NOTES
Module 1: Respiratory Disorders: Pleural and Thoracic Injury
Marnie Quick, RN, MSN, CNRN
Pleural Injury
Etiology/Pathophysiology
1. Normal physiology as it relates to pleural injury.
a. Pleura- tightly connected two-layered thin membrane that lines
the inner chest wall and hold the lungs to the thoracic wall. The
visceral pleura lines the lung surface; parietal pleura lines the
inner chest wall (p. 1033 Fig 34-3).
b. The pleura produce a lubricating serous pleura fluid that allows
the lungs to move during breathing.
c. On inspiration, the chest wall expands and the diaphragm
moves downward, increasing the lung volume.
d. The pleural cavity (potential space between the two-layered
pleura) becomes negative in relation to atmospheric pressure
(756 mg Hg) when inspiration occurs. This allows for air to
enter the lungs.
A. Pleural Injury- Pleural Effusion
Etiology/Pathophysiology of Pleural Effusion
1. Collection of excess fluid (normal 10-20 cc’s) in the pleural space. The
excess fluid may also contain pus (empyema) or blood.
2. Occurs with local disease, such as lung cancer, pneumonia trauma or
systemic disease, such as heart failure, liver or renal disease.
Common Manifestations/Complications of Pleural Effusion
1. Dyspnea, pleuritic pain, decreased/absent breath sounds, limited
chest wall movement.
Therapeutic Interventions of Pleural Effusion
1. Diagnostic tests- chest X-ray (most common), CT, ultrasound, analysis
of aspirated fluid from thoracentesis.
2. Treat underlying cause of pleural effusion
3. Treatment- administer O2
4. Treatment- thoracentesis:
a. p. 1145 Fig 36-15 and Nursing care in box at bottom
b. Done under local anesthesia at bedside with patient in an
upright position leaning forward with arms on overbed table
c. Fluid or air is removed from the pleural space with a needle.
d. No more than 1500 ml aspirated at one time because it may
cause cardiac collapse.
e. Fluid is analyzed for content including abnormal cells; culture
f. Potential complication is pneumothorax
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B. Plrural Injury- Pneumothorax
Etiology/Pathophysiology of Pneumothorax- Air in the pleural space
(p. 1147 Table 36-12) results in complete or partial collapse of a lung.
1. Spontaneous pneumothorax
a. Type of closed pneumothorax caused by rupture of a subpleural
air bleb.
b. Primary- previously healthy people, cause unknown- have a
history of smoking, thin individuals, or family history of same.
c. Secondary- over distention or rupture of alveolus as a result
respiratory disorders, such as COPD.
d. Risk of recurrence is 40-50%
2. Traumatic pneumothorax
a. Open- sucking chest wound (knife wound, etc). Air enters the
chest during inspiration and exits during expiration. A slight shift
of the affected lung may occur because of a decrease in
pressure as air moves out of the chest.
b. Closed- blunt (CPR/fall) or penetrating trauma (fractured ribs)
air enters from the lung into the pleural space.
c. Post thoracentesis, central line insertion or mechanical
ventilation
3. Tension pneumothorax
a. Injury causing air to enter the pleural space through chest wall
on inspiration and can’t leave the chest.
b. With each breath tension (positive pressure) is increased within
the affected pleural space.
c. The lung collapses and the heart, the great vessels, and the
trachea shift toward the unaffected side of the chest
(mediastinal shift)
d. Both respiratory and circulatory functions are compromised
because of the increased intrathoracic pressure.
e. Increased intrathoracic pressure decreases venous return to the
heart, causing decreased cardiac output and impairment of
peripheral circulation and pulse may be undetectable.
f. Shock symptoms develop.
g. *Tension pneumothorax is a medical emergency.
Common Manifestations/Complications of a Pneumothorax
1. Different types p. 1147 Table 36-12 with pictures
Therapeutic Interventions for a Pneumothorax
1. Diagnostic tests- Chest X-ray, O2 sat, ABG’s
2. High Fowlers position; O2; rest to decrease O2 demand
3. Treatment depends on severity, small one (<20% of lung affected)monitor with serial chest X-rays; with symptoms (>20%)- chest tube
insertion to reestablish negative pressure in the pleural space.
