Pathophysiology: Pneumothorax- A trauma occurs to the pleural space and air accumulates within the space. This puts positive pressure in a space that is normally filled with negative pressure. The air within the space compresses and collapses the lung.
Blood collects in the pleural cavity (the space between the chest wall and the lungs). This can cause the lungs to collapse.
- Pneumothorax – air rushes into pleural space
- Hemothorax – blood accumulates in pleural space
- Spontaneous – no obvious injury
- Primary – ruptured bleb in otherwise healthy patient
- Secondary – rupture of distended alveoli
- Positive Pressure Ventilation
- Penetrating Trauma
- Punctured lung – air escapes
- Tension Pneumothorax
- Buildup of air → shifts mediastinum to unaffected side
- Pressure on large vessels
- Decreased venous return
- ↓ cardiac output
- Medical Emergency
- Spontaneous – no obvious injury
- Penetrating or Blunt Trauma
- Ruptured vessels (rib fractures)
- Bleeding lesion/mass/tumor
- Decreased or absent breath sounds on affected side
- Decreased or asymmetrical chest expansion on affected side
- Dullness on percussion (Hemo)
- Hyperresonance on percussion (Pneumo)
- Tracheal deviation to unaffected side (Tension Pneumo)
- High-Fowler’s Position
- Remove air/blood
- Chest Tube Insertion
- Needle Decompression (for tension pneumothorax)
- Three-Sided Dressing
- For open pneumo (“sucking chest wound”)
- Nonporous, occlusive dressing taped on three sides
- Creates one-way valve to allow air to escape, but not return
- Oxygenation/Gas Exchange
- Supplemental O2
- Manage Chest Tube(s)
- Position of comfort
- Three-sided dressing
- Also used if chest tube accidentally dislodged
- Three-sided dressing
- Process for Chest Tube placement or thoracentesis (see those two lessons for details)
- Deep breathing exercises to prevent atelectasis in good lung
- Good lung down positioning to improve perfusion to good lung
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
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- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
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In this lesson, we’re going to talk about pneumothorax and hemothorax. Now, by the name you can tell that this is a condition that has something to do with our thorax or our thoracic cavity. Pneumo means air and hemo means blood. So a pneumothorax is air in the thoracic cavity and a hemothorax is blood in the thoracic cavity.
In a pneumothorax, air escapes out of the lungs and into the pleural space. That means it takes up room and prevents the lung from expanding completely. So what we see is a collapsed lung. This could be because of a ruptured bleb. A bleb is a little vesicle type lesion that can form on our lungs. If it ruptures, air will come out of the lungs and into the pleural space. Now this could happen spontaneously or it could be due to other conditions. It’s possible in COPD as well as with positive pressure ventilation where the alveoli can get so distended that they rupture. Then of course if they have any type of penetrating trauma like a stab wound, a gunshot wound, or even a rib fracture that punctures a lung, we will see air escaping from the lung tissue and filling this pleural space. When that happens, the lung cannot expand correctly.
In severe cases, patients can develop what’s called a tension pneumothorax. What happens in this case is that the air has built up so much that it begins to put pressure on the heart and the mediastinum. You can see here…. Everything has shifted to the patient’s right, or to the unaffected side, because of that buildup of air on the patient’s left. Now, remember here’s the heart and here’s the patient’s aorta as well as their Superior and inferior vena cava. If we’re putting pressure on these vessels, we’re actually going to see a decreased cardiac output because that venous return is impaired. There’s so much pressure on these vessels that they’re not allowing enough blood to get back into the heart. This is a medical emergency and needs to be addressed immediately.
The patient could also develop a hemothorax, which occurs when blood fills the pleural space as opposed to air. But it causes the same issue with lung expansion and therefore a collapsed lung. This could be because of ruptured vessels or bleeding masses within the lungs, or again due to penetrating trauma like a stab wound or a gunshot wound. As the blood builds up within the pleural space it compresses and collapses the lung, therefore preventing proper expansion.
