Pneumothorax

Copyright © 2006 by Mosby, Inc.Slide 1
PneumothoraxPneumothorax
GA
DD
CL
Dr.Njia Brg Ellil

Anatomic Alterations of the LungsAnatomic Alterations of the Lungs
 Lung collapseLung collapse
 AtelectasisAtelectasis
 Chest wall expansionChest wall expansion
 Compression of the great veins andCompression of the great veins and
decreased cardiac venous returndecreased cardiac venous return

Etiology—3 WaysEtiology—3 Ways
 From the lungs through a perforation of theFrom the lungs through a perforation of the
visceral pleuravisceral pleura
 From the surrounding atmosphere through aFrom the surrounding atmosphere through a
perforation of the chest wall and parietalperforation of the chest wall and parietal
pleura or, rarely, through an esophagealpleura or, rarely, through an esophageal
fistula or a perforated abdominal viscusfistula or a perforated abdominal viscus
 From gas-forming microorganisms in anFrom gas-forming microorganisms in an
empyema in the pleural space (rare)empyema in the pleural space (rare)

Pneumothorax ClassificationsPneumothorax Classifications
General TermsGeneral Terms
 Closed pneumothoraxClosed pneumothorax
 Open pneumothoraxOpen pneumothorax
 Tension pneumothoraxTension pneumothorax

Pneumothorax ClassificationsPneumothorax Classifications
Based on OriginBased on Origin
 Traumatic pneumothoraxTraumatic pneumothorax
 Spontaneous pneumothoraxSpontaneous pneumothorax
 Iatrogenic pneumothoraxIatrogenic pneumothorax

Spontaneous PneumothoraxSpontaneous Pneumothorax

Iatrogenic PneumothoraxIatrogenic Pneumothorax

Overview of the CardiopulmonaryOverview of the Cardiopulmonary
Clinical Manifestations AssociatedClinical Manifestations Associated
with PNEUMOTHORAXwith PNEUMOTHORAX
The following clinical manifestations result fromThe following clinical manifestations result from
the pathophysiologic mechanisms caused (orthe pathophysiologic mechanisms caused (or
activated) byactivated) by AtelectasisAtelectasis

Clinical Data Obtained at theClinical Data Obtained at the
Patient’s BedsidePatient’s Bedside
Vital signsVital signs
 Increased respiratory rateIncreased respiratory rate
 Stimulation of peripheral chemoreceptorsStimulation of peripheral chemoreceptors
 Other possible mechanismsOther possible mechanisms
• Decreased lung complianceDecreased lung compliance
• Activation of the deflation receptorsActivation of the deflation receptors
• Activation of the irritant receptorsActivation of the irritant receptors
• Stimulation of the J receptorsStimulation of the J receptors
• Pain/anxietyPain/anxiety
 Increased heart rate, cardiac output, blood pressureIncreased heart rate, cardiac output, blood pressure

Clinical Data Obtained at theClinical Data Obtained at the
Patient’s BedsidePatient’s Bedside
 CyanosisCyanosis
 Chest assessment findingsChest assessment findings
 Hyperresonant percussion note over theHyperresonant percussion note over the
pneumothoraxpneumothorax
 Diminished breath sounds over the pneumothoraxDiminished breath sounds over the pneumothorax
 Tracheal shiftTracheal shift
 Displaced heart soundsDisplaced heart sounds
 Increased thoracic volume on the affected sideIncreased thoracic volume on the affected side
• Particularly in tension pneumothoraxParticularly in tension pneumothorax

Clinical Data Obtained fromClinical Data Obtained from
Laboratory Tests and SpecialLaboratory Tests and Special
ProceduresProcedures

Pulmonary Function Study:Pulmonary Function Study:
Lung Volume and Capacity FindingsLung Volume and Capacity Findings
VT RV FRC TLC
N or ↓ ↓ ↓ ↓
VC IC ERV RV/TLC%
↓ ↓
↓ N
VT RV FRC TLC
N or ↓ ↓ ↓ ↓
VC IC ERV RV/TLC%
↓ ↓
↓ N

Arterial Blood GasesArterial Blood Gases
Small PneumothoraxSmall Pneumothorax
 Acute alveolar hyperventilation withAcute alveolar hyperventilation with
hypoxemiahypoxemia
pH PaCO2 HCO3
-
PaO2
↑ ↓ ↓ (Slightly) ↓

Time and Progression of Disease
100
50
30
80
0
PaCO
2
10
20
40
Alveolar Hyperventilation
60
70
90 Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Point at which PaO2
declines enough to
oxygen receptors
PaO2
Disease OnsetPaO2orPaCO2

