Plural effusion, PE & lung abscess, pneumothorax_014402.pptx

Respiratory disorders

1. INTRODUCTION Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease process but is usually secondary to other diseases The pleural space normally contains only about 10-20 ml of serous fluid. Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion

2. DEFINITION Pleural effusion is a collection of abnormal amount of fluid in the pleural space.

3. CLASSIFICATION Transudative effusions Exsudative effusions

4. Transudative effusions Transudative effusions also known as hydrothoraces , occur primarily in noninflammatory conditions; is an accumulation of low-protein fluid. CAUSES Increase hydrostatic pressure found in heart failure (most common cause of pleural effusion) Decrease oncotic pressure found in cirrhosis of liver or renal disease.

5. Exudative effusions Exudative effusions occur in an area of inflammation; is an accumulation of high-protein fluid. An exudative effusion results from increased capillary permeability characteristic of inflammatory reaction. This types of effusion occurs secondary to conditions such as pulmonary malignancies, pulmonary infections and pulmonary embolization.

6. PATHOPHYSIOLOGY Transudative pleural effusions: hydrostatic pressure,  oncotic pressure Unable to remain the fluid with in a intravascular space Fluid shift interstitial space Effusion

7. CONT.. Exudative effusions Invasion of microbes Initiation of inflammatory reaction Vasodilation increase capillary permeability decrease oncotic pressure leak of plasma protein fluid shift into interstitial space Effusion

8. CLINICAL MANIFESTATIONS When a small to moderate pleural effusion is present, dyspnea may be absent or only minimal. Malignant effusion may result in dyspnea and coughing Pleuritic chest pain, fever, chills Dullness or flatness to percussion Decreased or absent breath sounds

9. DIAGNOSTIC EVALUATION Chest X-ray or ultrasound detects presence of fluid. Thoracentesis, biochemical, bacteriologic, and cytologic studies of pleural fluid indicates cause.

10. MANAGEMENT The objectives of treatment are to discover the underlying cause, to prevent reaccumulation of fluid and to relieve discomfort, dyspnea, and respiratory compromise

11. CONT.. General effusion Treatment is aimed at underlying cause (heart disease, infection). Thoracentesis is done to remove fluid, collect a specimen, and relieve dyspnea For Malignant Effusions Chest tube drainage or pleurodesis Radiation Chemotherapy Surgical pleurectomy Pleuroperitoneal shunt

12. NURSING MANAGEMENT Nursing Assessment Obtain history of previous pulmonary condition Assess patient for dyspnea and tachypnea Auscultate and percuss lungs for abnormalities Nursing Diagnosis Ineffective Breathing Pattern related to collection of fluid in pleural space as evidenced by dyspnea.

13. CONT.. Nursing Interventions Observe patient's breathing pattern, oxygen saturation Administer oxygen as indicated by dyspnea and hypoxemia. Assist with thoracentesis if indicated Maintain chest drainage as needed Provide care after pleurodesis. Administer prescribed analgesic.

14. COMPLICATION Large effusion could lead to respiratory failure.

15. PULMONARY EMBOLISM

16. DEFINITION Pulmonary embolism (PE) refers to the obstruction of the pulmonary artery or one of its branches by a thrombus (or thrombi) that originates somewhere in the venous system or in the right side of the heart .

17. CAUSES Thrombus: Deep vein thrombosis, a related condition, refers to thrombus formation in the deep veins, usually in the calf or thigh. Embolism: there are several types of emboli: fat, air, amniotic fluid, and septic. Trauma Surgery: Venous Stasis , Prolonged immobilization Foreign bodies (IV/central venous catheters) Hypercoagulability: due to release of tissue thromboplastin after injury/surgery Heart failure Pregnancy, Oral contraceptive use Older than 50 years Atrial fibrillation

18. PATHOPHYSIOLOGY When a thrombus completely or partially obstructs a pulmonary artery or its branches. the alveolar dead space is increased . The area, although continuing to be ventilated, receives little or no blood flow (V:Q mismatch). Thus , gas exchange is impaired or absent in this area In addition, various substances are released from the clot and surrounding area, causing regional blood vessels and bronchioles to constrict . This causes an increase in pulmonary vascular resistance .

19. CONT.. This results in an increase in pulmonary arterial pressure and, in turn, an increase in right ventricular work to maintain pulmonary blood flow. When the work requirements of the right ventricle exceed its capacity, right ventricular failure occurs , leading to a decrease in cardiac output followed by a decrease in systemic blood pressure and the development of shock.

