PNEUMOTHORAX

Presented by:
Sunita Shrestha (13)
Sushma Pahadi (14)
Susma Limbu (15)
Tara Basnet (16)
Pneumothorax

• Pneumothorax is the accumulation of extrapulmonary air within the

chest, most commonly from leakage of air from within the lungs.

• Pneumothorax is the collection of air or gas in the pleural space.

• It may be developed due to rupture of subpleural or mediastinal nodes

through the parietal pleura.
Pneumothorax contd….

• Pneumothorax usually occurs along with fluid (hydro-pneumothorax),

with blood ( hemopneumothorax ) and purulent materials
(pyopneumothorax).

• It may occur spontaneously as spontaneous pneumothorax ( due to

trauma or pathological process ) or be introduced deliberately as
artificial pneumothorax.
Epidemiology

• Although all age groups are affected, the peak incidence of

pneumothorax occurs in individuals aged 16-64 years.

• In the pediatric population, the overall incidence of pneumothorax is

5-10 cases per 100,000 children younger than 18 years.

• The rate of pneumothorax is relatively higher during the newborn

period.
Epidemiology contd…

• Primary spontaneous pneumothorax may have a higher recurrence rate

in children than in adults.

• It can also present in reproductive-age girls as catamenial

pneumothorax
Causes

1. SPONTANEOUS

a. Primary idiopathic(no underlying lung disease)

• Spontaneous rupture of sub pleural blebs

b. Secondary (underlying lung disease)

congenital lung disease

• congenital cystic adenomatoid malformation
Causes contd…

• Bronchogenic cysts
• Pulmonary hypoplasia
• Birt-Hogg-Dube syndrome

Conditions associated with increased intrathoracic pressure

• Asthma
• Bronchiolitis
Causes contd…

• Cystic fibrosis
• Airway foreign body
• Smoking (cigarettes, marijuana, crack cocaine)

 Infection

• Tuberculosis
• Pneumocystis carinii (iroveci)
Causes contd…

• Echinococcosis

• Pneumatocele
• Lung abscess
• Bronchopleural fistula

 Lung disease
• Langerhans cell histiocytosis
Causes contd…

• Tuberous sclerosis
• Pulmonary fibrosis
• Sarcoidosis
• Rheumatoid arthritis, scleroderma
• Metastatic neoplasm usually osteosarcoma (rare)
• Pulmonary blastoma
Causes contd…

2. TRAUMATIC

Non-iatrogenic

• Penetrating trauma
• Blunt trauma

Iatrogenic
• Thoracotomy
Causes contd…

• Thoracoscopy, thoracentesis

• Tracheostomy
• Tube or needle puncture
• Mechanical ventilation
• High-flow therapy (moved from non-iatrogenic)
Pathophysiology
Clinical Manifestation

• Dyspnea

• Cyanosis

• Chest pain

• Mediastinal shift to healthy side

• Hyper-resonant percussion note

• Flat percussion indicates presence of fluid

Diagnosis

 History:
• Chief complaints, onset, duration, pain description, associated
symptoms such as cough, fever, fatigue, dizziness etc.

 Physical examination:
• General apperance, signs of distress, cyanosis, chest movement
during respiration, breathe sound, tracheal deviation etc.
Diagnosis Contd…

 Chest X-ray:
• This is the primary diagnostic tool to confirm the presence and
extent of pneumothorax.

 Chest ultrasonography:
• It is especially useful when a chest X-ray is inconclusive or in
cases where immediate bedside evaluation is needed to quickly
assess and diagnose pneumothorax.
Diagnosis Contd…
Arterial blood gas (ABG) analysis:
• ABG analysis can help assess the patient's respiratory function and
determine the severity of respiratory compromise caused by
pneumothorax.
• It provides information about oxygenation levels (PaO2) and
carbon dioxide retention (PaCO2) and can guide decision-making
on the need for supplemental oxygen or assisted ventilation.
Diagnosis Contd…

 CT scan:
• CT scans can provide a more comprehensive visualization of the
lungs and pleural spaces, allowing for a better assessment of the
condition and associated abnormalities.
Treatment and management
Goal- to evacuate air promptly and allow the lung to re-inflate.

Supplemental oxygen:
• To treat hypoxia, maintaining adequate oxygenation while awaiting
other interventions.