There’s a few general things were going to see with all of these situations. The patient will have decreased or absent breath sounds on the affected side, because they aren’t moving air in that lung tissue. We will also see decreased chest expansion or asymmetrical chest expansion on the affected side. That means when a patient takes a deep breath we may see their right side expand deeply and their left side only expand a little bit. And then of course the patient is probably going to complain of trouble breathing and we might see their oxygenation decrease as well. We typically diagnose with chest x-rays, but there are a couple things we can look for that will tell us right away what we’re dealing with. Normal percussion of the lungs gives a resonant sound because it’s an air-filled structure. If your patient has a hemothorax you will hear dullness when you percuss, because of the fluid buildup. In a pneumothorax you will hear hyperresonance. In this case you’re hearing only air, as opposed to air-filled tissue, so it will sound very hollow. Then, in a tension pneumothorax you will see the trachea deviate to the patient’s unaffected side. So if this is their trachea and they have a tension pneumo on the left side putting pressure toward the unaffected side we will also see the trachea shift over towards the unaffected side. That is considered a classic sign of a tension pneumo, along with evidence of decreased cardiac output. That’s your indication that you need to intervene immediately.
So what do we do for these patients? Well in terms of nursing specific interventions we want to put them into high Fowler’s position and give supplemental O2 to improve oxygenation. Most of the time these patients will receive a chest tube inserted through the chest wall and into the pleural space in order to drain the blood or to release the air. It functions like a one-way valve to allow the blood or air to escape without letting air back in. Be sure to check out the chest tube management lesson to learn more about how these work and how you take care of them. For a tension pneumothorax there’s an emergency procedure called a needle decompression. In this case the provider will stick a large needle into the pleural space to allow that air to escape quickly. You will actually hear a pssssssss sound when the needle goes in. Then finally for patients who have a buildup of fluid or blood around their lung we could also do something called a thoracentesis. We’ll talk in more detail about this in the thoracentesis lesson, but essentially we stick a large needle into the pleural space and allow it to drain into a bag or container to release pressure on the lungs.
The last thing you need to be aware of is what to do if your patient has an open pneumothorax. In this case they may have a hole in their chest wall, for example, if they had a gunshot wound. So every time they take a deep breath in that negative pressure pulls more air into the pleural space. That’s why we call them sucking chest wounds. Because of this, the pneumothorax continues to build. If we put a fully occlusive dressing over this hole and cover it completely, it’s true that no more air will get in through the hole, however, the air that’s escaping out of the lung tissue itself will now be trapped in that space, and it will make the pneumothorax worse. Instead, we place a non-porous, occlusive dressing over the site, then we tape it on three sides. What this does is allows air to escape when the patient breathes out, but when they breathe in it sucks dressing against the chest wall so that no more air can enter. Essentially it creates a one-way valve. This is not a permanent fix, but in an emergency it will keep the patient from getting worse while we work on fixing the problem.
So for nursing concepts, of course we’re going to see oxygenation and gas exchange, because we’ve talked about how these conditions prevent lung expansion. So we need to monitor their SpO2, listen to their lung sounds, and give O2 as needed. Now these patients will often receive some invasive procedures like chest tubes or a thoracentesis. So we want to make sure we give pain medication as ordered and make sure they’re comfortable. Make sure you check out the care plan attached to this lesson to see more specific nursing interventions.
So remember that pneumothorax and hemothorax cause the lung to be collapsed by either air or blood building in the pleural space. A tension pneumothorax puts pressure on the mediastinum and the major blood vessels, causing a decreased venous return and decreased cardiac output. This is a medical emergency so we need to be prepared to intervene. Remember the whole goal is to treat the cause by removing the air or the blood from the pleural space to allow the lung to expand completely. And then finally remember to be prepared for any of these emergent procedures and know how to place a three-sided dressing if necessary. Be sure to check out the chest tube lesson as well as the thoracentesis lesson to learn more about nursing care for these procedures.
We hope this lesson was helpful. Let us know if you have any questions. Now go out and be your best selves today. And, as always, Happy nursing!