Respiratory Disorders:

Pleural and Thoracic

Injury
 I. Disorders of the Pleura

 A. Pleural Effusion
 Definition: a collection of

excess fluid in the pleural

space.

07/05/21 1
  Etiology of Pleural
Effusions:
 Heart Failure
 Liver Disease
 Renal Disease
 Lupus, Rheumatoid Arthritis
 Pneumonia
 TB
 Lung Cancer
 Trauma

07/05/21 2
  Pathophysiology of Pleural
Effusion
capillary pressure
or capillary permeability=
plasma proteins Exudate

Formation of excess fluid= Accumulation of pus

Transudate in the pleural space=Empyema

07/05/21 3
 Clinical Manifestations
of Pleural Effusion
 Dyspnea
 Pleurisy
 Decreased breath sounds
 Decreased chest wall movement

07/05/21 4
 Diagnostic Tests Pleural
Effusion
 CXR
 CT scan
 ABG’s/O2 Saturation

07/05/21 5
 Therapeutic Interventions
 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.
07/05/21 6
  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???

07/05/21 7
 Clinical Manifestations of
Spontaneous Pnemo
 Abrupt onset
 Pleuritic chest pain
 SOB, dyspnea
 respiratory rate, tachycardia
 Unequal chest excursion
 Decreased breath sounds on
affected side

07/05/21 8
  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

07/05/21 9
 Closed Open Iatrogenic
Pneumothorax Pneumothorax Pneumothorax
No opening from Opening from Puncture or
external chest. external chest laceration of
wall into pleura. visceral pleura
during medical tx

Occurs in Occurs in Occurs in central

crashes, falls, stabbings, line placement,
MVAs, CPR, gunshot wounds, thoracentesis,
fractured ribs that impalement lung biopsy,
penetrate the injury. bronchoscopy, &
pleura. mechanical
ventilation
07/05/21 10
 Clinical Manifestations of
Pneumothorax
 Dyspnea
 Pleuritic Pain
 RR, pulse

 respiratory excursion

 Absent breath sounds on

affected side
07/05/21 11
 D. Tension Pneumothorax
 Definition: air/blood/fluid rapidly
enters pleural space and unable
to escape

 Lung collapses

Emergency situation!

07/05/21 12
 Tension
Pneumothorax

                           

07/05/21 13
 Pathophysiology of
Tension Pnemothorax
 Increase in Intrapleural pressure

 Compression of lung to other side

 Compresses against trachea, heart, aorta,

esophagus

 Ventilation and Cardiac Output greatly

compromised
07/05/21 14
 Clinical
Manifestations/Complications of
Tension Pneumo
 Severe Dyspnea
 Tracheal Deviation
 Decreased Cardiac Output
 Distended Neck Veins
 RR, pulse, blood pressure

 Shock

07/05/21 15
 Therapeutic Interventions for
Pneumothorax
 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 thoracoscopic
surgery)

07/05/21 16
 II. Trauma of the
Chest/Lung
 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

07/05/21 17
 Crash Test

07/05/21 18
 Pathophysiology of
Thoracic Injury
 Acceleration-Deceleration Injury

 Rapid change in velocity

 Body stops suddenly

 Chest cavity organs/tissues

move forward
07/05/21 19
 A. Rib Fracture
 Simple rib fracture in an at risk
client may lead to pneumonia,
atelectasis, respiratory failure

 Displaced rib fractures can

result in pnemo/hemothorax,
intrathoracic vessel tears, liver
or spleen injury

07/05/21 20
 Clinical Manifestations of
Rib Fractures
 Pain on inspiration/coughing
 Voluntary splinting
 Rapid, shallow respirations
 Decreased breath sounds
 Crepitus on palpation
 Signs/symptoms of
pneumo/hemothorax

07/05/21 21
 B. Flail Chest
 Etiology/Pathophysiology
 Occurs when 2+ consecutive ribs are
fractured in multiple places

 Segment of chest wall becomes “free-

floating” or flail

 Flail segment of chest wall is sucked in

during inspiration and moves outward with
expiration

07/05/21 22
 The client presents in the
ED:
 Chest trauma client
 Flail chest trauma client

 What did you note in this client? What

would you do 1st? 2nd?
\

07/05/21 23
 Clinical Manifestations of
Flail Chest
 Dyspnea
 Pain especially on
inspiration
 Palpable crepitus
 Decreased breath sounds
 Unequal Chest expansion

07/05/21 24
 What assessment finding
is present???

                           

07/05/21 25
 Flail Chest
 Right lung
affected

07/05/21 26
 Therapeutic Interventions Flail
Chest
 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

07/05/21 27
  Internal/External fixation of ribs in
Flail Chest

07/05/21 28
 Judet Plates for Fractured
Ribs/Flail Chest

07/05/21 29
 Sanchez Plates for Fractured
Ribs/Flail Chest

07/05/21 30
 C. Pulmonary Contusion
 Etiology/Pathophysiology
 Left Pulmonary contusion

07/05/21 31
 Abrupt Chest Compression then
Rapid Decompression

Intra-alveolar Hemorrhage

Interstitial/bronchial Edema

surfactant production leads to

decreased lung compliance

Pulmonary vascular resistance

blood flow

Airway obstruction, Atelectasis,

07/05/21
Impaired O2/CO2 exchange 32
 Clinical Manifestations of
Pulmonary Contusion
 SOB

 Restlessness, Anxiety
 Chest Pain
 Copius Sputum (blood tinged)
 RR, Pulse, Dyspnea, Cyanosis

07/05/21 33
 Therapeutic Interventions
Pulmonary Contusion
 Intubation/Mechanical Ventilation
 Bronchoscopy to remove secretions,
cellular debris
 Fluids, Volume expanders to treat shock
 Pulmonary Artery pressure monitoring

07/05/21 34