Conservative management:
• In some cases, pneumothorax may resolve on its own over time,
without the need for intervention but close monitoring is necessary.
Treatment and management Contd…

Pharmacotherapy:
• Local anesthetics (eg, lidocaine hydrochloride)
• Opioid anesthetics (eg, fentanyl citrate, morphine)
• Benzodiazepines (eg, midazolam, lorazepam)
• Antibiotics (eg, doxycycline, cefazolin)
Treatment and management contd…
Surgery: If the patient has had repeated episodes of pneumothorax or
if the lung remains unexpanded after 5 days with a chest tube in place,
operative therapy such as the following may be necessary:
• Needle aspiration/ decompression
• Chest tube insertion
• Thoracoscopy: Video-assisted thoracoscopic surgery (VATS)
• Pleurodesis or sclerotherapy
• Resection of blebs or pleura
• Open thoracotomy
Needle aspiration/ Simple aspiration:

• For clinically stable patients with larger pneumothorax or

symptoms present, needle aspiration may be performed.

• In needle aspiration, air is manuaaly withdrawn using an

intravenous catheter connected to a syringe and three way

stopcock.
Chest tube insertion

• In more severe cases or if needle aspiration is insufficient, a chest

tube may be inserted to drain the air and re-expand the lung.

• This is done under sterile conditions and usually requires

hospitalization.
Video-assisted thoracoscopic
surgery (VATS):

• Video-assisted thoracoscopic surgery (VATS) is a minimally

invasive procedure that utilizes a small video camera and
specialized instruments inserted through small incisions in the
chest wall.
• Less invasive surgical approach used to treat persistent or recurrent
pneumothorax.
Video-assisted thoracoscopic surgery
(VATS) contd…
• It allows for visualization and treatment of the pleural space,
including the resection of blebs or bullae, pleurodesis, or removal
of adhesions.
Pleurodesis or sclerotherapy
• Mechanical Pleurodesis or sclerotherapy: It can be performed using
electrocautery. Electrocautery uses heat to create intentional
inflammation and scarring between the two layers of the pleura,
promoting adhesion and preventing the recurrence of pneumothorax.
Pleurodesis or sclerotherapy contd…

• Chemical Pleurodesis: Chemical pleurodesis involves the instillation

of a sclerosing agent into the pleural space to create inflammation and
promote adhesion formation. Common sclerosing agents used include
talc (most commonly used), bleomycin, tetracycline, doxycycline, and
erythromycin.
Resection of blebs or pleura
• Blebs are thin-walled air-filled sacs on the lung's surface that are prone
to rupture and cause pneumothorax.

• Resection of blebs or bullae (larger air-filled spaces) can be performed

to prevent further episodes of pneumothorax.

• In some cases, the pleura (the membrane lining the chest cavity and
lungs) may also need to be resected if it is causing recurrent air leaks.
Open thoracotomy
• In severe or complicated cases, an open thoracotomy may be
necessary.

• This involves making a larger incision in the chest wall to access the
thoracic cavity and perform more extensive surgical procedures, such
as lung resection or repair of underlying lung diseases like
emphysema.
Nursing Management
 Assessment
• Assess the child's vital signs including oxygen saturation, respiratory
rate, breath sounds, and effort.

• Obtain a thorough health history, including any previous episodes of

pneumothorax, lung diseases, trauma, or underlying conditions.

• Monitor for signs of respiratory distress, such as increased work of

breathing, use of accessory muscles, and cyanosis.
Nursing Management Contd…

Nursing diagnosis:
• Impaired gas exchange related to lung collapse and decreased
oxygenation.

• Ineffective breathing pattern related to reduced lung expansion and

increased work of breathing.

• Acute Pain related to lung collapse and tissue irritation.

Nursing Management Contd…

• Parental Anxiety related to the child's condition and required medical

interventions.

• Risk for infection related to invasive procedures or interventions.

Nursing Management Contd…

 Nursing Interventions:

 To improve gas exchange:

• Monitor respiratory rate, effort, and oxygen saturation levels regularly.

• Administer oxygen therapy as prescribed to maintain adequate

oxygenation.
Nursing Management Contd…

• Position the child in a comfortable position that promotes lung

expansion and optimal gas exchange.

• Encourage deep breathing exercises and coughing to help remove

trapped air and improve lung function.

• Monitor and manage pain or discomfort that may interfere with

breathing and deep breathing exercises.
Nursing Management Contd…
 To alleviate pain

• Assess and document the child's pain level using appropriate pain
assessment tools.

