Lung Conditions & Traumatic Lung Conditions & Traumatic Injury to the LungInjury to the Lung

Read Neuro Chapter 60Read Neuro Chapter 60

ObjectivesObjectives

To outline and discuss management of To outline and discuss management of some of the commonly encountered some of the commonly encountered lung conditions and traumatic injuries lung conditions and traumatic injuries to the lung including:to the lung including:

PneumoniaPneumonia Pulmonary embolisPulmonary embolis PneumothoraxPneumothorax Pleural effusionPleural effusion BarotraumaBarotrauma Flail chestFlail chest

Figure U13-2: Structures of the Figure U13-2: Structures of the Lower AirwaysLower Airways

Pulmonary EmbolismPulmonary Embolism

Pulmonary Pulmonary embolism occurs embolism occurs when a blood clot when a blood clot becomes lodged becomes lodged in a lung artery, in a lung artery, blocking blood blocking blood flow to lung flow to lung tissue. Blood tissue. Blood clots often clots often originate in the originate in the legs.legs.

Video: PEVideo: PE

What is a Pulmonary Emoblism? What is a Pulmonary Emoblism? What are the symptoms What are the symptoms

associated with it?associated with it?

Pulmonary EmbolismPulmonary Embolism

Blockage makes it more difficult for Blockage makes it more difficult for the heart to pump blood through the heart to pump blood through lungs. As a result, less oxygen is lungs. As a result, less oxygen is available to the rest of the body. available to the rest of the body. If the If the blockage is large enough, tissue death blockage is large enough, tissue death (infarction) occurs in the lung area (infarction) occurs in the lung area cut off from circulation.cut off from circulation. Pulmonary embolisms are commonly Pulmonary embolisms are commonly misdiagnosed.misdiagnosed.

Signs and SymptomsSigns and Symptoms

Easily attributed to other Easily attributed to other conditions and vary with the size conditions and vary with the size and number of clots. and number of clots.

Such as a heart attack Such as a heart attack Pneumonia Pneumonia

HyperventilationHyperventilation Congestive heart failure Congestive heart failure

Panic attacks. Panic attacks.

No Classic Pattern: No Classic Pattern: Most Most common symptoms: common symptoms:

A A sudden unexplained onsetsudden unexplained onset of shortness of breath, of shortness of breath, tachypnea or tachycardia, as tachypnea or tachycardia, as well as sharp knife-like chest well as sharp knife-like chest pains (pleuritic chest pain), pains (pleuritic chest pain), when taking a breath, & when taking a breath, & sense of impending doom. sense of impending doom.

WHAT ELSE?WHAT ELSE?

Blood may be coughed up as a result Blood may be coughed up as a result of lung tissue damage of lung tissue damage

If the clot is particularly large, it can If the clot is particularly large, it can lead to dizziness and even fainting lead to dizziness and even fainting due to dangerously low blood due to dangerously low blood pressure. pressure.

Who is at risk?Who is at risk? Immobilization Immobilization — Being — Being

immobilized puts a strain on the immobilized puts a strain on the circulatory system. Although the circulatory system. Although the heart acts as the body’s main pump, heart acts as the body’s main pump, movement also assists in keeping movement also assists in keeping blood circulating properly. blood circulating properly.

Long periods of inactivityLong periods of inactivity may may increase risk of blood clots. increase risk of blood clots. Examples include lengthy road trips Examples include lengthy road trips or flights, or bed rest due to illness or flights, or bed rest due to illness or surgery. or surgery.

Blood abnormalitiesBlood abnormalities — Some people — Some people are born with blood that’s more are born with blood that’s more prone to clotting & those prone to clotting & those dehydrated, septic, have Ca, those dehydrated, septic, have Ca, those giving birth.giving birth.

Other Risk Factors for Pulmonary Other Risk Factors for Pulmonary EmbolismEmbolism

Advanced age (especially over age 70)Advanced age (especially over age 70)

Significantly overweightSignificantly overweight

Birth control pills, HRT drugs & the Birth control pills, HRT drugs & the osteoporosis drug raloxifene (Evista) osteoporosis drug raloxifene (Evista) are examples of drugs that list a small are examples of drugs that list a small risk of developing blood clots.risk of developing blood clots.

About 90 % of Pulmonary EmboliAbout 90 % of Pulmonary Emboli Result When Result When a Clot Travels from a Leg to a Lung - often no a Clot Travels from a Leg to a Lung - often no symptomssymptoms Blood tests, a chest X-ray, an Blood tests, a chest X-ray, an

electrocardiogram — to help rule out electrocardiogram — to help rule out other possible reasons for symptoms. other possible reasons for symptoms.

Sometimes a leg blood clot may Sometimes a leg blood clot may cause cause redness, swelling and pain in redness, swelling and pain in the calf muscle areathe calf muscle area.. Refer to a Refer to a physician promptly. physician promptly.