Arterial Blood GasesArterial Blood Gases
Large PneumothoraxLarge Pneumothorax
 Acute ventilatory failure with hypoxemiaAcute ventilatory failure with hypoxemia
pH PaCO2 HCO3
-
PaO2
↓ ↑ ↑ (Slightly) ↓

Time and Progression of Disease
100
50
30
80
0
PaO
2
10
20
40
Alveolar Hyperventilation
60
70
90
Point at which PaO2
declines enough to
oxygen receptors
Point at which PaO2
declines enough to
oxygen receptors
PaCO 2
Acute Ventilatory FailureDisease Onset
Point at which disease
becomes severe and patient
begins to become fatigued
Point at which disease
becomes severe and patient
begins to become fatigued
Pa02orPaC02

Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph
 Increased translucencyIncreased translucency
 Mediastinal shift to unaffected sideMediastinal shift to unaffected side
in tension pneumothoraxin tension pneumothorax
 Depressed diaphragmDepressed diaphragm
 Lung collapseLung collapse
 AtelectasisAtelectasis

A B

General Management ofGeneral Management of
 >20%—gas should be evacuated>20%—gas should be evacuated
 Negative pressure—5 to 12 cm HNegative pressure—5 to 12 cm H22OO
 Should not exceed negative 12 cm HShould not exceed negative 12 cm H22OO

Respiratory care treatment protocolsRespiratory care treatment protocols
 Oxygen therapy protocolOxygen therapy protocol
 Hyperinflation therapy protocolHyperinflation therapy protocol
 Mechanical ventilation protocolMechanical ventilation protocol

PLEURODESISPLEURODESIS
 Chemical or medication injected into theChemical or medication injected into the
chest cavitychest cavity
 TalcTalc
 TetracyclineTetracycline
 Bleomycin sulfateBleomycin sulfate
 Produces inflammatory reaction betweenProduces inflammatory reaction between
lungs and inner chest cavitylungs and inner chest cavity
 Causes lung to stick to chest cavityCauses lung to stick to chest cavity

Conditions requiring chestConditions requiring chest
drainagedrainage
Air between the pleuraeAir between the pleurae
is ais a pneumothoraxpneumothorax

Conditions requiring chestConditions requiring chest
drainagedrainage
Blood in the pleuralBlood in the pleural
space is aspace is a hemothoraxhemothorax

Conditions requiring chest drainageConditions requiring chest drainage
Transudate or exudateTransudate or exudate
in the pleural space is ain the pleural space is a
pleural effusionpleural effusion

Conditions requiring chest drainage:Conditions requiring chest drainage:
 PneumothoraxPneumothorax
 Occurs when there is an opening on the surface ofOccurs when there is an opening on the surface of
the lung or in the airways, in the chest wall — orthe lung or in the airways, in the chest wall — or
bothboth
 The opening allows air to enter the pleural spaceThe opening allows air to enter the pleural space
between the pleurae, creating an actual spacebetween the pleurae, creating an actual space

open pneumothoraxopen pneumothorax
 Open pneumothoraxOpen pneumothorax
 Opening in the chestOpening in the chest
wall (with or withoutwall (with or without
lung puncture)lung puncture)
 Allows atmospheric airAllows atmospheric air
to enter the pleuralto enter the pleural
spacespace
 Penetrating trauma:Penetrating trauma:
stab, gunshot,stab, gunshot,
impalementimpalement
 SurgerySurgery

Conditions requiring chest drainage: closedConditions requiring chest drainage: closed
 Closed pneumothoraxClosed pneumothorax
 Chest wall is intactChest wall is intact
 Rupture of the lungRupture of the lung
and visceral pleura (orand visceral pleura (or
airway) allows air intoairway) allows air into
the pleural spacethe pleural space

Conditions requiring chest drainage: openConditions requiring chest drainage: open
 AnAn open pneumothoraxopen pneumothorax is also called a “suckingis also called a “sucking
chest wound”chest wound”
 With the pressure changes in the chest thatWith the pressure changes in the chest that
normally occur with breathing, air moves in andnormally occur with breathing, air moves in and
out of the chest through the opening in the chestout of the chest through the opening in the chest
wallwall
 Looks bad and sounds worse, but the openingLooks bad and sounds worse, but the opening
acts as a vent so pressure from trapped airacts as a vent so pressure from trapped air
cannot build up in the chestcannot build up in the chest

