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Chapter 22

Pneumothorax

CL

GA

DD

Figure 22-1. Right-side pneumothorax. GA, Gas accumulation; DD, depressed diaphragm;
CL, collapsed lung. Inset, Atelectasis, a common secondary anatomic alteration of the lungs.
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Anatomic Alterations of the Lungs
Lung collapse
Atelectasis
Chest wall expansion
Compression of the great veins and
decreased cardiac venous return

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Etiology3 Ways
From the lungs through a perforation of the
visceral pleura
From the surrounding atmosphere through a
perforation of the chest wall and parietal
pleura or, rarely, through an esophageal
fistula or a perforated abdominal viscus
From gas-forming microorganisms in an
empyema in the pleural space (rare)

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Pneumothorax Classifications
General Terms
Closed pneumothorax
Open pneumothorax
Tension pneumothorax

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Pneumothorax Classifications
Based on Origin
Traumatic pneumothorax
Spontaneous pneumothorax
Iatrogenic pneumothorax

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Figure 22-3. Closed (tension) pneumothorax produced
by a chest wall wound.
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Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura
that functions as a check valve.
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Spontaneous Pneumothorax

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Iatrogenic Pneumothorax

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Overview of the Cardiopulmonary
Clinical Manifestations Associated
with PNEUMOTHORAX
The following clinical manifestations result from
the pathophysiologic mechanisms caused (or
activated) by Atelectasis (see Figure 9-7)the
major anatomic alterations of the lungs
associated with pneumothorax (see Figure 22-1).

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Figure 9-7. Atelectasis clinical scenario.
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Clinical Data Obtained at the
Patients Bedside
Vital signs
Increased respiratory rate
Stimulation of peripheral chemoreceptors
Other possible mechanisms
Decreased lung compliance
Activation of the deflation receptors
Activation of the irritant receptors
Stimulation of the J receptors
Pain/anxiety

Increased heart rate, cardiac output, blood pressure


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Figure 22-5. Venous admixture in pneumothorax.
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Clinical Data Obtained at the
Patients Bedside
Cyanosis
Chest assessment findings
Hyperresonant percussion note over the
pneumothorax
Diminished breath sounds over the pneumothorax
Tracheal shift
Displaced heart sounds
Increased thoracic volume on the affected side
Particularly in tension pneumothorax

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Figure 22-6. Because the ratio of extrapulmonary gas to solid tissue increases in a
pneumothorax, hyperresonant percussion notes are produced over the affected area.
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Figure 22-7. Breath sounds diminish as gas accumulates in the intrapleural space.
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Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter
increases on the affected side in a tension pneumothorax.
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Clinical Data Obtained from
Laboratory Tests and Special
Procedures

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Pulmonary Function Study:
Lung Volume and Capacity Findings

VT RV FRC TLC
N or

VC IC ERV RV/TLC%
N

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Arterial Blood Gases
Small Pneumothorax
Acute alveolar hyperventilation with
hypoxemia

pH PaCO2 HCO3- PaO2


(Slightly)

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Time and Progression of Disease
Disease Onset Alveolar Hyperventilation
100

90 Point at which PaO2


declines enough to
80 stimulate peripheral
oxygen receptors
70
PaO2 or PaCO2

60
PaO2
50

40

30

20

10

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood Gases
Large Pneumothorax
Acute ventilatory failure with hypoxemia

pH PaCO2 HCO3- PaO2


(Slightly)

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Time and Progression of Disease
Disease Onset Alveolar Hyperventilation Acute Ventilatory Failure
100

90 Point at which disease


becomes severe and patient
Point at which PaO2
begins to become fatigued
80 declines enough to
stimulate peripheral
70 oxygen receptors
Pa02 or PaC02

60

50

40

30

20

10

0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
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Oxygenation Indices

QS/QT DO2 VO2 C(a-v)O2


Normal (severe)

O2ER SvO2

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Hemodynamic Indices
(Large Pneumothorax)

CVP RAP PA PCWP


CO SV SVI CI

RVSWI LVSWI PVR SVR


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Radiologic Findings

Chest radiograph
Increased translucency
Mediastinal shift to unaffected side
in tension pneumothorax
Depressed diaphragm
Lung collapse
Atelectasis

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Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the heart and
mediastinum to the right away from the tension pneumothorax.
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A B

Figure 22-10. A, Development of a small tension pneumothorax in the lower part of the right lung (arrow).
B, The same pneumothorax 30 minutes later. Note the shift of the heart and mediastinum to the left away
from the tension pneumothorax. Also note the depression of the right hemidiaphragm (arrow).
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General Management of
Pneumothorax
>20%gas should be evacuated
Negative pressure5 to 12 cm H2O
Should not exceed negative 12 cm H2O

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General Management of
Pneumothorax
Respiratory care treatment protocols
Oxygen therapy protocol
Hyperinflation therapy protocol
Mechanical ventilation protocol

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General Management of
Pneumothorax
PLEURODESIS
Chemical or medication injected into the
chest cavity
Talc
Tetracycline
Bleomycin sulfate
Produces inflammatory reaction between
lungs and inner chest cavity
Causes lung to stick to chest cavity
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Classroom Discussion
Case Study: Pneumothorax

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