Pleural Space Complications (Pneumothorax, Hemothorax, Pleural Effusion, Empyema, Chylothorax)

Definition/Etiology:

• Definition: Changes in the pleural space (which envelopes the lungs) that affect COMPLIANCE aka normal negative pressure changes.
• Analogy: Negative pressure = ever try to pull two wet plates apart? Lungs normally display negative pressure (fancy word for vacuum), which is much like two wet plates sticking together.
• Etiology
  • Trauma
    • Accidental or surgery
  • Severe Respiratory INfection
  • Lung Cancer
  • Pump Failure
    • Heart Failure
    • Kidney DIsease

Pathophysiology:

• The space between its two layers, that wraps around the lung, is called the pleural space.
• A small amount of fluid called surfactant (SUPPOSED to be there) fills the pleural space, and when you breathe in and out, this fluid helps the pleural layers glide smoothly against each other.
• An injury, inflammation, or infection can cause fluid or air to build up in the pleural space and lead to a pleural disorder.
• Air or Fluid That DOESN’T Belong!
  • Air – Pneumothorax
  • Blood – Hemothorax
  • Fluid – Pleural Effusion
  • Pus – Empyema
  • Lymph – Chylothorax

Noticing: Assessment & Recognizing Cues:

• Subjective Cues
  • SOB
  • Chest pain with breathing
  • Coughing
• Objective Cues
  • Vitals
    • Suggestive of hypoxia
    • 02 sat will only continue to decrease until this is fixed
  • Bulging of the intercostal spaces
    • over-expansion of lung tissue
  • Unilateral Lung Expansion
    • Atelectasis
  • Decreased/Wet lung sounds
    • Rales/Crackles

Interpreting: Analyzing & Planning:

• Labs
  • ABGs – Resp Failure
    • ↑c02 ↓Pa02
  • Sputum
    • Culture and sensitivity
      • What is growing
      • What Abx works the best on that bug?
    • Collected in the morning by cough
    • Color, Odor Viscosity/Blood
• Diagnostics
  • US Guided Thoracentesis
    • Remove fluid + analysis
  • Imaging – Look at lungs and for the cause
  • Biopsy -lung disease or cancer is present

Responding: Patient Interventions & Taking Action:

• ABCs
  • Oxygen Modalities to reduce hypoxia
• Pharmacological – Underlying Cause
  • Abx if infection
  • Steroids/NSAIDS almost always to strengthen lungs and reduce inflammation
  • Low Dose Morphine
    • Chest tubes are painful often with referred back pain when moving or coughing
• Interventions Non-Pharmacological.
  • Pleural Chest tube
    • Pleural tubes remove free air, drain the intrapleural space, and reestablish negative pressure in pleural space.
    • Make sure to review and understand bubbling, tidaling, suction settings, etc.
  • Positioning
    • Prone unless it’s a mediastinal chest tube (anterior chest from CABG)
    • Turning side to side help chest tube remove fluid.
• Adjunct Medical Therapy
  • Surgeon & RT

Reflecting: Evaluating Patient Outcomes:

• Oxygenation & Gas Exchange
  • Monitor CHEST TUBE
    • Assessment starts at the patient’s incision and THEN move down to the tubing and the drain.
    • Don’t forget Subcutaneous Emphysema “Crepitus” which is the rice krispie effect.
• Symptoms
  • Resp DIstress
  • Pain – sometimes in upper back (referred)
• Patient Education
  • Emergency = Tube falls out
    • Slap a gloved hand on that hole and yell for help. Risk of tension pneumothorax
  • Splint coughing
    • Reduced pain
    • Protects Chest Tube incisions

Linchpins (Key Points):

• Notice – Resp Distress
  • Hypoxia and usually Unilateral Lung Expansion
• Interpret – Sputum and Diagnostics
  • Underlying cause?
  • Tons of imaging here, CXR, CT, MRI
• Respond
  • Monitor Chest tube -Incision to drain
  • Review all the pieces and parts of charting
  • Pain – Medicate
• Reflect
  • Double check ALL chest tube compliments – common error!
  • Trace from the patient to the container