4. Treatment- chest tube (p. 1148 Fig 36-16; p. 1149 Box)
a. Self contained closed chest drainage system. Disposable single
unit (Pleur-evac, Thoraseal) most commonly used. Work the
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same as the 3-bottle system. Less frequently used are the 1, 2,
and 3 sterile glass bottle drainage system.
b. Closed system allows air and fluid to flow out of the pleural
space and prevents outside air from entering the pleural cavity.
c. Chest tube for a pneumothorax is placed into the pleural space.
d. Disposable system has three chambers:
1) Drainage chamber: collects drainage and can be marked
once per shift or more frequently to track amount and
color of drainage over time
2) Water seal chamber: prevents air in drainage tubing
and collection container from flowing back into chest;
chamber is filled to the 2cm mark with sterile water to
maintain underwater seal; it is imperative that this seal
not be interrupted. The water-seal restores negative
intrathoracic pressure so that inspiration can occur.
‘Tidaling’, the rise and fall of the sterile water with
respirations should occur. This will stop when lung has
expanded. Constant bubbling in the water seal chamber
should not occur and means there is an air leak in the
system.
3) Suction control chamber: helps to reestablish negative
intrathoracic pressure; chamber is filled with water to
the proper level to regulate the amount of suction- most
commonly 20 cm. It is connected to wall suction to
maintain suction so that gentle bubbling can be seen in
this suction chamber.
e. All drainage systems will have an air vent to allow drained air to
escape so pressure does not build up in the drainage container.
f. When physician ready to remove, tube will be clamped and Xrays taken. It usually takes 2-3 days of chest drainage for lungs
to fully expand. If no symptoms and chest X-ray negative, then
chest tube removed by the physician. Sutures are removed and
a sterile petroleum gauze is used to cover the site and then
covered with an air-tight dressing.
5. Treatment- Heimlich valve on chest tube
a. a collapsible rubber tube attached to the external end of the
chest tube. Used in place of the water seal closed system.
b. It is a one way valve that opens whenever the pressure is
greater than atmospheric and closes when the reverse occurs.
c. The Heimlich valve functions as a water seal and is especially
useful in emergency situations, transport, etc
6. Treatment- throacotomy tube
a. When more than 30% of the lung has collapsed, reexpansion of
the lung is performed by placing a thoracotomy tube in the
second or third intercostals space at the midclavicular line.
b. This procedure is done to allow air to rise to the top of the
intraplural space. The tube is connected to an underwater seal
with suction at low pressure.
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7. Pleurodesis- instillation of chemical agent (doxycycline) into the pleural
space to create inflammatory response (scar tissue) to cause
adhesions- the visceral and parietal pleura then adhere
8. Surgery- VATS (video assisted thoracic surgery) a minimally invasive
surgical technique to view the intrapleural space, or to induce scaring
adhesions so that the pleura adhere.
C. Pleural Injury- Hemothorax
Etiology/Pathophysiology of Hemothorax
1. Blood in the pleural space
a. Caused by:
1) Injury often associated with pneumothorax with
laceration of blood vessels or lung tissue
2) Lung malignancy, pulmonary embolus
3) Complication of anticoagulant therapy
b. Like pneumothorax, lung can collapse.
Common Manifestations/Complications of Hemothorax
1. Similar to pneumothorax. Lung sounds diminished, dull percussion
over collected blood, and blood loss symptoms.
Therapeutic Interventions of Hemothorax
1. Diagnostic tests- similar to pneumothorax.
2. Treatment- similar to pneumothorax with chest tube placed into
pleural space, generally inserted in a lower intercostals space than for
air (pneumothorax). Drains the blood that settles at the lower part of
the lung. May use autotransfusion from chest tube drainage set-up to
give blood back to patient.
Pleural Injury: A. Pleural effusion B. Pneumothorax & C. Hemothorax
Nursing Assessment Specific to Pleural Injury
1. Health history- history of respiratory disease, injury or smoking;
progression of symptoms
2. Physical exam- degree of apparent respiratory distress, lung sounds,
O2 sat, VS (q 1 hr in acute phase), level of consciousness, neck vein
distention, position of trachea
Pertinent Nursing Problems and Interventions Pleural Injury
1. Impaired gas exchange
a. Assess respiratory status/vital signs
b. Place in Fowler’s for lung expansion, O2, rest
c. A chest tube may be inserted to remove air or fluid.
d. Nursing care with chest tube- (p. 1149- Box; p. 1148 Fig 36-16)
1) Occlusive dressing at chest tube insertion site, chest
tube securely taped to the chest, avoid tension on tube.
2) Keep drainage system 2-3 feet below individuals’ chest.
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3)
No kinks, dependent loops or clots in tubing, tape all
connections well.