A pulmonary angiogram is a more A pulmonary angiogram is a more definitive test, although it involves definitive test, although it involves some risk and is more expensive.some risk and is more expensive.

the CT scan (computed tomography the CT scan (computed tomography scan) — instead of lung scan or scan) — instead of lung scan or pulmonary angiogram. CT scan is a pulmonary angiogram. CT scan is a less invasive test that provides fast less invasive test that provides fast and accurate results.and accurate results.

Thoracic SurgeryThoracic Surgery Teaching: why frequent monitoring of Teaching: why frequent monitoring of

vital signs, hematocrit, and amount of vital signs, hematocrit, and amount of plural drainage is important following plural drainage is important following thoracic surgery. thoracic surgery.

At what point should the attending At what point should the attending physician be called?physician be called?

Explain why regular assessment of the Explain why regular assessment of the trachea is important post-op.trachea is important post-op.

Why are pulmonary function tests Why are pulmonary function tests important? What results may indicate important? What results may indicate an increased risk of complications?an increased risk of complications?

The patient is nursed upright in bed to allow for maximum chest expansion and unrestricted drainage and may even be extubated in the upright position. Because the patient is not in the recovery position, particular care must be taken that the airway is not obstructed and respiration rate, effort and oxygen saturation levels are closely monitored. As there is a risk of CO retention, a maximum of four litres per minute of oxygen is given and blood gases may have to be checked. The ECG is checked for cardiac arrhythmias, a potential complication for these patients (Schedel & Connolly)

ThinkThink What should you do, if while turning a What should you do, if while turning a

client just back from the OR following a client just back from the OR following a segmental or wedge resection, there is a segmental or wedge resection, there is a sudden gush of fluid through the chest sudden gush of fluid through the chest tube?tube?

Shouldn’t pooled blood have clots in it?Shouldn’t pooled blood have clots in it? Following post-op chest surgery, why is Following post-op chest surgery, why is

the client at risk of hypoxemia? Identify the client at risk of hypoxemia? Identify how gas exchange may be improved. how gas exchange may be improved. Should the “good lung or bad lung” be Should the “good lung or bad lung” be down?down?

Common Respiratory Common Respiratory Problems Following Problems Following Thoracic SurgeryThoracic Surgery

Refer also to student presentations Refer also to student presentations & presentation on Lung Cancer & presentation on Lung Cancer

earlier in term they all relateearlier in term they all relate

Keep in mind!!Keep in mind!!

Patients tend to Patients tend to gasp gasp milliseconds milliseconds before a crash or before a crash or a fall.a fall.

This fills lungs This fills lungs with air, distends with air, distends alveoli, making alveoli, making them more prone them more prone to rupture.to rupture.

PNEUMOTHORAXPNEUMOTHORAX

PneumothoPneumothoraxrax

PneumothoraxPneumothoraxOpenOpen

Air enters the Air enters the chest during chest during inspiration & inspiration & exits during exits during expiration. A expiration. A slight shift of slight shift of the affected the affected lung may occur lung may occur because of a because of a decrease in decrease in pressure as air pressure as air movesmoves out of the out of the chest chest (Smeltzer, (Smeltzer, 2000, p. 468)2000, p. 468)

TensionTension

Air enters but cannot leave Air enters but cannot leave the chest. As the the chest. As the pressure increases, the pressure increases, the heart & great vessels are heart & great vessels are compressed & the compressed & the mediastinal structures mediastinal structures are shifted towards the are shifted towards the opposite side of the chest. opposite side of the chest. The trachea is pushed The trachea is pushed from its normal midline from its normal midline position toward the position toward the opposite side of the chest opposite side of the chest & the unaffected lung is & the unaffected lung is compressed compressed

(see picture- next)(see picture- next)

CT scan of the chest showing a pneumothorax on the patient's left side. A chest tube is in place (small black mark on the right side of the image), the

air-filled pleural cavity (black) and ribs (white) can be seen. The heart can be seen in the center.

Chest Tube

Pneumothorax

Inspiration Expiration

Tension Pneumothorax

Nursing AlertNursing Alert

Traumatic open pneumothorax is Traumatic open pneumothorax is an acute emergency requiring an acute emergency requiring immediate intervention. immediate intervention.

Stopping the air from entering Stopping the air from entering the chest is life saving. Relief of the chest is life saving. Relief of tension pneumothorax is an tension pneumothorax is an emergency measureemergency measure

Signs and SymptomsSigns and Symptomsof an open/closed of an open/closed

pneumothoraxpneumothorax Respiratory Respiratory

distressdistress hypotensionhypotension compensatory compensatory

tachycardiatachycardia Increased central Increased central

venous pressurevenous pressure pallorpallor cyanosiscyanosis

Sounds of an air Sounds of an air leak, bubbles in leak, bubbles in blood from wound blood from wound in chest wall.in chest wall.

Compression/Compression/compromise of compromise of heart and heart and unaffected lung is unaffected lung is a LIFE-a LIFE-THREATENING THREATENING EMERGENCY!!!EMERGENCY!!!

Open versus Closed Open versus Closed PneumothoraxPneumothorax

If chest injury is caused by blunt If chest injury is caused by blunt trauma and chest wall remains trauma and chest wall remains intact, pneumothorax is CLOSED. intact, pneumothorax is CLOSED. Air enters chest cavity from the Air enters chest cavity from the lungs.lungs.

