Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations of pneumothorax
- Describe the diagnostics and laboratory values in the disease of pneumothorax
- Apply nursing concepts and plan associated nursing care for the patient with pneumothorax
- Evaluate the efficacy of nursing care for the patient with pneumothorax
- Describe the medical therapies that apply to the care of pneumothorax
The pleural space typically contains only 10 to 20 milliliters of pleural fluid. When air enters pleural space, a pneumothorax develops. Each year, approximately 20,000 cases of pneumothorax occur in the United States. The large umbrella diagnosis of pneumothorax includes both traumatic and nontraumatic cases (Table 11.5). Nontraumatic pneumothoraxes are further categorized into primary spontaneous pneumothorax, secondary spontaneous pneumothorax, and iatrogenic. All types of pneumothoraxes are more common in males. Primary spontaneous pneumothorax is most common in individuals ages twenty to thirty. Secondary spontaneous pneumothorax is most prevalent in older adults, ages sixty to sixty-five.
| Type of Pneumothorax | Cause |
|---|---|
| traumatic pneumothorax | Air enters the pleural space due to a traumatic injury |
| Nontraumatic pneumothoraxes | |
| primary spontaneous pneumothorax | Air enters the pleural space spontaneously; there is no underlying lung disease. |
| secondary spontaneous pneumothorax | Air enters the pleural space spontaneously as a complication of underlying lung disease. |
| iatrogenic pneumothorax | Air enters the pleural space due to a complication from a surgery or invasive procedure (e.g., placement of a central venous catheter). |
Pathophysiology
The pleural space is the area between the inner (visceral) pleural layer and the outer (parietal) pleural layer. Under normal circumstances, the two pleural layers are separated by only a small volume of pleural fluid (Figure 11.21). Pneumothorax occurs when air enters the pleural space. Air can enter the pleural space when there is trauma through the chest wall, or if there is a rupture of the inner (visceral) pleural layer. The accumulation of air increases pressure, causing the lung to collapse and deflate. As a result of collapse and deflation, the lung area available for oxygenation and ventilation is dramatically decreased.
The volume of air that has entered the pleural space affects the degree of lung collapse. When a small volume of air enters the pleural space, the degree of collapse may be minor. With a large volume of air, a tension pneumothorax can occur. In addition to causing a major amount of lung collapse, the large volume of air exerts high pressure; this can force the heart and trachea to shift (Figure 11.22).
Risk Factors
Pneumothorax can occur as a result of many medical conditions, especially respiratory diseases such as COPD, asthma, cystic fibrosis, pneumonia, and tuberculosis. Smoking, pregnancy, and a family history of pneumothorax also increase a patient’s risk. Various medical procedures, such as lung biopsy, tracheostomy placement, or placement of a central venous catheter, carry a risk of pneumothorax (McKnight & Burns, 2023). Patients with COPD have a significantly higher incidence of pneumothorax when compared with non-COPD patients. For heavy smokers, the risk of pneumothorax is 102 times higher when compared with nonsmokers (McKnight & Burns, 2023).
Clinical Manifestations
The high pressure of the air in the pleural space collapses the lung, limiting the body’s ability to oxygenate and ventilate. While a patient with a small pneumothorax may be asymptomatic, most patients will have symptoms. Respiratory distress is a common clinical manifestation of pneumothorax. Patients commonly report a rapid onset of dyspnea, cough, and intense chest pain that is worse with movement.
Vital sign abnormalities can include an increased respiratory rate, decreased oxygen saturation, and increased heart rate. Physical assessment findings can include unequal chest expansion and decreased or absent breath sounds. When high pressure air is forced through the tissues, subcutaneous emphysema can occur. This creates a “popping” sensation with palpitation and can cause visible swelling. If the pneumothorax is a result of penetrating trauma through the chest wall, a wound may be visible. With tension pneumothorax, low blood pressure, cyanosis, and tracheal deviation (trachea in a non-midline position) can occur (McKnight & Burns, 2023).
Assessment and Diagnostics
Prompt diagnosis of pneumothorax is essential to prevent the possibility of life-threatening complications. Imaging and physical assessment are utilized to identify signs of pneumothorax. It is imperative the nurse realize that without immediate intervention, the patient’s life is at risk.