4) Maintain negative suction so that gentle bubbling can be
seen in the suction chamber.
5) Observe for ‘tidaling’ in the water seal chamber. Tidaling
is the rise and fall of the fluid in the water seal chamber
that is synchronous with respiration. This may stop after
2-3 days when lung has re-expanded.
6) Look for possible air leak in the system- constant
bubbling in water seal chamber.
7) Record amount, color, consistency of chest tube
drainage every 8 hrs. Mark on drainage unit time.
Drainage of greater than 70-100 cc/hr is heavy, notify
Doctor.
8) If collection chamber becomes full, whole system
changed
9) Monitor respiratory status
10) Encourage coughing and deep breathing every hour, use
splinting technique.
11) A bottle of sterile water should be readily available. If
system breaks/cracks/disconnected the chest tube
should be submerged in the sterile water bottle to
maintain a water seal until a new system can be
obtained.
12) If the chest tube comes out of the chest, apply a
dressing to the site, tape on three sides, then notify the
physician.
13) Chest tubes may be clamped momentarily only, only to
change the unit or check for leaks. Physician may order
continuous clamping prior to removal after the lung has
re-expanded. When chest tube removed an airtight
petrolatum gauze and dressing is utilized.
14) Ambulation as ordered. In most cases individual can
ambulate without suction attached. Water-seal must be
maintain and the kept below level of chest.
e. Nursing care pre/post thoracentesis (p. 1145 box)
2. Risk for injury
a. Prevent injury from chest tube complications. Refer to previous
section on nursing care of chest tube.
3. Home care- gradually increase activity, seek medical attention if
develop infection symptoms or recurrent respiratory symptoms
Thoracic Injury
Etiology/Pathophysiology of Thoracic Injury (three types)
1. Fib fractures- most common chest injury- takes approx 6 wks to heal.
2. Flail chest- two or more ribs on the same side & in more than one
place are fractured and are detached from the rib cage. The ribs
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become free floating. That part of the chest moves independentlymoves in on inspiration and out on expiration (paradoxical movement).
May have pneumothorax or hemothorax if rib punctures pleura/lung.
Progressive hypoxemia and hypercapnia may be fatal.
3. Pulmonary contusion- chest injury causing alveoli and pulmonary
arterioles rupture causing bleeding and edema in the lung tissue. This
impairs the production of surfactant decreasing compliance, impairing
gas exchange
Common Manifestations/Complications of Thoracic Injury
1. Rib fracture- pain esp on inspiration, shallow breathing, holding chest
2. Flail chest- severe dyspnea, cyanosis, tachypnea, paradoxical
movement of the chest (p. 1152 Fig 36-17), crepitus; watch for the
complications of pneumothorax, hemothorax or pneumonia
3. Pulmonary contusion- may not be seen until 12-24 hrs post injury,
increasing respiratory difficulty, restlessness, chest pain, coughing up
sputum (may be blood tinged)
Therapeutic Interventions of Thoracic Injury
1. Diagnostic tests- All require chest X-ray, ABG’s.
2. Rib fracture- analgesics, do not restrict chest movement.
3. Flail chest- mild- deep breathing and pain management -intercostal
nerve blocks; if in respiratory distress intubation and mechanical
ventilation. Positive pressure to stabilize flail chest. External traction.
4. Pulmonary contusion- endotracheal tube and mechanical ventilation.
Bronchoscopy to remove secretions to prevent atelectasis.
Nursing Assessment Specific to Thoracic Injury
1. Health history- of respiratory disorders/injury; progression of
symptoms
2. Physical exam- VS, O2 sats, respiratory assessment of lungs, pain
3. All require observation for pneumothorax/hemothorax symptoms
Pertinent Nursing Diagnosis and Interventions of Thoracic Injury
1. Acute pain
a. Pain causes the individual to guard chest, restricting respirations
b. Assess and control pain- may need PCA
2. Ineffective airway clearance
a. Assess respiratory status
b. Teach how to splint with pillow when coughing to stabilize and
reduce movement of chest- therefore reduce pain
c. Keep airway open
d. Elevate head of bed
3. Impaired gas exchange
a. Assess respiratory status, intake and output, weight,
hemodynamic monitoring.
b. Maintain oxygen therapy & mechanical ventilation if used
c. Bedrest/activity restriction
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4. Home
a.
b.
c.
care
Pain management
Importance of cough and deep breathing
Symptoms to report- respiratory infection symptoms, increasing
respiratory distress
d. Avoid respiratory irritants, such as smoking
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