If chest injury is penetrating and If chest injury is penetrating and chest wall is compromised, chest wall is compromised, pneumothorax is OPEN. Air enters pneumothorax is OPEN. Air enters chest cavity from the chest cavity from the wound.wound.

Nursing Alert

Traumatic open pneumothorax is an acute emergency requiring immediate intervention.

Stopping the air from entering the chest is life saving.

Relief of tension pneumothorax is an emergency measure

Chest TubeChest Tube

Chest Tube

Pleural EffusionPleural Effusion

Abnormal buildup of fluid between Abnormal buildup of fluid between linings of the lung and chest walllinings of the lung and chest wall

result of a disease process or result of a disease process or inflammationinflammation

Normally 5 to 10 mL of serous Normally 5 to 10 mL of serous fluid in the visceral and parietal fluid in the visceral and parietal pleura.pleura.

Any more can cause great changes Any more can cause great changes in intrathoracic pressure.in intrathoracic pressure.

Pleural EffusionPleural Effusion

Pleural = Pleural Cavity Effusion = abnormal, excessive collection of this fluid

Signs and SymptomsSigns and Symptoms

Pleural effusion in itself does not Pleural effusion in itself does not cause symptoms.cause symptoms.

If effusion expands and presses If effusion expands and presses on lung, patient may developon lung, patient may develop sharp, localized pain that worsens sharp, localized pain that worsens

with coughing, or deep breathing.with coughing, or deep breathing. DyspneaDyspnea non-productive cough.non-productive cough.

Signs and Symptoms cont...Signs and Symptoms cont...

Early signs include decreased or Early signs include decreased or bronchial breath sounds on the bronchial breath sounds on the affected side, dullness to affected side, dullness to percussion, and decreased percussion, and decreased fremitus over area of fluid fremitus over area of fluid accumulationaccumulation

Auscultation: EGOPHONYAuscultation: EGOPHONY Hear “A” over fluid accumulation Hear “A” over fluid accumulation

when patient speaks “E”.when patient speaks “E”.

Complications of Pleural Complications of Pleural EffusionEffusion

Respiratory compromise and distress Respiratory compromise and distress from fluid compressing lung.from fluid compressing lung.

Infection in pleural Infection in pleural space---Sepsis/Empyemaspace---Sepsis/Empyema

Fistulas in bronchi or chest wallFistulas in bronchi or chest wall Inflammation/infection in pleural Inflammation/infection in pleural

space leads to increased potential for space leads to increased potential for adhesions. Adhesions isolate effusion adhesions. Adhesions isolate effusion to one lung and complicates to one lung and complicates treatment.treatment.

BarotraumaBarotrauma

Barotrauma results from increased Barotrauma results from increased airway pressure and decreased airway pressure and decreased expiratory flowexpiratory flow mechanical bag-valve-mask ventilationmechanical bag-valve-mask ventilation faulty equipmentfaulty equipment misuse of positive pressure ventilationmisuse of positive pressure ventilation

Thus, Thus, BarotraumaBarotrauma is physical damage to body is physical damage to body tissues caused by a difference in pressure tissues caused by a difference in pressure between an air space inside or beside the between an air space inside or beside the body and the surrounding gas or liquid body and the surrounding gas or liquid

BarotraumaBarotrauma

4% of all mechanically ventilated 4% of all mechanically ventilated patients develop a pneumothorax patients develop a pneumothorax

20% of patients receiving 20% of patients receiving positive end-expiratory pressure positive end-expiratory pressure develop a pneumothoraxdevelop a pneumothorax

Cor Pulmonale Cor Pulmonale Enlarged right side of heart due to Enlarged right side of heart due to

diseases that affect the structure diseases that affect the structure and function of the lungand function of the lung Signs and symptomsSigns and symptoms

Increased edema in hands and feetIncreased edema in hands and feet Distended neck veinsDistended neck veins Enlarged liverEnlarged liver Pleural effusionPleural effusion Ascites and heart murmur Ascites and heart murmur SOBSOB WheezeWheeze Cough and fatigueCough and fatigue

AtelectasisAtelectasis

Collapsed or airless condition of alveoliCollapsed or airless condition of alveoli Caused by Caused by

hypoventilation, obstruction to the airways hypoventilation, obstruction to the airways or compressionor compression

ManifestationsManifestations Shallow breathing, dyspnea, pleural pain, Shallow breathing, dyspnea, pleural pain,

central cyanosis, increased heart rate, central cyanosis, increased heart rate, cough, sputum production and low grade cough, sputum production and low grade fever fever

Atelectasis

Cardiac TamponadeCardiac Tamponade

Compression of the heart as a result Compression of the heart as a result of fluid within the pericardial sacof fluid within the pericardial sac Usually due to chest trauma Usually due to chest trauma

ManifestationsManifestations HypotensionHypotension Jugular-venous distention Jugular-venous distention Muffled heart sounds Muffled heart sounds