Pneumothorax

• Left-sided pneumothorax (on the

Pathophysiology:
• “Accumulation of air
or gas in the pleural
cavity”
right side of the image) on CT
scan of the chest with chest tube
in place.
 Pneumothorax
Anatomy Review-
Pleural cavity
• Visceral pleura
– Encases lungs
• Pleural space/cavity
– Area between pleura
– Contains fluid (4ml)
– Fluid prevents friction
– Fluid circulated by…
• lymph system
• Parietal pleura
– Lines chest wall
 Pneumothorax
Anatomy review - Breathing
• Diaphragm &
accessory muscles
move outward 
• Negative pressure in the
thoracic cavity 
• Negative pressure pulls
air into the lungs via the
nose and mouth
• Diaphragm & accessory
muscle relax ( ) 
• air exhaled
 Pneumothorax
• If the visceral pleural
is perforated or the
chest wall & parietal
pleural are
perforated
– air enters the pleural
space 
– negative pressure is
lost 
– Lung on the affected
side collapses
 Pneumothorax
• An abnormal chest x-ray shows the presence of an air pocket (arrows) in the pleural sac
surrounding one lung, which has collapsed. This finding is typical of a severe
pneumothorax. A normal chest x-ray is shown on the right for comparison; the heart (H),
lungs (L), vertebrae (v), and collarbone (C) can be seen.
 Pneumothorax
Classifications of
pneumothorax
• Spontaneous
pneumothorax
– with out injury
– Air enters the pleural
cavity via the airway
– Farther classified as:
• Primary
• Secondary
 Pneumothorax
Spontaneous (Primary)
Pneumothorax
• Pt. with no known
lung disease.
• D/T a rupture of a
bulla in the lung.
• Most often tall, thin
men between 20 and
40 years old.
 Pneumothorax
Spontaneous Secondary
Pneumothorax
• occurs in pt. with known
lung disease
– most often COPD
• Other lung diseases
commonly assoc. with
– Tuberculosis
– Pneumonia
– Asthma
– lung cancer
• Often severe & life
threatening
 Pneumothorax
• Traumatic
Pneumothorax
– D/T injury to the
chest wall
– Further classified as
Open or closed
 Pneumothorax
Open Pneumothorax
• Air enters pleural cavity
via outside
• A free communication
between the exterior and
the pleural space as
through an open wound
– blowing wound
– sucking wound
• may be caused by a
penetrating injury
– stab wound,
– gunshot wound
– impaled object
 Pneumothorax
Closed pneumothorax
• Air enters the pleural
cavity via lungs
• D/t/ blunt chest
trauma
– Car crash
– Fall
– Crushing chest injury
 Pneumothorax
Iatrogenic
pneumothorax
• D/T procedure /
treatment
 Pneumothorax
Tension Peumothorax
• air accumulates in the pleural
space with each breath.
• The remorseless increase in
intrathoracic pressure 
• massive shifts of the
mediastinum away from the
affected lung 
• compressing intrathoracic
vessels 
• cardiovascular collapse
 Pneumothorax
Tension
Pneumonthorax
• a piece of tissue
forms a one-way
valve that allows air to
enter the pleural
cavity but not to
escape, overpressure
can build up with
every breath
Pneumothorax
 Pneumothorax
Etiology / Contributing factors
• Spontaneous
– Lung disease - COPD
– Tall, thin men
• Traumatic
– A penetrating chest wound
– Barotrauma
• scuba divers
• Iatrogenic Pneumothorax
– * insertion of a central line
– * thoracic surgery
– * thoracentesis
– * pleural or transbronchial
biopsy.
 Pneumothorax
Clinical Manifestations (all
types)
• Sudden sharp chest pain
• Asymmetrical chest
expansion
• dyspnea
• Cyanosis
• Percussion
– Hyper resonance or
tympany
• Breath sounds
– diminished
– Absent
 Pneumothorax
Clinical
Manifestations (all
types)
• Respiratory distress
• O2 Sats
– decreased
• Tachypnea
• Tachycardia
• Restlessness/ Anxiety
 Pneumothorax
S&S of open
pneumothorax
• Crepitus
– (subcutaneous
emphysema)
• Sucking chest
wound”
 Pneumothorax
S&S Tension pneumothorax
cardiac output
• Hypotension
• Tachycardia
(compensatory)
• Tachypnea
• Mediastinal shift and
tracheal deviation
– To the unaffected side
• Cardiac arrest
• Distended neck veins
 Pneumothorax
Dx exam and tests
• HX & PE
• Chest x-ray
• ABG’s
– Initial PaCO2
• Decreased
• respiratory alkalosis
– Later ABG’s
• Hypoxemia
• Hypercapnia
• Acidosis
 Pneumothorax
Treatment - First aid:
Open pneumothorax
• Cover immediately
with an occlusive
dressing, made air-
tight with petroleum
jelly or clean plastic
sheeting.
 Pneumothorax
Tx: Small
pneumothorax
• Spontaneous
recovery
– Bed rest
– resolve on its own in
1 to 2 weeks
• Remove with small
bore needle inserted
into the pleural
space
 Pneumothorax
Tx: Larger
pneumothorax
• Chest tube
• Surgery repair
• Pleurodesis
– “glue”
– Very painful
– Prep with analgesic
• O2
• Surgery
 Pneumothorax
Nursing interventions
• Closely monitor resp
status • Notify MD for:
• Frequent assess – SpO2 < 90% or
– LOC Change Greater
– Color Than 5%
– VS – Respiratory Distress
– Chest pain?
– Restlessness?
– Inadequate Sedation
• Chest Tube  Peak Airway
• Rest/Activity Balance Pressure (Especially
• Sedation with Pressure
• Provide a means for Control Mode)
communicate
• Educate patient & family
 Pneumothorax
Complications
• Recurrent
pneumothorax
– D/C
• smoking
• high altitudes
• scuba diving
• flying in
unpressurized
aircrafts
• Cardiac damage
 Question?
A client who has been on a ventilator for two
days experiences acute respiratory
distress accompanied by distended neck
veins. The best action of the nurse is to:
B. hand ventilate the client.
C. prepare for chest tube insertion.
D. call the physician immediately.
E. perform emergency chest
decompression.
• The question is asking what the nurse should do when a
client on a ventilator has these symptoms. When acute
respiratory distress occurs along with neck vein
distension, cyanosis and tracheal shift are evident, a
tension pneumothorax has probably occurred. The client
should be removed from the machine and ventilated by
hand. Then the physician should be notified (option c).
Equipment for chest tube insertion should be gathered
(option b) so it will be ready for immediate use by the
physician. Emergency chest decompression (option d)
should only be attempted after specific training and if the
physician will be delayed.
 Small Group Questions
1. What is the pathophysiology of a
pneumothorax?
2. Describe the anatomy of the pleural
membrane (including nerves endings)
3. What is a spontaneous pneumothorax?
4. What are some examples of an iatrogenic
pneumothorax?
5. Define an open and closed pneumothorax.
 Small Group Questions
1. Describe the mediastial shift in an
pneumothorax.
2. What is the first aid treatment of a traumatic
pneumothorax (include assessment)
3. What is Pleurodesis?
4. What ABG’s would you expect to see late in a
patient with a pneumothorax?