Respiratory Disorders:
Pleural and Thoracic
Injury

I. Disorders of the Pleura
 A.
Pleural Effusion
 Definition: a collection of
excess fluid in the pleural
space.
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Pleural effusion Chest x-ray of a pleural
effusion. The arrow A shows fluid layering
in the right pleural cavity. The B arrow
shows the normal width of the lung in the
cavity
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Etiology of Pleural Effusions:
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Congestive Heart Failure
Liver Disease
Renal Disease
Lupus, Rheumatoid Arthritis
Pneumonia
TB
Lung Cancer
Trauma
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What would you think is
happening in this client?
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Answer:
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Massive left sided pleural
effusion in a patient presenting
with lung cancer.
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Pathophysiology of Pleural
Effusion
capillary pressure
or
plasma proteins
Formation of excess fluid=
Transudate
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capillary permeability=
Exudate
Accumulation of pus
in the pleural space=Empyema
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Transudate
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Non-inflammatory
Trans means movement of
fluid due to changes in
pressure gradients
What do you remember
about oncotic pressure
and serum albumin
levels???
What is hydrostatic
pressure?
3/24/2016
vs Exudate
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Inflammatory in nature
Exudate means there is a
release of fluid.
Exudative pleural effusion
are due to changes in
capillary permeability.
The capillaries are
inflammed and are not as
selective and allow fluid to
leak into the pleural space.
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Let’s try to classify Transudative or
Exudative Pleural Effusion….
Etiology of Pleural Effusions:
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Congestive Heart Failure
Liver Disease
Renal Disease
Lupus, Rheumatoid Arthritis
Pneumonia
TB
Lung Cancer
Trauma
ARDS
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Clinical Manifestations
of Pleural Effusion
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Dyspnea
Pleurisy
Decreased breath sounds
Decreased chest wall movement
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Diagnostic Tests Pleural
Effusion
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CXR
CT scan
ABG’s/O2 Saturation
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Therapeutic Interventions
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Thoracentesis-needle aspiration of fluid in
pleural space. Usually 1200-1500ml /time.
Antibiotics if due to infectious process.
Chest tube to drain fluid/air.
Pleurodesis-instillation of chemical agent
(doxycycline) into pleural space to create
inflammatory response (scar tissue) to
adhese the visceral and parietal pleura.
Treat underlying condition that is causing the
effusion.
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Nursing Diagnosis #1
Ineffective breathing
pattern related to
decreased lung
expansion of left lung
secondary to
accumulation of fluid in
the pleural space, pain
and discomfort of
breathing deeply
secondary to
inflammation and
irritation of pleural
space, and poor
positioning in bed
secondary to inability to
reposition self without
assistance.
Nursing Diagnosis #2
Impaired gas exchange
related to ineffective
capillary – alveolar gas
exchange secondary to
presence of atelectasis in
lower left lung and
respiratory fatigue caused
by presence of pleural
effusion in left lung
compromising ability to
inspire deeply and causing
pain.
PleurX® Pleural Catheter
System

B. Spontaneous Pneumothorax
 Definition-accumulation
of air in the
pleural space
 Pathophysiology
 Rupture
of bleb on the lung surface
allows air into the pleural space
• Primary pneumothorax- affects previously
healthy individuals
• Secondary pneumothorax-affects
individuals with preexisting lung disease
– Which diseases can you think of???
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Clinical Manifestations
of Spontaneous Pnemo
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Abrupt onset
Pleuritic chest pain
SOB, dyspnea
respiratory rate, tachycardia
Unequal chest excursion
Decreased breath sounds on
affected side
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
C. Traumatic Pneumothorax

Definition/Pathophysiology:
 Accumulation of air into pleural space
due to blunt or penetrating trauma of
chest wall/lungs.
 Types
of Traumatic Pneumothorax
• Closed Pneumo
• Open Pneumo
• Iatrogenic Pneumo
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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,
fractured ribs that
penetrate the
pleura.
Occurs in
stabbings,
gunshot wounds,
impalement
injury.
Occurs in central
line placement,
thoracentesis,
lung biopsy,
bronchoscopy, &
mechanical
ventilation
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I’m just asking….

