COPD with PNEUMOTHORAX = loss of negative interpleural pressure results in collapse of the lung.

SPONTANEOUS
occurs with the rupture of a bleb.

Secondary spontaneous pneumothorax. This develops in people who already have a lung disorder, especially
emphysema, which progressively damages your lungs. Other conditions that can lead to secondary spontaneous
pneumothorax include tuberculosis, pneumonia, cystic fibrosis and lung cancer. In these cases, the pneumothorax
occurs because the diseased lung tissue is next to the pleural space.

Secondary spontaneous pneumothorax can be more severe and even life-threatening because diseased tissue may open
a wider hole, allowing more air into the pleural space than does a small, ruptured bleb. Additionally, people with lung
disease already have reduced lung reserves, making any reduction in lung function more serious. A secondary
spontaneous pneumothorax almost always requires chest tube drainage for treatment.

Characteristics

 Sharp chest pain made worse by coughing or moving

 Shortness of breath due to inability to fully expand the lungs upon inspiration
 Absent breath sounds on affected side
 Decreased chest expansion
 Cyanosis
 Hypotension

 Subcutaneous emphysema (presence of air beneath the skin) CRACKLING
 Tachycardia and Tachypnea when the body attemps to meet respiratory needs
 Mediastinal shift and tracheal deviation toward the unaffected side with (tension pneumothorax)

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COPD, or chronic obstructive pulmonary (PULL-mun-ary) disease, is a progressive disease that makes it hard to breathe.
"Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath,
chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPD smoke or used to smoke. Long-term
exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

Overview

To understand COPD, it helps to understand how the lungs work. The air that you breathe goes down your windpipe into
tubes in your lungs called bronchial tubes, or airways.

The airways are shaped like an upside-down tree with many branches. At the end of the branches are tiny air sacs called
alveoli (al-VEE-uhl-eye).

The airways and air sacs are elastic. When you breathe in, each air sac fills up with air like a small balloon. When you
breathe out, the air sac deflates and the air goes out.

In COPD, less air flows in and out of the airways because of one or more of the following:

 The airways and air sacs lose their elastic quality.

 The walls between many of the air sacs are destroyed.

 The walls of the airways become thick and inflamed (swollen).

 The airways make more mucus than usual, which tends to clog the airways.
Healthy Alveoli and Damaged Alveoli

The illustration shows the respiratory system and images of healthy alveoli and alveoli damaged by COPD.

In the United States, the term "COPD" includes two main conditions—emphysema (em-fi-SE-ma) and chronic obstructive
bronchitis (bron-KI-tis).

In emphysema, the walls between many of the air sacs are damaged, causing them to lose their shape and become
floppy. This damage also can destroy the walls of the air sacs, leading to fewer and larger air sacs instead of many tiny
ones.

In chronic obstructive bronchitis, the lining of the airways is constantly irritated and inflamed. This causes the lining to
thicken. Lots of thick mucus forms in the airways, making it hard to breathe.

Most people who have COPD have both emphysema and chronic obstructive bronchitis. Thus, the general term "COPD"
is more accurate.

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A collapsed lung, or pneumothorax, is the collection of air in the space around the lungs. This buildup of air puts
pressure on the lung, so it cannot expand as much as it normally does when you take a breath.

Symptoms

Almost everyone who has a collapsed lung has the following symptoms:

 Sharp chest pain, made worse by a deep breath or a cough

 Shortness of breath

A larger pneumothorax will cause more severe symptoms, including:

 Chest tightness

 Easy fatigue

 Rapid heart rate

 Bluish color of the skin caused by lack of oxygen

Note: Symptoms may begin during rest or sleep.

Other symptoms that can occur with a collapsed lung include:

 Nasal flaring

 Low blood pressure (hypotension)

Treatment
A small pneumothorax may go away on its own. You may only need oxygen and rest. The health care provider may use a
needle to pull the extra air out from around the lung so it can expand more fully. You may be allowed to go home if you
live near the hospital.
If you have a large pneumothorax, a chest tube will be placed between the ribs into the space around the lungs to help
drain the air and allows the lung to re-expand.
The chest tube can be left in place for several days. You must stay in the hospital while the chest tube is in place.
Some patients with a collapsed lung need extra oxygen, which helps the air around the lung be reabsorbed more quickly.
Lung surgery may be needed to treat your pneumothorax or to prevent future episodes. The area where the leak
occurred may be repaired. Sometimes, a special chemical is placed into the area of the collapsed lung. This chemical
causes a scar to form.
Causes
A collapsed lung may result from chest trauma, such as gunshot or knife wounds, rib fracture, or after certain medical
procedures.
In some cases, a collapsed lung occurs without any cause. This is called a spontaneous pneumothorax. A small area in
the lung that is filled with air, called a bleb, ruptures, and the air leaks into the space around the lung.
Certain activities may lead to a collapsed lung. These include scuba diving, smoking marijuana or cigarettes, high altitude
hiking, and flying.
Tall, thin people are more likely to a collapsed lung.
Lung diseases such as COPD, asthma, cystic fibrosis, tuberculosis, and whooping cough also increase your risk for a
collapsed lung.
Tests & diagnosis
There are decreased or no breath sounds on the affected side when heard through a stethoscope.
Tests include:
 Chest x-ray to tell whether there is air outside the lung
 Arterial blood gases
Prognosis
If you have a collapsed lung, you are more likely to have another one in the future if you:
 Are tall and thin
 Continue to smoke
 Have had two collapsed lungs in the past
How well a person does after having a collapsed lung depends on what caused it.
Prevention
There is no known way to prevent a collapsed lung, but you can decrease your risk by not smoking.
Complications
 Another collapsed lung in the future and Shock

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DRY SUCTION

The next step in the evolution of chest drainage units was the development of dry suction control
chambers. Dry suction control systems provide many advantages: higher suction pressure levels can be
achieved, set-up is easy, no continuous bubbling provides for quiet operation, and there is no fluid to
evaporate which would decrease the amount of suction applied to the patient.