• Administer prescribed pain medications, such as opioids, as ordered

by the healthcare provider.

• Provide non-pharmacological pain relief measures, such as distraction

techniques, comfort measures, and repositioning.
Nursing Management Contd…

• Educate the child and family about pain management strategies and
the importance of reporting any changes in pain intensity or location.
Nursing Management Contd…

 To prevent infection

• Practice appropriate hand hygiene and aseptic technique during any

invasive procedures.

• Monitor the child's vital signs, temperature, and signs of infection

(e.g., fever, increased white blood cell count).
Nursing Management Contd…

• Assess and monitor the insertion site for chest tube or other invasive
procedures for signs of infection or inflammation.

• Educate the child and family about signs and symptoms of infection
and when to seek medical attention.
Nursing Management Contd…

 To reduce parental anxiety

• Explain the condition of pneumothorax, its causes, and treatment

options to parents.

• Provide a safe and supportive environment for parents to express their

feelings and concerns.

• Listen actively and empathetically to parents' anxieties, fears, and

frustrations.
Nursing Management Contd…
• Validate their emotions and reassure them that their feelings are
understandable and normal.

• Involve parents in their child's care as much as possible

• Teach parents how to perform non-invasive tasks, such as positioning

their child comfortably or assisting with activities of daily living.

• Keep parents informed about their child's progress and any changes in
the treatment plan.
Nursing Responsibilities/Care of Patient
with Chest Tube
• Keep drainage system 2-3 feet below patient's chest

• Keep tubing patent; make sure no kinks or clots present

• Observe and record amount of drainage ( > 100cc/hr is heavy...notify

physician).

• Encourage TCDB, ambulation as ordered.

Prognosis

• Prognosis varies depending in patient’s underlying disease and

pulmonary reserve.

• If other trauma was sustained at the same time or tension

pneumothorax occurred with subsequent shock and hypoperfusion, the
prognosis worsens.

• If the patient was allowed to be hypoxic for a long period, brain injury
is possible.
Prognosis contd…

• Recurrence after the first episode of primary spontaneous

pneumothorax in children is frequent and difficult to predict.

• The recurrence rate of spontaneous pneumothoraces can range from

40-87%.

• Patients with obstructive pulmonary disease (eg, asthma, cystic

fibrosis) have an especially high rate of recurrence.
Complication
• Hypoxemic respiratory failure
• Respiratory or cardiac arrest
• Hemopneumothorax
• Bronchopulmonary fistula
• Pulmonary edema (following lung reexpansion)
• Empyema
• Pneumomediastinum, Pneumopericardium, Pneumoperitoneum
• Pyopneumothorax
Complication contd…
Complications of surgical procedures include the following:
• Acute respiratory distress or failure
• Infection of the pleural space
• Cutaneous or systemic infection
• Persistent air leak
• Reexpansion pulmonary edema
• Pain at the site of chest tube insertion
• Prolonged tube drainage and hospital stay
Prevention

• Prompt recognition and treatment of bronchopulmonary infections

decreases the risk of progression to a pneumothorax

• Encourage children to maintain a healthy lifestyle by engaging in

regular physical activity, eating a balanced diet, and avoiding smoking
or exposure to secondhand smoke.
Prevention contd…
• Preventive measures should be taken to reduce the risk of traumatic
injuries in children e.g. promoting seatbelt and helmet use,
childproofing the home to prevent falls or accidents, and supervising
children during play or sports activities.

• Medical procedures, such as central line insertion or mechanical

ventilation, should be performed by trained healthcare professionals
using proper techniques to minimize the risk of iatrogenic (procedure-
related) pneumothorax.
Prevention contd…

• Educate children, parents, and caregivers about the signs and

symptoms of pneumothorax, especially in those with underlying lung
conditions as the prompt recognition and seeking medical attention at
the earliest signs can help in early diagnosis and management.
References
• Ghai, O., Paul, K.V and Bagga. A. Essential Pediatrics(7th ed.). CBS
Publisher and Distributor
• Hockenberry, M. J., Wilson, D., & Rodgers, C. C. (2018). Wong’s Nursing
Care of Infants and Children (11th ed.). St. Louis, MO: Elsevier.
• Kliegman, M.R (2014).Nelson Textbook of pediatrics(1st ed.). Klsevier
• https://www.slideshare.net/PushpaNepal/pneumothorax-ppt-368-final
• https://emedicine.medscape.com/article/1003552overview?&icd=login_success_e
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