NCM 112 - Care of Clients with Problems in Oxygenation, Fluid & Electrolytes, Infectious
Inflammatory and Immunologic Response, Cellular Aberrations (Acute & Chronic)
PNEUMOTHORAX
Definition
 Pneumothorax, or a collapsed lung, is the
collection of air in the spaces around the
lungs. The air buildup puts pressure on the
lungs, so it cannot expand as much as it
normally.
 The pressure in the pleural space is
normally negative.
 Chest injury that allows air to enter the
pleural space resulting in a rise in
intrathoracic pressure and the reduction in
vital capacity.
Etiology/Causes
 Chest injury. Any blunt or penetrating
injury to your chest can cause lung
collapse. Some injuries may happen
during physical assaults or car crashes,
while others may inadvertently occur
during medical procedures that involve
the insertion of a needle into the chest.
 Lung disease. Damaged lung tissue is
more likely to collapse. Lung damage can
be caused by many types of underlying
diseases, such as chronic obstructive
pulmonary disease (COPD), cystic
fibrosis, lung cancer or pneumonia.
Cystic lung diseases, such as
lymphangioleiomyomatosis and Birt-
Hogg-Dube syndrome, cause round, thin-
walled air sacs in the lung tissue that can
rupture, resulting in pneumothorax.
 Ruptured air blisters. Small air blisters
(blebs) can develop on the top of the lungs.
These air blisters sometimes burst
allowing air to leak into the space that
surrounds the lungs.
 Mechanical ventilation. A severe type of
pneumothorax can occur in people who
need mechanical assistance to breathe.
The ventilator can create an imbalance of
air pressure within the chest. The lung
may collapse completely.
Risk Factors
 Smoking. The risk increases with the
length of time and the number of
cigarettes smoked, even without
emphysema.
 Genetics. Certain types of pneumothorax
appear to run in families.
 Previous pneumothorax. Anyone who
has had one pneumothorax is at increased
risk of another.
Pathophysiology
Air enters pleural space
Air accumulation in pleural cavity (Build up
positive pressure)
Compression and collapse of lungs
Decrease vital capacity of lungs and
mediastinal shift
Pressure on lungs, trachea, heart and other
structures
PNEUMOTHORAX
 Classification DISEASE ASSOCIATED WITH SECONDARY
SPONTANEOUS PNEUMOTHORAX
 Spontaneous pneumothorax.
 COPD
 Traumatic pneumothorax.
 Tension pneumothorax.  Asthma
 HIV with pneumocystis pneumonia
Sponteneous Pneumothorax
 Necrotizing pneumonia
 A simple or spontaneous pneumothorax
occurs when air enters the pleural space  Tuberculosis
through a breach of either the parietal or
visceral pleura.  Sarcoidosis
 Spontaneous pneumothorax refers to the  Cystic fibrosis
abnormal collection of gas in the pleural
space between the lungs and the chest  Bronchogenic carcinoma
wall.  Idiopathic pulmonary fibrosis
 Spontaneous pneumothorax occurs
without an obvious etiology such as  Severe ARDS
trauma or iatrogenic causes.  Langerhans cell histiocytosis
SYMPTOMS  Lymphangioleiomyomatosis
 Tachycardia
 Collagen vascular disease
 Dyspnea
 Inhalational drug use like cocaine or
 A feared COMPLICATION is tension marijuana
pneumothorax.
 The DIAGNOSIS of spontaneous  Thoracic endometriosis
pneumothorax is based on clinical 
suspicion and can be confirmed with
imaging. Traumatic Pneumothorax
 MANAGEMENT of spontaneous  A traumatic pneumothorax occurs when
pneumothorax depends on multiple factors air escapes from a laceration in the lung
including the patient’s stability, the size of itself and enters the pleural space or from
the pneumothorax a wound in the chest wall.
 Traumatic pneumothorax occurs when air
CLASSIFICATION
accumulates between the chest wall and
the lung because of an injury. It causes
 Primary- Primary spontaneous
the lung to collapse partially or completely.
pneumothorax (PSP) occurs when the
patient does not have a history of the
underlying pulmonary disease
 Secondary- secondary spontaneous CAUSES:
pneumothorax (SSP) is associated with a  Penetrating or blunt trauma
history of an underlying pulmonary
disease.  Rib fracture
 Diving or flying
RISK FACTORS FOR PRIMARY
SPONTANEOUS PNEUMOTHORAX
SYMPTOMS:
 Smoking
 Tall thin body habitus in an otherwise  Chest pain. (Most of the pain is due to the
healthy person injury that caused the pneumothorax)