Instead of regulating the level of suction with a column of water, the dry suction units are controlled
by a self-compensating regulator. A dial to set the suction control setting is located on the upper left
side of each unit. To set the suction setting, rotate the dial until the red stripe appears in the
semi-circular window at the prescribed suction level and clicks into place. Suction can be set at –10, –15,
–20, –30, or –40 cm of water. The unit is pre-set at –20 cm of water when opened (figure 16).

Connect the short suction tubing or suction port to the suction source. Source suction must be capable
of delivering a minimum of 16 liters per minute (LPM) air flow. Increase suction source until the
orange float appears in the suction control indicator window.

The unique design of the Pleur-evac dry suction control immediately responds to changes in patient pressure
(patient air leak) or changes in suction pressure (surge/decrease at the suction source). The setting of
the suction control dial determines the approximate amount of suction imposed regardless of the amount
of source suction — as long as the orange float appears in the indicator window.

Patient situations that may require higher suction pressures of –30 or –40 cm H2O include: a large air
leak from the lung surface, empyema or viscous pleural effusion, a reduction in pulmonary compliance, or
anticipated difficulty in expansion of the pulmonary tissue to fill the hemithorax.

In the presence of a large air leak, air flow through the Pleur-evac may be increased by increasing source
suction, WITHOUT increasing imposed negativity. It is not necessary to change the suction setting on the
Pleur-evac unit to accommodate high air flows. The suction control level can be changed at any time
as prescribed by simply rotating the dial to the new suction setting. Confirm that the orange float remains
in the suction control indicator window at the new suction setting. If suction setting is changed from a
HIGHER to a LOWER level, the patient negativity may remain at the higher level unless the negativity is
relieved. Use the manual high negativity relief valve to reduce negativity to desired level.

Both the wet suction and dry suction series of Pleurevac have a positive pressure relief valve that opens
with increases in positive pressure, preventing pressure accumulation (figure 15). Normally, air exits
through the suction port. Obstruction of this route (i.e. a bed wheel rolls on top of the suction tube, or
the suction port is capped after suction discontinued) could cause accumulation of air in the system leading
to tension pneumothorax. This safety feature allows venting of the positive pressure automatically, thus
minimizing the risk of tension pneumothorax.

TO CLAMP OR NOT TO CLAMP?

The decision whether to clamp a chest tube when the drainage system has been knocked over and
disconnected or otherwise disrupted is based on your initial assessment of the water seal chamber and air
leak meter. If there has been no bubbling in the water seal, you can deduce there is no air leak from
the lung. Therefore, the tube may be clamped for the short time it takes to reestablish drainage. If there has
been bubbling and your assessment has determined there is an air leak from the lung, you MUST NOT
clamp the chest tube. Doing so will cause air to accumulate in the pleural cavity since the air has no
means of escape. This can rapidly lead to tension pneumothorax.

The few times you should clamp a chest tube are when: 1) You are performing a physician-ordered
procedure such as sclerosing, 2) Assessing for a leak, or 3) Prior to removing the chest tube to determine if
the patient can do without the chest tube (with a physician order).

You should never clamp a chest tube during patient transport unless the chest drainage system becomes
disrupted during patient movement, and then only if there is no air leak.

Closed-chest
drainage system

 Once the tube/catheter is secure in the pleural space (by M.D.), nurse hooks up the Pleur-Evac system. Make
sure all connections are secure (use adhesive tape to prevent a break in the system) and sterile petroleum- jelly
based occlusive gauze/ dressing are applied over insertion site to prevent air leaks!

 The whole system is based on maintaining a “Negative intra-thoracic pressure” so we need a water seal
bottle/chamber ( bottle # 2)

 Each time client exhales=air is trapped in pleural space and it travels down the chest tube to water seal
bottle/chamber under water and then bubbles up and out of the bottle! The water acts as a seal allowing air to
escape from pleural space but preventing air from getting back into the lungs via negative pressure of
inspiration!

 The water level in the water seal bottle/chamber will fluctuate gently up and down with each
inspiration/expiration. This is called “tidaling”

 Only time tidaling should stop is 1.= when the lung is “re-inflated” and no longer requires a chest tube or

 2.= if a problem occurs with the tubing (kinked, occlusion, breaks in the system) and should be checked ASAP!

 3.=If constant or vigorous “bubbling” occur please check for a “leak” something is wrong

 Suction bottle/chamber (bottle #3) used to speedily re-inflate the lungs. Water is added to the bottle/chamber.
Suction is applied. (the force of suction is solely dependent on amount of water in bottle not the amount of
suction set on suction machine. If water evaporates=add more water to prescribed level of water.
 See gentle bubbling in suction bottle

 If vigorous bubbling=suction will not be maintained; did the water evaporate? Add prescribed amount.

 If suction not used: chamber is then left open to allow air to escape.

 General guidelines:

 Check system for any breaks,cracks, kinks in tubing, or broken connections

 Auscultate lung sounds, any sudden SOB, dyspnea, pain, hear any “crepitous sounds= think …SQ emphysema?”
hear & palpate for leakage of air into SQ tissue

 Tight occlusive dressing intact? Clamps at bedside?

 No dependent loops tubing? Is the drainage system below chest level?

 Check water seal chamber and or suction chamber for the correct amount of water in chambers? Any vigorous
bubbling? leaks?

 Record drainage as output