Most basic concept
  • Straw attached to chest tube from patient is
    placed under 2cm of fluid (water seal)
  • Just like a straw in a drink, air can push
    through the straw, but air cant be drawn back up
    the straw

Tube open to atmosphere vents air
Tube from patient
Prevent air fluid from returning to the pleural
  • For drainage, a second bottle was added
  • The first bottle collects the drainage
  • The second bottle is the water seal
  • With an extra bottle for drainage, the water seal
    will then remain at 2cm

Restore negative pressure in the pleural space
  • Many years ago, it was believed that suction was
    always required to pull air and fluid out of the
    pleural space and pull the lung up against the
    parietal pleura
  • However, recent research has shown that suction
    may actually prolong air leaks from the lung by
    pulling air through the opening that would
    otherwise close on its own
  • If suction is required, a third bottle is added

Restore negative pressure in the pleural space
  • The depth of the water in the suction bottle
    determines the amount of negative pressure that
    can be transmitted to the chest, NOT the reading
    on the vacuum regulator

How a chest drainage system works
  • Expiratory positive pressure from the patient
    helps push air and fluid out of the chest (cough,
  • Gravity helps fluid drainage as long as the chest
    drainage system is below the level of the chest
  • Suction can improve the speed at which air and
    fluid are pulled from the chest

From bottles to a box
From patient
To suction
from patient
Suction control bottle
Water seal bottle
Collection bottle
Suction control chamber
Collection chamber
Water seal chamber
From box to bedside
At the bedside
  • Keep drain below the chest for gravity drainage
  • This will cause a pressure gradient with
    relatively higher pressure in the chest
  • Fluid, like air, moves from an area of higher
    pressure to an area of lower pressure
  • Same principle as raising an IV bottle to
    increase flow rate

Setting up the Chest drainage system
  • Follow the manufacturers instructions for adding
    water to the 2cm level in the water seal chamber,
    and to the 20cm level in the suction control
    chamber (unless a different level is ordered)
  • Connect 6' patient tube to thoracic catheter
  • Connect the drain to vacuum, and slowly increase
    vacuum until gentle bubbling appears in the
    suction control chamber

Setting up suction
  • Vigorous bubbling is loud and disturbing to most
  • Will also cause rapid evaporation in the chamber,
    which will lower suction level
  • Too much bubbling is not needed clinically in 98
    of patients more is not better
  • If too much, turn down vacuum source until
    bubbles go away, then slowly increase until they
    reappear, then stop

  • Water seal is a window into the pleural space
  • Not only for pressure
  • If air is leaving the chest, bubbling will be
    seen here
  • Air meter (1-5) provides a way to measure the
    air leaving and monitor over time getting
    better or worse?

Disposable chest drains
  • Collection chamber
  • Fluids drain directly into chamber, calibrated in
    mL fluid, write-on surface to note level and time
    When full will need to change ENTIRE system
  • Water seal
  • One way valve, U-tube design, can monitor air
    leaks changes in intrathoracic pressure
  • Suction control chamber
  • U-tube, narrow arm is the atmospheric vent, large
    arm is the fluid reservoir, system is regulated,
    easy to control negative pressure

Portable chest drainage system
What about dependent loops?
If chest tube comes out? Three sided taped gauze
Nursing assessment and pertinent nursing
  • Health history-respiratory disease, injury,
    smoking, progression of symptoms
  • Physical exam- degree of apparent resp distress,
    lung sounds, O2 sat, VS, LOC, neck vein
    distention, position of trachea
  • All require observation for lung symptoms
  • Pertinent nursing problems
  • Acute pain
  • Ineffective airway clearance
  • Impaired gas exchange
  • Home care
  • Nursing Care Plans Thoracotomy 28-2 Chest tube

Atrium chest video -Website
  • If desire more information go to the website
  • Once on website- go to the bottom of the page and
    select video player to view videos
  • http//

Est of thoracic expansionA. ExhalationB.
Maximal inhalation
Normal auscultatory sounds
Lung percussions areas sounds