 Pregnancy  Short of breath or breathe rapidly and feel

that their heart is racing (particularly if the
 Marfan syndrome amount of air is large)
 Familial pneumothorax
If air accumulates under the skin, the skin
feels crackly and makes a crackling sound
when touched.
DIAGNOSTIC
 Chest x-ray
Doctors usually diagnose a pneumothorax
based on a chest x-ray. Sometimes
pneumothorax is diagnosed when CT or
ultrasonography is done to diagnose other
chest or abdominal injuries.
TREATMENT
 Removal of air from the pleural space
The goal of treatment is to remove the air
from the pleural space and allow the lung to
reinflate. Usually, a tube (thoracostomy or
chest tube) is inserted into the chest between
two ribs. The tube is attached to a suction
device to remove the air and to allow the lung
to reinflate. This procedure can be done using
only a local anesthetic.
Tension Pneumothorax
 A tension pneumothorax occurs when air
is drawn into the pleural space from a
lacerated lung or through a small opening
or wound in the chest wall.
 Tension pneumothorax is an uncommon
condition with a malignant course that
might result in death if left untreated.
 It is a severe condition that results when
air is trapped in the pleural space under
positive pressure, displacing mediastinal
structures and compromising
cardiopulmonary function.
CAUSES
 Penetrating or blunt trauma
 Barotrauma due to positive pressure
ventilation
 Percutaneous tracheostomy
 Conversion of
spontaneous pneumothorax to tension
 Open pneumothorax when occlusive
dressing work as one way valve
SIGNS AND SYMPTOMS
 severe shortness of breath
 shallow breathing
 acute chest pain
 low blood oxygen levels
 increased heart rate
 low blood pressure
 altered mental status
 Jugular venous distension
 Cyanosis
 Respiratory failure
 Cardiac arrest
Signs and Symptoms
 Sharp chest or shoulder pain, made worse
by a deep breath or a cough
 Shortness of breath
 Nasal flaring (from shortness of breath)
 Bluish color of the skin due to lack of
oxygen
 Chest tightness
 Lightheadedness and near fainting
 Easy fatigue
 Abnormal breathing patterns or increased
effort of breathing
 Rapid heart rate
 Shock and collapse
Diagnostics
 Thoracic CT: Studies show that CT is
more sensitive than x-ray in detecting
thoracic injuries, lung contusion,
hemothorax, and pneumothorax. Early CT
may influence therapeutic management.
 Chest x-ray: Reveals air and/or fluid
accumulation in the pleural space; may
show a shift of mediastinal structures
(heart).
 ABGs: Variable depending on the degree
of compromised lung function, altered
breathing mechanics, and the ability to
compensate. Paco2 occasionally elevated.
Pao2 may be normal or decreased;
oxygen saturation usually decreased.
 Thoracentesis: Presence
of blood/serosanguineous fluid indicates
hemothorax.
 Hb: Maybe decreased, indicating blood
loss.
Medical Management
 Chest tube. A small chest tube is inserted
near the second intercostal space to drain
the fluid and air. For patients with
jeopardized gas exchange, chest
tube insertion may be necessary to
 achieve lung re-expansion. The priority is  Monitor ABG levels.
to maintain the airway, breathing, and
circulation. The most important  Assist with chest tube thoracostomy.
interventions focus on reinflating the lung
by evacuating the pleural air. Patients with
 Encourage deep breathing exercises.
a primary spontaneous pneumothorax that
is small with minimal symptoms may have
spontaneous sealing and lung re-  Conduct a comprehensive pain
expansion. assessment.

 Maintain a closed chest drainage Nursing Diagnosis

system. Be sure to tape all connections,  Acute pain related to the positive pressure
and secure the tube carefully at the in the pleural space.
insertion site with adhesive bandages.  Ineffective breathing pattern related to
Regulate suction according to the chest respiratory distress.
tube system directions; generally, suction  Ineffective peripheral tissue
does not exceed 20 to 25 cm H2O perfusion related to severe hypoxemia.
negative pressure.  Anxiety related to difficulty in breathing.

 Monitor a chest tube unit for any kinks

or bubbling. These could indicate an air Evaluation
leak, but do not clamp a chest tube  Pain is relieved.
without a physician’s order because  Adhered to prescribed pharmacological
clamping may lead to tension regimen.
pneumothorax.  Established a normal, effective respiratory
pattern as evidenced by absence of
 Autotransfusion. Autotransfusion cyanosis.
involves taking the patient’s own blood  Demonstrated increase in perfusion.
that has been drained from the chest,  Patient is relaxed and reported anxiety is
filtering it, and then transfusing it back into reduced to a manageable level.
the vascular system.

 Antibiotics. Antibiotics are usually Prepared by:

prescribed to combat infection from
contamination. PASCUA, HEANGEL ORIO

 Oxygen therapy. The patient with SALDUA, MARJELLA

possible tension pneumothorax should
immediately be given a high concentration
of supplemental oxygen to treat the
hypoxemia.

Surgical Management
If more than 1500 ml of blood is aspirated
initially by thoracentesis, the rule is to open the
chest wall surgically.

 Thoracotomy. The chest wall is opened

surgically to remove the blood or air
trapped in the pleural space.

Nursing Intervention
 Assess lung sounds.

 Assess respiratory rate and rhythm.

 Evaluate imaging studies.

 Apply oxygen as ordered.