Pneumothorax
A pneumothorax (sometimes just called a "pneumo") is a condition in which there is air or gas in the pleural space. Simply put, it is a collapsed lung.
Causes
A pneumothorax happens when air leaks into the pleural cavity. This can be caused by a variety of mechanisms:
- Blunt force trauma: This can happen during traumatic accidents including car accidents or assaults in which the chest is hit with extreme force.
- Penetrating injury: A pneumothorax can be caused by a penetrating injury meaning something physically enters the pleural cavity causing air to leak in. One example includes a stab wound.
- Mechanical ventilation: Patients on a ventilator are always at risk for developing a pneumothorax. Patients with acute respiratory distress syndrome are on ventilation settings requiring a large amount of positive end-expiratory pressure (PEEP), which essentially means that the lungs are intentionally overinflated. This makes it much easier to cause damage to the lungs and cause a pneumothorax.
- Certain medical procedures: One of the most common ways that I see pneumothoraxes caused is by central line insertion. It is one of the risks that providers should always address when obtaining consent. This rarely happens with the intensivists in my ICU, but it does happen sometimes.
- Underlying lung disease: Lungs that are already damaged are more likely to collapse. Common lung diseases include COPD, cystic fibrosis, and pneumonia.
Symptoms
Common symptoms include shortness of breath, chest pain, hypoxia (decreased oxygen levels), decreased or absent breath sounds, and tachycardia. If your patients have any factors that put them at risk for a pneumothorax, be sure to look out for these symptoms. Are you increasing the amount of oxygen they need to keep a 90% oxygen saturation level? Think about what could be happening within the respiratory system that may be causing this.
Diagnosis & Treatment
The fastest way to determine if a patient has a collapsed lung is to get a chest x-ray. Providers may order an arterial blood gas (ABG) or venous blood gas (VBG) to determine if the patient is able to compensate on their own for the pneumothorax. Small pneumothoraxes may resolve on their own. Providers would monitor with frequent chest x-rays to be sure that the air has reabsorbed and the pneumothorax is gone.
If patient is deteriorating, the provider may decide to do either a needle aspiration (removing the excess air with a needle and syrgine) or by placing a chest tube. The needle or chest tube is placed between the ribs and inserted into the pleural cavity. The chest tube may be attached to suction to remove the air from the pleural cavity
Nursing Interventions
The nursing interventions that you perform depend on what stage of the pneumothorax you are managing.
Onset: Initially, you will be performing your basic nursing assessment. This will be a more focused assessment. You will see many of the symptoms that are listed above. The patient will have sudden onset of chest pain and respiratory distress. You will be listening for breath sounds (which will be diminished or absent), watching their respiratory rate (which should be elevated), and increasing the oxygen flow as needed. You should be paging the provider after you have obtained this information.
Assisting the provider: The provider should (hopefully) come to the bedside to assess the patient as well. During this time, you can expound on the information that you gave (symptoms that the patient is having, etc.). The provider may ask for you to get an ABG or VBG as well as chest tube insertion supplies. They should order a stat chest x-ray to see the magnitude of the pneumothorax. The provider will (in many cases) insert a chest tube to decompress the chest. You will need extra suction tubing to hook it up to the wall suction.
Management: After chest tube insertion, continue to monitor the patient's respiratory status closely. Watch to be sure they are starting to improve. If the patient continues to worsen, alert the provider to see if any other interventions need to be performed. Pay close attention to the chest tube to be sure it is functioning correctly. There should be an air leak in the chest tube atrium because it is draining out air from the pleural cavity.
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