The client has a spontaneous
pneumothorax….which type of
pneumothorax is this:

A- Iatrogenic
B- Open
C- Closed
D- Gee… I dunno
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Clinical Manifestations
of Pneumothorax
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Dyspnea
Pleuritic Pain
RR, pulse
respiratory excursion
Absent breath sounds on
affected side
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D. Tension Pneumothorax
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Definition: air/blood/fluid
rapidly enters pleural space and
unable to escape

Lung collapses
Emergency situation!
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Tension
Pneumothorax
Is this a right sided or left sided tension pnemothorax?
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Pathophysiology of
Tension Pnemothorax
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Compression of lung to other side
Compresses against trachea, heart, aorta,
esophagus
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Increase in Intrapleural pressure
Ventilation and Cardiac Output greatly
compromised
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Clinical
Manifestations/Complications of
Tension Pneumo
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Severe Dyspnea
Tracheal Deviation
Decreased Cardiac Output
Distended Neck Veins
RR, pulse,
blood pressure
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Shock
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Therapeutic Interventions
for Pneumothorax
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High Fowlers position
O2 as ordered
Rest to decrease O2 demand
Chest tube insertion
Pleurodesis
Surgery: Thoracotomy to remove blebs,
partial excision of parietal pleura done
using VATS (video assisted thorascopic
surgery)
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II. Trauma of the
Chest/Lung
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Chest injury is the leading cause of death
from trauma
May involve chest wall, lungs, heart, great
vessels, esophagus
Life threatening chest injuries include:
Airway obstruction
 Tension pneumo, open pneumo, massive
hemothorax
 Flail chest with pulmonary contusion
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Pathophysiology of
Thoracic Injury

Acceleration-Deceleration Injury
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Rapid change in velocity
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Body stops suddenly
Chest cavity organs/tissues
move forward
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A. Rib Fracture
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Simple rib fracture in an at risk
client may lead to pneumonia,
atelectasis, respiratory failure
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Displaced rib fractures can
result in pnemo/hemothorax,
intrathoracic vessel tears, liver
or spleen injury
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Clinical Manifestations
of Rib Fractures
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Pain on inspiration/coughing
Voluntary splinting
Rapid, shallow respirations
Decreased breath sounds
Crepitus on palpation
Signs/symptoms of
pneumo/hemothorax
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B. Flail Chest
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Etiology/Pathophysiology

Occurs when 2+ consecutive ribs are
fractured in multiple places
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Segment of chest wall becomes “freefloating” or flail
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Flail segment of chest wall is sucked in
during inspiration and moves outward with
expiration
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The client presents in
the ED:
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Chest trauma client
http://www.youtube.com/watch?v=PyDcGBi7OQ&feature=related
What did you note in this client? What
would you do 1st? 2nd?
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Clinical Manifestations
of Flail Chest
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Dyspnea
Pain especially on
inspiration
Palpable crepitus
Decreased breath sounds
Unequal Chest expansion
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What assessment
finding is present???
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Flail Chest
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Right lung
affected
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Therapeutic Interventions
Flail Chest
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O2 as ordered
Elevate HOB
Intercostal nerve block or epidural
analgesia to decrease pain
Suction as ordered
Splint affected area
Preferred treatment= Intubation and
positive pressure ventilation
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Internal/External fixation of ribs in
Flail Chest
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Judet Plates for Fractured
Ribs/Flail Chest
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Sanchez Plates for Fractured
Ribs/Flail Chest
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C. Pulmonary Contusion

Etiology/Pathophysiology
 Left
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Pulmonary contusion
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Abrupt Chest Compression then
Rapid Decompression
Intra-alveolar Hemorrhage
Interstitial/bronchial Edema
surfactant production leads to
decreased lung compliance
Pulmonary vascular resistance
blood flow
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Airway obstruction, Atelectasis,
Impaired O2/CO2 exchange
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Clinical Manifestations of
Pulmonary Contusion
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SOB
Restlessness, Anxiety
Chest Pain
Copius Sputum (blood tinged)
RR, Pulse, Dyspnea, Cyanosis
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Therapeutic Interventions
Pulmonary Contusion
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Intubation/Mechanical Ventilation
Bronchoscopy to remove secretions,
cellular debris
Fluids, Volume expanders to treat shock
Pulmonary Artery pressure monitoring
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