Chapter 22
Pneumothorax
CL
GA
DD
Figure 22-1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm;
CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs.
Slide 1
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Anatomic Alterations of the Lungs
Slide 2

Lung collapse

Atelectasis

Chest wall expansion

Compression of the great veins and
decreased cardiac venous return
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Etiology—3 Ways
Slide 3

From the lungs through a perforation of the
visceral pleura

From the surrounding atmosphere through a
perforation of the chest wall and parietal
pleura or, rarely, through an esophageal
fistula or a perforated abdominal viscus

From gas-forming microorganisms in an
empyema in the pleural space (rare)
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Pneumothorax Classifications
General Terms
Slide 4

Closed pneumothorax

Open pneumothorax

Tension pneumothorax
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Pneumothorax Classifications
Based on Origin
Slide 5

Traumatic pneumothorax

Spontaneous pneumothorax

Iatrogenic pneumothorax
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Figure 22-3. Closed (tension) pneumothorax produced
by a chest wall wound.
Slide 6
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Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura
that functions as a check valve.
Slide 7
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Spontaneous Pneumothorax
Slide 8
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Iatrogenic Pneumothorax
Slide 9
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Overview of the Cardiopulmonary
Clinical Manifestations Associated
with PNEUMOTHORAX
The following clinical manifestations result from
the pathophysiologic mechanisms caused (or
activated) by Atelectasis (see Figure 9-7)—the
major anatomic alterations of the lungs
associated with pneumothorax (see Figure 22-1).
Slide 10
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Figure 9-7. Atelectasis clinical scenario.
Slide 11
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Clinical Data Obtained at the
Patient’s Bedside
Vital signs

Increased respiratory rate

Stimulation of peripheral chemoreceptors

Other possible mechanisms
•
•
•
•
•

Slide 12
Decreased lung compliance
Activation of the deflation receptors
Activation of the irritant receptors
Stimulation of the J receptors
Pain/anxiety
Increased heart rate, cardiac output, blood pressure
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Figure 22-5. Venous admixture in pneumothorax.
Slide 13
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Clinical Data Obtained at the
Patient’s Bedside
Slide 14

Cyanosis

Chest assessment findings

Hyperresonant percussion note over the
pneumothorax

Diminished breath sounds over the pneumothorax

Tracheal shift

Displaced heart sounds

Increased thoracic volume on the affected side
• Particularly in tension pneumothorax
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Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a
pneumothorax, hyperresonant percussion notes are produced over the affected area.
Slide 15
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Figure 22-7. Breath sounds diminish as gas accumulates in the intrapleural space.
Slide 16
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Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter
increases on the affected side in a tension pneumothorax.
Slide 17
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures
Slide 18
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Pulmonary Function Study:
Lung Volume and Capacity Findings
VT
Slide 19
RV
FRC
TLC
N or 



VC

IC

ERV

RV/TLC%
N
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Arterial Blood Gases
Small Pneumothorax

pH

Slide 20
Acute alveolar hyperventilation with
hypoxemia
PaCO2

HCO3 (Slightly)
PaO2

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Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
100
90
PaO2 or PaCO2
80
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
70
60
PaO2
50
40
30
20
10
0
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Slide 21
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Arterial Blood Gases
Large Pneumothorax

Acute ventilatory failure with hypoxemia
pH

Slide 22
PaCO2

HCO3 (Slightly)
PaO2

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Time and Progression of Disease
Disease Onset
Alveolar Hyperventilation
Acute Ventilatory Failure
100
90
Pa02 or PaC02
80
70
Point at which PaO2
declines enough to
stimulate peripheral
oxygen receptors
Point at which disease
becomes severe and patient
begins to become fatigued
60
50
40
30
20
10
0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Slide 23
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Oxygenation Indices
QS/QT
DO2
VO2


Normal
O2ER

Slide 24
C(a-v)O2
(severe)
SvO2

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Hemodynamic Indices
(Large Pneumothorax)
Slide 25
CVP
RAP
PA
PCWP




CO
SV
SVI
CI




RVSWI
LVSWI
PVR
SVR




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Radiologic Findings
Chest radiograph
Slide 26

Increased translucency

Mediastinal shift to unaffected side
in tension pneumothorax

Depressed diaphragm

Lung collapse

Atelectasis
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Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the heart and
mediastinum to the right away from the tension pneumothorax.
Slide 27
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A
B
Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the right lung (arrow).
B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away
from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow).
Slide 28
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General Management of
Pneumothorax

>20%—gas should be evacuated

Negative pressure—5 to 12 cm H2O

Slide 29
Should not exceed negative 12 cm H2O
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General Management of
Pneumothorax
Respiratory care treatment protocols
Slide 30

Oxygen therapy protocol

Hyperinflation therapy protocol

Mechanical ventilation protocol
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General Management of
Pneumothorax
PLEURODESIS


Chemical or medication injected into the
chest cavity

Talc

Tetracycline

Bleomycin sulfate
Produces inflammatory reaction between
lungs and inner chest cavity

Slide 31
Causes lung to stick to chest cavity
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Classroom Discussion
Case Study: Pneumothorax
Slide 32
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