Pneumothorax is diagnosed using imaging to visualize the area of collapsed lung. Most often, x-ray is used, although CT scan and ultrasound can also be utilized. Pulse oximetry and blood gas analysis may be performed, but results indicating low oxygen level can occur with many medical conditions and are not specific to pneumothorax. However, tension pneumothorax is an emergency, and treatment needs to be initiated immediately, without waiting for imaging (McKnight & Burns, 2023).
Read the Electronic Health Record
Assessment of a Patient with a Pneumothorax
Patient InformationName: Charles Brenman
Age: 47 years
Sex: Male
Chief complaint:
- Severe shortness of breath and sharp stabbing chest pain
- Diagnosed with hypertension 3 years ago.
- Previous episodes last year of mild spasms related to gallstones, treated successfully with antispasmodics and diet change; no recurrence noted
- Temperature: 93.3°F
- Heart rate: 132 bpm
- Blood pressure: 152/94 mm Hg
- Respiratory rate: 32 breaths per minute
- Oxygen saturation: 82% on room air
- BMI: 34
- WBC count: 10,000 /µL (normal)
- Hemoglobin: 13.5 g/dL (normal)
- Hematocrit: 40.5% (normal)
- Platelets: 250,000 /µL (normal)
- Electrolytes:
- Sodium: 138 mmol/L (normal)
- Potassium: 4.0 mmol/L (normal)
- Chloride: 102 mmol/L (normal)
- Ultrasound of chest: Findings consistent with small pneumothorax. The presence of a visible rim of less than 2 cm between the lung margin and the chest wall
- Patient reports sudden onset of sharp pleuritic chest pain and shortness of breath, after falling off a ladder.
- Mild diaphoresis observed upon admission.
- Otherwise presents as an active middle-aged adult with mild health disparities
- Acetaminophen 500 mg every night as needed for pain
- Norvasc 10 mg a day day for hypertension
Nursing Care of the Patient with Pneumothorax
Nursing care for a patient with pneumothorax focuses on prompt identification of potential respiratory and circulatory compromise. Anticipating and preparing for potential treatment interventions are key nursing roles.
Recognizing Cues and Analyzing Cues
The nurse caring for a patient with suspected or confirmed pneumothorax synthesizes patient-reported subjective data and objective assessment findings. Self-reported symptoms may include a rapid onset of dyspnea, cough, and intense chest pain that worsens with movement. The nurse may inquire about the patient’s past medical history, especially any known lung diseases.
Objectively, vital signs are evaluated with a focus on respiratory rate and oxygen saturation. Respiratory rate may be increased while oxygen saturation may be decreased. Lung auscultation may reveal diminished or absent breath sounds in the affected lung field(s), and unequal chest expansion may be present. Skin assessment may demonstrate subcutaneous emphysema, which can cause the skin to appear swollen and has a popping sensation with palpation. If the pneumothorax occurred as a result of a traumatic injury, a penetrating wound may be visible (McKnight & Burns, 2023).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
In patients with pneumothorax, signs of respiratory distress and decreased oxygenation are a high priority. The nurse may need to monitor vital signs, administer oxygen, or prepare a patient for imaging and/or procedures. If there is an open chest wound from a penetrating trauma, or if a chest tube becomes dislodged, the nurse must be ready to apply a three-sided occlusive dressing, which allows trapped air to escape while preventing more air from entering. If signs of tension pneumothorax are present, the nurse should anticipate emergent treatment due to the risk of decompensation and death. Tension pneumothorax is treated with immediate needle decompression, also known as needle thoracostomy. A needle is inserted between ribs into the pleural space, which allows the air that has accumulated in the pleural space to escape out of the body.
If a chest tube is inserted, it’s important for the nurse to ensure that the tube from the patient is securely connected to the drainage device. Additionally, the nurse monitors output, evaluates the dressing at the insertion site, and, if ordered by the provider, may connect suction to the drainage device (McKnight & Burns, 2023).
