Chapter 022

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.
Slide 1 Copyright © 2006 by Mosby, Inc.
Anatomic Alterations of the Lungs
 Lung collapse
 Atelectasis
 Chest wall expansion
 Compression of the great veins and
decreased cardiac venous return

Etiology—3 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)

Pneumothorax Classifications
General Terms
 Closed pneumothorax
 Open pneumothorax
 Tension pneumothorax

Pneumothorax Classifications
Based on Origin
 Traumatic pneumothorax
 Spontaneous pneumothorax
 Iatrogenic pneumothorax

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

Iatrogenic Pneumothorax

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).

Figure 9-7. Atelectasis clinical scenario.

Clinical Data Obtained at the
Patient’s 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

Figure 22-5. Venous admixture in pneumothorax.
Clinical Data Obtained at the
Patient’s 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

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.
Figure 22-7. Breath sounds diminish as gas accumulates in the intrapleural space.
Figure 22-8. As gas accumulates in the intrapleural space, the chest diameter
increases on the affected side in a tension pneumothorax.
Clinical Data Obtained from
Laboratory Tests and Special
Procedures

Pulmonary Function Study:
Lung Volume and Capacity Findings
VT RV FRC TLC
N or    
VC IC ERV RV/TLC%
 
 N

Arterial Blood Gases
Small Pneumothorax
 Acute alveolar hyperventilation with
hypoxemia
pH PaCO2 HCO3- PaO2

   (Slightly) 

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 PaC
O
2
20
10
Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Arterial Blood Gases
Large Pneumothorax
 Acute ventilatory failure with hypoxemia
pH PaCO2 HCO3- PaO2

   (Slightly) 

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
CO2
60
P a
50
40
30 Pa
O
2
20
10
0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Oxygenation Indices
QS/QT D O2 V O2 C(a-v)O2
  Normal (severe)
O2ER SvO2
 

Hemodynamic Indices
(Large Pneumothorax)
CVP RAP PA PCWP

   
CO SV SVI CI
   
RVSWI LVSWI PVR SVR

   

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

Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the heart and
mediastinum to the right away from the tension pneumothorax.
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).
General Management of
Pneumothorax
 >20%—gas should be evacuated
 Negative pressure—5 to 12 cm H2O
 Should not exceed negative 12 cm H2O

Pneumothorax
Respiratory care treatment protocols
 Oxygen therapy protocol
 Hyperinflation therapy protocol
 Mechanical ventilation protocol

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

Classroom Discussion
Case Study: Pneumothorax

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Chapter 22

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Figure 9-7. Atelectasis clinical scenario.

 Increased heart rate, cardiac output, blood pressure

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Slide 18 Copyright © 2006 by Mosby, Inc.

Slide 19 Copyright © 2006 by Mosby, Inc.

pH PaCO2 HCO3- PaO2

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90 Point at which PaO2

pH PaCO2 HCO3- PaO2

Slide 22 Copyright © 2006 by Mosby, Inc.

90 Point at which disease

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CVP RAP PA PCWP

RVSWI LVSWI PVR SVR

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Slide 26 Copyright © 2006 by Mosby, Inc.

Slide 29 Copyright © 2006 by Mosby, Inc.

Slide 30 Copyright © 2006 by Mosby, Inc.

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