Conditions requiring chest drainage: closedConditions requiring chest drainage: closed
 In aIn a closedclosed
pneumothoraxpneumothorax, a, a
patient who is breathingpatient who is breathing
spontaneously canspontaneously can
have an equilibration ofhave an equilibration of
pressures across thepressures across the
collapsed lungcollapsed lung
 The patient will haveThe patient will have
symptoms, but this issymptoms, but this is
not life-threateningnot life-threatening

tension pneumothoraxtension pneumothorax
 AA tension pneumothoraxtension pneumothorax can killcan kill
 Chest wall is intactChest wall is intact
 Air enters the pleural space from the lung orAir enters the pleural space from the lung or
airway, and it has no way to leaveairway, and it has no way to leave
 There is no vent to the atmosphere as there is inThere is no vent to the atmosphere as there is in
an open pneumothoraxan open pneumothorax
 Most dangerous when patient is receivingMost dangerous when patient is receiving
positive pressure ventilation in which air ispositive pressure ventilation in which air is
forced into the chest under pressureforced into the chest under pressure

 Tension pneumothoraxTension pneumothorax
occurs when aoccurs when a closedclosed
pneumothoraxpneumothorax createscreates
positive pressure in thepositive pressure in the
pleural space thatpleural space that
continues to buildcontinues to build
 That pressure is thenThat pressure is then
transmitted to thetransmitted to the
mediastinum (heart andmediastinum (heart and
great vessels)great vessels)

mediastinal shiftmediastinal shift
Mediastinal shift
 Mediastinal shiftMediastinal shift occursoccurs
when the pressure getswhen the pressure gets
so high that it pushes theso high that it pushes the
heart and great vesselsheart and great vessels
into the unaffected sideinto the unaffected side
of the chestof the chest
 These structures areThese structures are
compressed fromcompressed from
external pressure andexternal pressure and
cannot expand to acceptcannot expand to accept
blood flowblood flow

mediastinal shiftmediastinal shift
 Mediastinal shiftMediastinal shift can quickly lead tocan quickly lead to
cardiovascular collapsecardiovascular collapse
 The vena cava and the right side of the heartThe vena cava and the right side of the heart
cannot accept venous returncannot accept venous return
 With no venous return, there is no cardiac outputWith no venous return, there is no cardiac output
 No cardiac output = not able to sustain lifeNo cardiac output = not able to sustain life

 When the pressure isWhen the pressure is
external, CPR will notexternal, CPR will not
help – the heart will stillhelp – the heart will still
not accept venous returnnot accept venous return
 Immediate, live-savingImmediate, live-saving
treatment is placing atreatment is placing a
needle toneedle to
relieve pressurerelieve pressure
followed byfollowed by
chest tubechest tube

hemothoraxhemothorax
 HemothoraxHemothorax occurs after thoracic surgery andoccurs after thoracic surgery and
many traumatic injuriesmany traumatic injuries
 As with pneumothorax, the negative pressureAs with pneumothorax, the negative pressure
between the pleurae is disrupted, and the lung willbetween the pleurae is disrupted, and the lung will
collapse to some degree, depending on thecollapse to some degree, depending on the
amount of bloodamount of blood
 The risk of mediastinal shift is insignificant, as theThe risk of mediastinal shift is insignificant, as the
amount of blood needed to cause the shift wouldamount of blood needed to cause the shift would
result in a life-threatening intravascular lossresult in a life-threatening intravascular loss

Remove fluid & airRemove fluid & air
ThoracostomyThoracostomy creates an opening in the chest wallcreates an opening in the chest wall
through which a chest tube (also called thoracicthrough which a chest tube (also called thoracic
catheter) is placed, which allows air and fluid tocatheter) is placed, which allows air and fluid to
flow out of the chestflow out of the chest

Remove fluid and airRemove fluid and air

Remove fluid & airRemove fluid & air
Choose site
Explore with finger
Place tube with clamp
Suture tube to chest

Remove fluid & air through chest tubeRemove fluid & air through chest tube

Remove fluid and air after thoracicRemove fluid and air after thoracic
surgerysurgery
At the end of theAt the end of the
procedure, theprocedure, the
surgeon makes asurgeon makes a
stab wound in thestab wound in the
chest wall throughchest wall through
which the chestwhich the chest
tube is placed intotube is placed into

Prevent air & fluid from returning toPrevent air & fluid from returning to
Chest tube is attached to aChest tube is attached to a drainage devicedrainage device
 Allows air and fluid to leave the chestAllows air and fluid to leave the chest
 Contains a one-way valve to prevent air & fluidContains a one-way valve to prevent air & fluid
returning to the chestreturning to the chest
 Designed so that the device is below the level of theDesigned so that the device is below the level of the
chest tube for gravity drainagechest tube for gravity drainage