20. CLINICAL MANIFESTATIONS Dyspnea, tachypnea (very rapid respiratory rate) is the most frequent sign . The duration and intensity of the dyspnea depend on the extent of embolization. Chest pain is common and is usually sudden and pleuritic. Other symptoms include anxiety, fever, tachycardia, cough, diaphoresis, hemoptysis, and syncope.

21. DIAGNOSTIC FINDINGS Death from PE commonly occurs within one hour after the onset of symptoms; therefore, early recognition and diagnosis are priorities. Ventilation–perfusion scan Pulmonary angiography Chest x-ray ECG Peripheral vascular studies, and arterial blood gas analysis. Doppler ultrasonography and venography

22. MEDICAL MANAGEMENT General measures to improve respiratory and vascular status Anticoagulation therapy Thrombolytic therapy Surgical intervention

23. General management Oxygen therapy is administered to correct the hypoxemia. Using elastic compression stockings or leg compression devices reduces venous stasis. Elevating the leg (above the level of the heart) also increases venous flow. Active leg exercises to prevent deep venous thrombosis

24. Anticoagulation Therapy Anticoagulant therapy (heparin, warfarin sodium) has traditionally been the primary method for managing acute deep vein thrombosis and PE. Heparin is used to prevent recurrence of emboli but has no effect on emboli that are already present. Heparin is administered as an intravenous bolus of 5,000 to 10,000 units, followed by a continuous infusion initiated at a dose of 18 U/kg per hour, not to exceed 1,600 U/hour

25. Thrombolytic therapy It resolves the thrombi or emboli more quickly Restores normal hemodynamic functioning of the pulmonary circulation, Reducing pulmonary hypertension Improving perfusion, oxygenation and cardiac output. Thrombolytic therapy (urokinase, streptokinase) may be used in treating PE, particularly in patients who are severely compromised (e.g., those who are hypotensive and have significant hypoxemia despite oxygen supplementation).

26. Surgical management Pulmonary embolectomy requires a thoracotomy with cardiopulmonary bypass technique. Transvenous catheter embolectomy is a technique in which a vacuum-cupped catheter is introduced trans venously into the affected pulmonary artery. Suction is applied to the end of the embolus and the embolus is aspirated into the cup.

27. Nursing Management Nursing Assessment All patients are evaluated for risk factors for thrombus formation and pulmonary embolus. Health history: To determine any previous cardiovascular disease. Family history: History of any cardiovascular disease in the family may predispose the patient to PE. Medication record: There are certain medications that can increase the risk for PE. Physical exam: Extremities are evaluated for warmth, redness, and inflammation.

28. Nursing Management Nursing Diagnosis Ineffective peripheral tissue perfusion related to obstructed pulmonary artery. Risk for shock related to increased workload of the right ventricle. Acute pain related to pleuritic origin.

29. Nursing Management Goal and planning Increase perfusion Display hemodynamic stability. Report pain is relieved or controlled. Follow prescribed pharmacologic regimen. Verbalize understanding of condition, therapy regimen, and medication side effects.

30. Nursing Management Nursing Interventions Prevent venous stasis: Encourage ambulation and active and passive leg exercises. Monitor thrombolytic therapy: Evaluating INR or PTT report. Manage pain: Turn patient frequently and reposition to improve ventilation-perfusion ratio. Manage oxygen therapy: Assess for signs of hypoxemia and monitor the pulse oximetry values. Relieve anxiety: Encourage the patient to talk about any fears or concerns related to this frightening episode.

31. COMPLICATIONS Cardiogenic shock : The cardiopulmonary system is endangered in a massive PE. Right ventricular failure: A sudden increase in pulmonary resistance increases the work of the right ventricle.

32. DEFINITION Lung abscess is a pus containing lesion of the lung parenchyma that gives to a cavity. The cavity is formed by necrosis of the lung tissue.

33. RISK FACTORS/CAUSES Most lung abscess are caused by aspiration of material from the GI tract into the lungs. Risk factors for aspiration include— Alcoholism. Seizure disorder. Neuromuscular disorders. Drug overdose. General anesthesia. Stroke

34. CONT.. Infectious agents generally cause lung abscesses. Examples: gram negative organisms (Klebsiella, S. aureus) and anaerobic bacilli. Malignant growth. TB Various parasitic and fungal disease of the lung.

35. CLINICAL MANIFESTATION Cough with purulent sputum Hemoptysis Fever Chills Pleuritic chest pain Dyspnea Weight loss

36. CONT.. On physical examination : Dullness to percussion. Decreased breath sounds on auscultation over the segment of lung involved. