Care of Endotracheal tube patients

 Pneumothorax (collapsed lung)

What is Pneumothorax?

A pneumothorax (collapsed lung) is air in the pleural space occurring spontaneously or from trauma. In patients with chest trauma, it is usually the result of a laceration to the lung parenchyma, tracheobronchial tree, or oesophagus. The patient's clinical status depends on the rate of air leakage and the size of the wound. 

Types of Pneumothorax

Spontaneous pneumothorax

     Spontaneous pneumothorax: sudden onset of air in the pleural space with deflation of the affected lung in the absence of trauma.

  Tension pneumothorax

     Tension pneumothorax: the buildup of air under pressure in the pleural space resulting in interference with filling of both the heart and lungs.

Open pneumothorax (sucking wound of the chest)

     Open pneumothorax (sucking wound of the chest): implies an opening in the chest wall large enough to allow air to pass freely in and out of thoracic cavity with each attempted respiration.

  In open pneumothorax, air enters the chest during inspiration and exits during expiration. There may be slight inflation of the affected lung due to a decrease in pressure as air moves out of the chest. In tension pneumothorax, air can enter but not leave the chest. As the pressure in the chest increases, the heart and great vessels are compressed and the mediastinal structures are shifted toward the opposite side of the chest. The trachea is pushed from its normal midline position toward the opposite side of the chest, and the unaffected lung is compressed.

Care of Endotracheal tube patients

Pathophysiology and Cause Pneumothorax (collapsed lung)

1. When there is a large, open hole in the chest wall, the patient will have a 'steal' in ventilation of other lung.
2. A portion of the VT will move back and forth through the hole in the chest wall, rather than the trachea as it normally does.
3. Spontaneous pneumothorax is usually due to rupture of a subpleural bleb.
1. May occur secondary to chronic respiratory disease or idiopathic ally.
2. May occur in healthy people, particularly in thin, white males those with family history of pneumothorax.

Signs and Symptoms of Pneumothorax (collapsed lung)

1. Moderate to very severe dyspnea and often severe chest discomfort radiating to the back.
2. Hyperresonance and diminished breath sounds on affected side.
3. Reduced mobility of affected half of thorax
4. Tracheal deviation away from affected side in tension pneumothorax.
5. Clinical picture of open or tension pneumothorax is one of air hunger, agitation, hypotension, and cyanosis.

Diagnostic Evaluation Pneumothorax (collapsed lung)

1. Chest X-ray confirms the presence of air in pleural space.

Treatment and Management of Pneumothorax (collapsed lung)

Treatment of Spontaneous pneumothorax

1. Observe and allow for spontaneous resolution for less than 50% pneumothorax in otherwise healthy person.
2. Needle aspiration or chest tube if less than 50% of pneumothorax.
3. Pleurodesis may be done to prevent recurrence. Chemical pleurodesis uses various solutions inserted through chest tube to irritate and thereby cause adhesion of parietal and visceral pleura. Surgical pleurodesis uses mechanical irritation to achieve adhesion, with possible removal of parietal pleura.
4. Thoracotomy to remove apical blebs in some cases.

Treatment of Tension Pneumothorax

1. Immediate decompression to prevent cardiovascular collapse by chest tube insertion to let air escape.
2. Chest tube drainage with underwater-seal suction to allow for full lung expansion and healing.

Treatment of Open pneumothorax

1. Close the chest wound immediately to restore adequate ventilation and respiration.

• Patient is instructed to inhale and exhale gently against a closed glottis (Valsalva maneuver) as a pressure dressing ( petroleum gauze secured with elastic adhesive) is applied. This maneuver helps to expand collapsed lung.

2. Chest tube is inserted and water-seal drainage set up to permit evacuation of fluid/air and produce reexpansion of the lung.

3. Surgical interventions may be necessary to repair trauma.

Chest Drain Insertion:( ICD ) Procedure, Management and Complications

Complications Pneumothorax (collapsed lung)

1. Acute respiratory failure

2. Cardiovascular collapse with tension Pneumothorax

Nursing Assessment of Pneumothorax (collapsed lung)

1. Obtain history for chronic respiratory disease, trauma, and the onset of symptoms.

2. Inspect chest for reduced mobility and tracheal deviation.

3. Auscultate chest for diminished breath sounds and percuss for hyper resonance.

Nursing Diagnosis Pneumothorax (collapsed lung)

1. Ineffective breathing pattern related to air in the pleural space.

2. Impaired gas exchange related to atelectasis and collapse of the lung.

CHEST TUBE INSERTION AND MONITORING

Nursing Interventions Pneumothorax (collapsed lung)

Achieving Effective Breathing Pattern

1. Provide emergency care as indicated.

• Apply petroleum gauze to sucking chest wound.
• Assist with emergency thoracentesis or thoracostomy.
• Be prepared to perform cardiopulmonary resuscitation or administer medication if the cardiovascular collapse occurs.

2. Maintain patient airway; suction as needed.

3. Position the patient upright if the condition permits to allow greater chest expansion.

4. Maintain patency of chest tube.

Resolving Impaired Had Exchange

1. Encourage patient in the use of incentive spirometer.

2. Monitor oximetry and ABG levels to determine oxygenation.

3. Provide oxygen as needed.