How does a chest drainage system work?How does a chest drainage system work?
It’s all aboutIt’s all about
bottles andbottles and
strawsstraws

Tube from patient
Tube open to
atmosphere
vents air
 Most basic conceptMost basic concept
 Straw attached toStraw attached to
chest tube from patientchest tube from patient
is placed under 2cm ofis placed under 2cm of
fluid (water seal)fluid (water seal)
 Just like a straw in aJust like a straw in a
drink, air can pushdrink, air can push
through the straw, butthrough the straw, but
air can’t be drawn backair can’t be drawn back
up the strawup the straw

 This system works if only air is leaving the chestThis system works if only air is leaving the chest
 If fluid is draining, it will add to the fluid in theIf fluid is draining, it will add to the fluid in the
water seal, and increase the depthwater seal, and increase the depth
 As the depth increases, it becomes harder forAs the depth increases, it becomes harder for
the air to push through a higher level of water,the air to push through a higher level of water,
and could result in air staying in the chestand could result in air staying in the chest

Tube open to
atmosphere
vents air Tube from patient
Fluid
drainage
2cm
fluid
 For drainage, a secondFor drainage, a second
bottle was addedbottle was added
 TheThe first bottlefirst bottle collectscollects
thethe drainagedrainage
 TheThe second bottlesecond bottle isis
thethe water sealwater seal
 With an extra bottle forWith an extra bottle for
drainage, the waterdrainage, the water
seal will then remain atseal will then remain at
2cm2cm

 The two-bottle system is the key for chestThe two-bottle system is the key for chest
drainagedrainage
 A place for drainage to collectA place for drainage to collect
 A one-way valve that prevents air or fluid fromA one-way valve that prevents air or fluid from
returning to the chestreturning to the chest

Restore negative pressure in the pleuralRestore negative pressure in the pleural
spacespace
 Many years ago, it was believed that suction wasMany years ago, it was believed that suction was
always required to pull air and fluid out of thealways required to pull air and fluid out of the
pleural space and pull the lung up against thepleural space and pull the lung up against the
parietal pleuraparietal pleura
 However, recent research has shown that suctionHowever, recent research has shown that suction
may actually prolong air leaks from the lung bymay actually prolong air leaks from the lung by
pulling air through the opening that wouldpulling air through the opening that would
otherwise close on its ownotherwise close on its own
 IfIf suctionsuction is required, ais required, a third bottlethird bottle is addedis added

Restore negative pressure in theRestore negative pressure in the
pleural spacepleural space
Tube to
vacuum
source
Tube open to
atmosphere
vents air
Tube from patient
Fluid
drainage
Straw under
20 cmH2O

spacespace
 The straw submerged in the suction control bottleThe straw submerged in the suction control bottle
(typically to 20cmH(typically to 20cmH22O) limits the amount ofO) limits the amount of
negative pressure that can be applied to thenegative pressure that can be applied to the
pleural space – in this case -20cmHpleural space – in this case -20cmH22OO
 The submerged straw is open at the topThe submerged straw is open at the top
 As the vacuum source is increased, once bubblingAs the vacuum source is increased, once bubbling
begins in this bottle, it means atmosphericbegins in this bottle, it means atmospheric
pressure is being drawn in to limit the suction levelpressure is being drawn in to limit the suction level

Restore negative pressure in theRestore negative pressure in the
pleural spacepleural space
TheThe depth of the waterdepth of the water
in the suction bottlein the suction bottle
determines the amountdetermines the amount
of negative pressureof negative pressure
that can be transmittedthat can be transmitted
to the chest,to the chest, NOT theNOT the
reading on thereading on the
vacuum regulatorvacuum regulator

spacespace
 There is no research to support this number ofThere is no research to support this number of
-20cmH-20cmH22O, just conventionO, just convention
 Higher negative pressure can increase the flowHigher negative pressure can increase the flow
rate out of the chest, but it can also damagerate out of the chest, but it can also damage
tissuetissue

How a chest drainage systemHow a chest drainage system
worksworks
 Expiratory positive pressureExpiratory positive pressure from the patientfrom the patient
helps push air and fluid out of the chest (cough,helps push air and fluid out of the chest (cough,
Valsalva)Valsalva)

GravityGravity helps fluid drainage as long as the chesthelps fluid drainage as long as the chest
drainage system is below the level of the chestdrainage system is below the level of the chest
 SuctionSuction can improve the speed at which air andcan improve the speed at which air and
fluid are pulled from the chestfluid are pulled from the chest