Evaluation of Nursing Care for the Patient with Pneumothorax
When evaluating nursing care for patients with pneumothorax, respiratory assessment provides important information about patient status. Over time, respiratory status should improve as the air in the pleural space decreases. The most important outcomes related to pneumothorax center on improved oxygenation and lung reexpansion. The nurse monitors pulse oximetry, oxygen requirement, and lung sounds. Repeat imaging may be ordered and evaluated. If a chest tube is present, the nurse assesses the chest drainage system. As the pneumothorax resolves, the nurse should observe decreased air output (McKnight & Burns, 2023).
Medical Therapies and Related Care
Medical therapies vary based on the severity of the pneumothorax. Collaboration between nurses, physicians, and respiratory therapists is needed for optimal outcomes. Patients with a small, asymptomatic pneumothorax may not require any treatment because the body will reabsorb air in the pleural space over time. Some minor cases of pneumothorax are treated with high flow oxygen administration. Oxygen speeds up the body’s ability to reabsorb air from the pleural space.
If the patient is symptomatic, the size of the pneumothorax is larger, or with a pneumothorax that occurs secondary to a disease (e.g., COPD, pneumonia), a provider may aspirate the pneumothorax using a needle (Figure 11.23). The needle is inserted between ribs, into the pleural space, and allows accumulated air to flow out of the body. For some patients, aspiration will be adequate treatment. If the patient’s clinical status does not improve, the next treatment option is a thoracostomy tube placed by a provider. A thoracostomy tube, also referred to as a chest tube, is a tube inserted through the skin into the pleural space, to drain air, fluid, or blood (Figure 11.24). Both procedures have the potential for moderate to severe pain. The nurse may advocate for, administer, and monitor the effects of analgesia.
To prevent air in the room from traveling through the chest tube and into the patient’s pleural space, the chest tube needs to be connected to a specialized drainage device (Figure 11.25). While there are a variety of device models and manufacturers, all of these devices are designed for one-way drainage. This means that air and fluids can flow out of the body, but nothing can flow back in. To help the air drain out of the patient, suction needs to be applied to the chest drainage device. The amount of wall suction is specified in the provider order.
Parts of the drainage device are:
- Collection chamber: This is where any fluid evacuated from the pleural space collects. Milliliter markings allow the amount of drainage to be quantified.
- Water seal/air leak monitor: In most devices, the water seal maintains one-way drainage, though some achieve this without a water seal area. This area can also show evidence of air moving through the system. When a pneumothorax is being treated, the device pulls air from the pleural space through the drainage system, so bubbles are expected to appear here as air flows through the system. When a chest tube drainage device is used to evacuate fluids from the pleural space, bubbles are not expected to appear here, and can indicate a break in the system.
- Suction control: The suction control dial indicates how much suction will be delivered to the patient when adequate wall suction is applied.
- Bellows: The bellows is used to determine if adequate wall suction has been applied. Typically, there is a marking where the bellows should expand.
If penetrating chest trauma is the cause of the pneumothorax, a temporary dressing may be necessary while more definitive treatment is in progress (Figure 11.26). To complete this process:
- An occlusive material (for example, Vaseline gauze, or something plastic) is placed over the wound.
- The dressing is taped in place fully on three edges, leaving an opening on one side.
- When the patient breathes in, the dressing is pulled toward the skin, sealing the opening, and preventing air from entering.
- When the patient exhales, air from the pleural space can escape through the open part of the dressing.
Some patients may require surgical intervention. Surgical treatment may be indicated in a patient with recurrent pneumothorax, bilateral pneumothoraxes, or in cases where the pneumothorax has not resolved after seven days of treatment. Patients in professions that expose them to dramatic changes in barometric pressure, such as aviation or diving, may also require surgery. A surgical technique called pleurodesis is used to heal the break in the pleural space and can be mechanical or chemical. Mechanical pleurodesis involves abrading the parietal pleura, causing the inflammatory response to patch up the break in the pleural space. Chemical pleurodesis involves instilling chemicals into the pleural space, with the irritation creating an inflammatory response.
Because tension pneumothorax is an emergency that can result in death, immediate treatment is required to stabilize circulatory status. Tension pneumothorax is treated with needle decompression, where a large needle is inserted through the skin, between the ribs, into the pleural space. The large volume of air in the pleural space escapes through the needle and the lung can reexpand (McKnight & Burns, 2023).