Pleural Cavity

Pleura  The thin serous membrane around the lungs

and inner walls of the chest.
Parietal Pleura  Pleura that lines the inner chest walls and
covers the diaphragm. (Outer pleura)
Pleural Cavity  Has 5 – 15 mL. Acts as lubricant that
allows the pleural surfaces to move without
friction.
Visceral Pleura  Pleura that covers the lungs. (Inner pleura)
Mediastinum  The space in the thoracic cavity behind the
sternum and in between the two pleural
sacs (containing the lungs).
Definition
Pneumothorax, or collapsed lung, is a potential medical emergency caused by
accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or
spontaneously.
Pathophysiology
The lungs are located inside the chest cavity, which is a hollow space. Air is drawn
into the lungs by the diaphragm. The pleural cavity is the region between the chest wall
and the lungs. If air enters the pleural cavity, either from the outside (open
pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it
becomes mechanically impossible for the injured person to breathe, even with an open
airway. If a piece of tissue forms a one-way valve that allows air to enter the pleural
cavity from the lung but not to escape, overpressure can build up with every breath; this
is known as tension pneumothorax. It may lead to severe shortness of breath as well as
circulatory collapse, both life-threatening conditions. This condition requires urgent
intervention.

Puncture / tear in an internal

Motor vehicular accident
respiratory structure
Gun or Knife wound in Chest
Alveoli, Bronchus, Bronchioles
wall or Diaphragm
(e.g. alveolar collapse)

Open Pneumothorax Closed Pneumothorax

Air enter pleural space a

with every inhalation; and
cannot escape during
expiration
Air enters the
Pleural Space

Pneumothorax
 Kinds of Pneumothorax
Open Pneumothorax
 Air enters pleural space to the hole  Air escapes in pleural space from a
in chest wall or diaphragm.
 Cause of surgery on the chest or
trauma to the chest wall. (e.g. stab
wound)
(it allows air to enter the pleural space)
Closed Pneumothorax
puncture or tear in an internal
respiratory structure such as
bronchus, bronchioles, and alveoli.
 This condition over time results in a
gradual accumulation of air to the
degree that it begins to put pressure
on the Mediastinum, compressing
the heart and decreasing cardiac
output due to the reduced amount of
diastolic filling of the ventricles,
leading to circulatory problems.

Classification of Pneumothorax
Spontaneous Tension Traumatic
 Cause is “Unknown”  Site of Pleural rapture  May lead to lung
acts as one way valve, collapse resulting
 Could be result of permitting air to enter from either blunt form
another disease such on inspiration but trauma to chest wall
as COPD, PTB and preventing its escape creating of an open
Cancer by closing up during sucking chest wound
expiration. cause either gun or
 Chest wall is intact; knife wound, motor
blebs/bulla is rapture vehicle accident.
causing collapse
lungs.

(a bladder-like structure
more than 5 mm in
diameter with thin walls
that may be full of fluid)
 Clinical Manifestation

 Sudden shortness of breath

 Dry coughs
 Cyanosis (turning blue)
 Pain felt in the chest, back and/or arms are the main symptoms.
 In penetrating chest wounds, the sound of air flowing through the puncture
hole may indicate pneumothorax, hence the term "sucking" chest wound.
 If untreated hypoxia may lead to loss of consciousness and coma.
 In addition, shifting of the Mediastinum away from the site of the injury
can obstruct the superior and inferior vena cava resulting in reduced
cardiac preload and decreased cardiac output.
 Untreated, a severe pneumothorax can lead to death within several
minutes.

Spontaneous Tension
 Pleural pain  Severe hypoxemia
 Tachypnea  Dyspnea
 Mild Dyspnea  Hypotension
 P.E.  Venous return is decreased (result of
o Reveal Absent / decreased breath compression by the increasing
sound pressure)
o Hyperesonance (percussion) on the  Shock
affected side.  Bradycardia
 Assessment and Diagnostic
findings
 Dyspnea To diagnose pneumothorax, it is
 Tachycardia necessary for the health care provider

 Tachypnea to:

 Sharp chest pain  Auscultation

Note the one part of the chest that
 Pleural Pain
doesn’t transmit the normal sounds of
 Absent of breath sound
breathing.
 Decreased expansion unilaterally
 Cyanosis
 Chest X-Ray
 Hypotension
Will show the air pocket and the
 Sucking Wound collapsed lung and show that the
 Tracheal deviation to the unaffected trachea is being pushed to one side
side with tension pneumothorax because of a collapsed lung.

 Electrocardiogram (ECG)
Will be performed to record the
electrical impulses that control the
heart's activity.

 Arterial Blood Gases (ABGs)

Blood samples may be taken to check
for the level of O2 and CO2 level
Treatment
 A small pneumothorax may resolve on its own, but most require medical treatment.
The object of treatment is to remove air from the chest and allow the lung to re-
expand. This is done by inserting a needle and syringe (if the pneumothorax is small)
or chest tube through the chest wall. This allows the air to escape without allowing
any air back in. The lung will then re-expand itself within a few days. Surgery may be
needed for repeat occurrences.
 A chest tube is placed quickly or a large-bore needle is inserted into the pleural space
to decompress it until a chest tube can be placed
 An outward gush of air as the needle or chest tube is inserted confirms the presence of
tension pneumothorax
 The chest tube is connected to water seal drainage and suction until the damage pleura
is healed.
 After the pneumothorax is evacuated and the pleural rupture is healed, the chest tube
is removed.
Chest Tube Thoracostomy
 Returns (-) pressure to the internal pleural space
 Remove abnormal accumulation of air
 Serves as lung while healing is ongoing.

The insertion of chest tube permits removal of the air or bloody fluid and allows re-
expansion of the lungs and restoration of the normal negative pressure in the pleural
space. Because air rises, a chest tube inserted to remove air is usually placed anteriorly
through the 2nd ICS. A chest tube inserted to remove fluids is placed posteriorly in the 8th
and 9th ICS because fluid tends to flow to the bottom of the pleural space.

Chest Drainage Container

A waterseal at the end of a chest tube is essential to allow air to escape through the
tube but prevent air from traveling back up the tube and into the pleural space. The
waterseal drainage system is placed below the level of the patient’s chest, taking
advantage of the force or gravity to promote drainage and prevent backflow of bottle
contents into the pleural space.