From bottles to a boxFrom bottles to a box
 The bottle system worked, but it was bulky at theThe bottle system worked, but it was bulky at the
bedside and with 16 pieces and 17 connections,bedside and with 16 pieces and 17 connections,
it was difficult to set up correctly whileit was difficult to set up correctly while
maintaining sterility of all of the partsmaintaining sterility of all of the parts
 In 1967, a one-piece, disposable plastic box wasIn 1967, a one-piece, disposable plastic box was
introducedintroduced
 The box did everything the bottles did – andThe box did everything the bottles did – and
moremore

At the bedsideAt the bedside
 Keep drain below the chestKeep drain below the chest
for gravity drainagefor gravity drainage
 This will cause aThis will cause a pressurepressure
gradientgradient with relativelywith relatively
higher pressure in the chesthigher pressure in the chest
 Fluid, like air, moves fromFluid, like air, moves from
an area of higher pressurean area of higher pressure
to an area of lower pressureto an area of lower pressure
 Same principle as raising anSame principle as raising an
IV bottle to increase flowIV bottle to increase flow
raterate

Monitoring intrathoracic pressureMonitoring intrathoracic pressure
 The water seal chamber and suction controlThe water seal chamber and suction control
chamber provide intrathoracic pressure monitoringchamber provide intrathoracic pressure monitoring
 Gravity drainage without suctionGravity drainage without suction: Level of water in: Level of water in
thethe water seal chamber = intrathoracic pressurewater seal chamber = intrathoracic pressure
(chamber is calibrated manometer)(chamber is calibrated manometer)
 Slow, gradual rise in water level over time means moreSlow, gradual rise in water level over time means more
negative pressure in pleural space and signals healingnegative pressure in pleural space and signals healing
 Goal is to return to -8cmHGoal is to return to -8cmH2200
 With suctionWith suction: Level of water in: Level of water in suction control +suction control +
level of water inlevel of water in water sealwater seal chamberchamber ==
intrathoracic pressureintrathoracic pressure

Monitoring air leakMonitoring air leak
 Water seal is a window intoWater seal is a window into
 Not only for pressureNot only for pressure
 If air is leaving the chest,If air is leaving the chest,
bubbling will be seen herebubbling will be seen here
 Air leak meter (1-5) provides aAir leak meter (1-5) provides a
way to “measure” the leak andway to “measure” the leak and
monitor over time – gettingmonitor over time – getting
better or worse?better or worse?

Setting up the drainSetting up the drain
 Follow the manufacturer’s instructions for addingFollow the manufacturer’s instructions for adding
water to the 2cm level in the water seal chamber,water to the 2cm level in the water seal chamber,
and to the 20cm level in the suction controland to the 20cm level in the suction control
chamber (unless a different level is ordered)chamber (unless a different level is ordered)
 Connect 6' patient tube to thoracic catheterConnect 6' patient tube to thoracic catheter
 Connect the drain to vacuum, and slowly increaseConnect the drain to vacuum, and slowly increase
vacuum untilvacuum until gentle bubblinggentle bubbling appears in theappears in the
suction control chambersuction control chamber

Setting up suctionSetting up suction
 You don’t need to boil spaghetti!You don’t need to boil spaghetti!
 Vigorous bubbling isVigorous bubbling is loudloud andand
disturbing to most patientsdisturbing to most patients
 Will also causeWill also cause rapid evaporationrapid evaporation in thein the
chamber, which willchamber, which will lower suction levellower suction level
 Too much bubbling isToo much bubbling is not needed clinicallynot needed clinically inin
98% of patients – more is not better98% of patients – more is not better
 If too much, turn down vacuum source untilIf too much, turn down vacuum source until
bubbles go away, then slowly increase until theybubbles go away, then slowly increase until they
reappear, then stopreappear, then stop

Disposable chest drainsDisposable chest drains
 Collection chamberCollection chamber
 Fluids drain directly into chamber, calibrated in mL fluid,Fluids drain directly into chamber, calibrated in mL fluid,
write-on surface to note level and timewrite-on surface to note level and time
 Water sealWater seal
 One way valve, U-tube design, can monitor air leaks &One way valve, U-tube design, can monitor air leaks &
changes in intrathoracic pressurechanges in intrathoracic pressure
 Suction control chamberSuction control chamber
 U-tube, narrow arm is the atmospheric vent, large arm isU-tube, narrow arm is the atmospheric vent, large arm is
the fluid reservoir, system is regulated, easy to controlthe fluid reservoir, system is regulated, easy to control
negative pressurenegative pressure

Pneumothorax

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