Respiratory Disorders:
Pleural & Thoracic Injury
by Charlotte Cooper RN, MSN, CNS
modified by Kelle Howard, RN, MSN
Thoracic Cavity
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Normal Anatomy
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Thoracic cavity
Chest wall
Pleural space
Fluid
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Terminolgy
• 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
• Viceral Pleura
– Pleura that lines the lung itself
• Pleural Fluid
– pleura that lines the inner chest wall and covers the diaphragm
Pleural Fluid
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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
• Viceral pleura –
– Covers surface of
the lung
– Cannot 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
• 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
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Categories for Traumatic Injuries
• Blunt trauma
• Penetrating trauma
Traumatic Chest Injuries
Mechanism of Injury
Blunt Trauma
Blunt steering wheel injury to chest
Common Related Injury
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 trauma
Gunshot, stab wound to chest
Open pneumothorax, tension pneumothorax,
hemopneumothorax, cardiac tamponade,
esophageal damage, tracheal tear, great vessel
tears
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Respiratory Disorders:
Pleural and Thoracic Injury
• Pleural Effusion
• A collection of excess fluid in the pleural space
• Classification
• Transudative
causes
aka: hydorthoraces ----- systemic
– Usually not caused by inflammatory processes
– Most common type
• Exudative
----- localized cause
– Usually caused by an inflammatory process
– Often recurrent, difficult to treat
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Empyema
• What is it?
• What causes it?
• How do we treat it?
Etiology: Pleural Effusion
Identify the Class of Effusion
Disease Process
Classification of Effusion
Heart Failure
TB
Lupus/RA
Renal Disease
Lung Cancer
Trauma
Pneumonia
Liver Failure
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Other Types
• Hemothorax
• Chylothorax
Clinical Manifestations:
Pleural Effusion
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Dyspnea
Pleurisy
Decreased breath sounds
Decreased chest wall movement
Dullness on percussion
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How do we diagnosis
pleural effusions?
Pleural Effusion -- Diagnositcs
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____________
____________
____________
____________
How do we
know what type of
pleural effusion it is?
Interventions: Pleural Effusion
• Thoracentesis
Diagnostic
vs.
Therapeutic
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Interventions: Pleural Effusion
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Thoracentesis
• What are your nursing responsibilities pre &
post thoracentesis?
– ______________
– ______________
– ______________
– ______________
– ______________
– ______________
Interventions: Pleural Effusion
Chest tube placement/
PleurX catheter
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Interventions: Pleural Effusion
 Treat underlying condition
 CHF/Renal failure
 Pneumonia
 Liver Disease
 Lupus/RA
 Malignancy
 Pleurodesis
 Chest tube insertion
 Allow to resolve
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Complications of Pleural Effusion
• Trapped Lung
• Recurrent effusions
• Pneumothorax
PNEUMOTHORAX
• 3 types
– Closed
– Open
• aka? __________________
– 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, central
line placement
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Clinical Manifestations: Pneumothorax
• Describe what you would see:
– Respiratory
– Cardiac
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Tension Pneumothorax
• Air/blood/fluid rapidly entering the pleural
space
• Lung collapses
• Emergency situation
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Pathophysiology: Tension Pneumo
 Increase in intrapleural pressure
 Compression of lung
 Compresses against trachea, heart, aorta, esophagus
 What is this called?
 Ventilation and cardiac output greatly compromised
__________________________
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Clinical Manifestations:
Tension Pneumo
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Severe dyspnea
Tracheal deviation
Decreased cardiac output
Distended neck veins
Increased respiratory rate
Increased heart rate
Decreased blood pressure
Shock
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Treatment Tension Pneumo
• Emergency --- quick intervention
– Needle decompression
– Chest tube placement
Intervention: Pneumothorax
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High Fowlers position
Oxygen as ordered
Rest to decrease oxygen demand
***Chest tube insertion
Pleurodesis
Surgery
?
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Clinical Manifestations:
Rib Fractures
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Ribs 5-10 most commonly fractured
Pain
Splinting & rapid, shallow respirations
Decreased breath sounds
Crepitus
Signs/symptoms of pneumothorax
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Treatment: Rib Fractures
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Reduce or minimize pain
Do we wrap or bind the chest?
Do we use opiods?
Goal?
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
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Clinical Manifestations: Flail Chest
• Dyspnea with rapid, shallow inspiration
• Pain
• Palpable crepitus
• Decreased breath sounds
• Unequal chest expansion
• Tachycardia
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Interventions: Flail Chest
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Oxygen as ordered
Elevate HOB
Analgesia
Suction
Splint affected side?
*Intubation
*Mechanical ventilation
• What do you think the major goals are?
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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
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Clinical Manifestation:
Pulmonary Contusion
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Increased SOB
Restlessness
Anxiety
Chest pain
Copious sputum
Increased respiratory
Increased heart rate
Dyspnea
Cyanosis
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Intervention: Pulmonary Contusion
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Intubation
Mechanical ventilation
Bronchoscopy
Fluids
Volume expanders
Pulmonary artery pressure monitoring
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Chest Surgeries
Lewis 573 Table 28-24; 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