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.
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Anatomic Alterations of the Lungs

Slide 2

Lung collapse

Atelectasis

Chest wall expansion

Compression of the great veins and

decreased cardiac venous return

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Etiology3 Ways

Slide 3

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)

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Pneumothorax Classifications
General Terms

Slide 4

Closed pneumothorax

Open pneumothorax

Tension pneumothorax

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Pneumothorax Classifications
Based on Origin

Slide 5

Traumatic pneumothorax

Spontaneous pneumothorax

Iatrogenic pneumothorax

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Figure 22-3. Closed (tension) pneumothorax produced

by a chest wall wound.
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Figure 22-4. Pneumothorax produced by a rupture in the visceral pleura

that functions as a check valve.
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Spontaneous Pneumothorax

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Iatrogenic Pneumothorax

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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).

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Figure 9-7. Atelectasis clinical scenario.

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Clinical Data Obtained at the

Patients Bedside
Vital signs

Increased respiratory rate

Stimulation of peripheral chemoreceptors

Other possible mechanisms

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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

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Figure 22-5. Venous admixture in pneumothorax.

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Clinical Data Obtained at the

Patients Bedside

Slide 14

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

Laboratory Tests and Special
Procedures

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Pulmonary Function Study:

Lung Volume and Capacity Findings
VT

Slide 19

RV

FRC

TLC

N or

VC

IC

ERV

RV/TLC%

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Arterial Blood Gases

Small Pneumothorax

pH

Slide 20

Acute alveolar hyperventilation with

hypoxemia
PaCO2

HCO3 (Slightly)

PaO2

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Time and Progression of Disease

Disease Onset

Alveolar Hyperventilation

100
90

PaO2 or PaCO2

80

Point at which PaO2

declines enough to
stimulate peripheral
oxygen receptors

70
60

PaO2

50
40
30
20
10
0

Figure 4-2. PaO2 and PaCO2 trends during acute alveolar hyperventilation.
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Arterial Blood Gases

Large Pneumothorax

Acute ventilatory failure with hypoxemia

pH

Slide 22

PaCO2

HCO3 (Slightly)

PaO2

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Time and Progression of Disease

Disease Onset

Alveolar Hyperventilation

Acute Ventilatory Failure

100
90

Pa02 or PaC02

80
70

Point at which PaO2

declines enough to
stimulate peripheral
oxygen receptors

Point at which disease

becomes severe and patient
begins to become fatigued

60
50
40
30
20
10
0
Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.

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Oxygenation Indices
QS/QT

DO2

VO2

Normal

O2ER

Slide 24

C(a-v)O2
(severe)

SvO2

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Hemodynamic Indices
(Large Pneumothorax)

Slide 25

CVP

RAP

PA

PCWP

CO

SV

SVI

CI

RVSWI

LVSWI

PVR

SVR

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Radiologic Findings
Chest radiograph

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Increased translucency

Mediastinal shift to unaffected side

in tension pneumothorax

Depressed diaphragm

Lung collapse

Atelectasis

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Figure 22-9. Left-sided pneumothorax (arrows). Note the shift of the heart and
mediastinum to the right away from the tension pneumothorax.
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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).
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General Management of
Pneumothorax

>20%gas should be evacuated

Negative pressure5 to 12 cm H2O

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Should not exceed negative 12 cm H2O

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General Management of
Pneumothorax
Respiratory care treatment protocols

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Oxygen therapy protocol

Hyperinflation therapy protocol

Mechanical ventilation protocol

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General Management of
Pneumothorax
PLEURODESIS

Chemical or medication injected into the

chest cavity

Talc

Tetracycline

Bleomycin sulfate

Produces inflammatory reaction between

lungs and inner chest cavity

Slide 31

Causes lung to stick to chest cavity

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Classroom Discussion
Case Study: Pneumothorax

Slide 32

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