Nursing Management in Pleural Disorders

Pleural Disorders: Overview

• Pleura is tissue covering the outside of the lungs and lining the inside of the chest cavity
• Visceral pleura is the inner layer covering the lungs
• Parietal pleura is the outer layer lining the chest wall and diaphragm

Pleural Disorders

• Pleurisy (Definition?): Inflammation of the pleura
• Empyema: Pus in the pleural space
• Pleural Effusion: Fluid in the pleural space
• Hemothorax: Blood in the pleural space
• Pneumothorax: Air in the pleural space

Common Etiology of Pleural Disorders

• Pleurisy: Infection (e.g., autoimmune, pneumonia), other pulmonary conditions
• Empyema: Bacterial Infections, Medical procedures (e.g., esophageal perforation)
• Pleural Effusion: Transudative (fluid imbalance - e.g., CHF, kidney failure, liver failure), Exudative (local inflammation/damage - e.g., TB, pneumonia, cancer)
• Hemothorax: Spontaneous (e.g., coagulopathy, pulmonary infarction, lung/pleural cancer), Trauma (e.g., lung/heart surgery, CVC placement)
• Pneumothorax: Spontaneous (e.g., primary, secondary), Traumatic (e.g., MVA, GSW, stab wound, contact sports), Tension (life-threatening, air leaks, tracheal deviation, mediastinal shift, common causes: PSP, trauma, iatrogenic, mechanical)

Empyema

• Caused by bacterial infections (e.g., pneumonia), medical procedures (e.g., surgery)
• Involves accumulation of pus in the pleural space

Pleural Effusion

• Transudative
  • Caused by systemic factors like fluid imbalance (e.g., CHF, kidney failure, liver failure)
• Exudative
  • Caused by local inflammation or damage (e.g., TB, pneumonia, cancer)

Hemothorax

• Spontaneous
  • Caused by coagulopathy, pulmonary infarction, or lung/pleural cancer
• Trauma
  • Caused by lung or heart surgery, or CVC placement

Pneumothorax

• Spontaneous:
  • Primary: no prior lung pathology
  • Secondary: compromised pulmonary function (e.g., TB, COPD, CF, Asthma)
• Traumatic: Injury-related (e.g., MVA, GSW, stab wound, contact sport)
• Tension: Life-threatening, air trapped between the pleura and lung; tracheal deviation, mediastinal shift

Pathophysiology

• Intrapleural pressure is normally negative
• Air in the pleural cavity causes positive pressure
• Lung compression & collapse
• Vital capacity decrease, mediastinal shift

Intrapulmonary Pressure

• Intrapulmonary pressure decreases during inspiration and increases during expiration

Spontaneous Pneumothorax

• Sudden onset without an injury
• PSP: no underlying lung pathology - tall, thin male smokers
• SSP: compromised pulmonary function (TB, COPD, CF, Asthma)

Traumatic Pneumothorax

• Injury related (MVA, GSW, stab wound, contact sports)
• Medical procedures (lung biopsy, CVC placement)

Tension Pneumothorax

• Air leaks and is trapped between the pleura and lung
• Tracheal deviation and mediastinal shift (common causes: PSP, trauma/iatrogenic, mechanical)

Recognize Cues

• Pleuritic pain
• Tracheal deviation
• Hyperresonance
• Sudden onset of dyspnea with decreased breath sounds and absent fremitus

Risk factors for collapsed lung

• Chest injury
• Lung diseases (e.g.TB, COPD, CF)
• Spontaneous Pneumothorax
• Smoking
• Genetics (male, 20-40 year olds)

Screening Tests

• Medical history, physical exam
• Laboratory tests, Imaging tests (e.g. CT, MRI, CXR, Ultrasound)
• Endoscopy
• Thoracentesis

Surgical Intervention

• Pleurodesis: Adhesion of the lung to the chest wall
• Talc pleurodesis: Injecting talc into the pleural space
• Pleurectomy/decortication: Removing fibrous tissue over the lung, chest wall, and diaphragm, to re-expand the lung and restore chest wall compliance.
• Thoracotomy (surgical opening to gain access into the pleural space)

Types of Thoracotomy

• Wedge resection

• Segmentectomy

• Lobectomy

• Pneumonectomy

• Types of Thoracotomy incisions:

  • Anterolateral
  • Axillary
  • Posterolateral

Chest Tube Indication

• Promote lung re-expansion
• Restore negative pressure
• Prevent returning air to the pleural space

Nursing Management

• Main Goal Pain management, breathing/oxygenation, tube placement/positioning
• Dressing/insertion site care, monitor tubes (patent and securely connected; drainage amount and character; water seal & suction; keep system below patient's chest level)
• Bedside equipment (O2, nasal cannula, suction, Kelly clamps, sterile NSS bottle, occlusive dressings)
• Transport of patient, collection device position (below chest level)

Evaluation Indicators for Chest Tube Removal

• Clear breath sounds bilaterally
• Symmetric expansion of the chest
• Absence of bubbling in the water seal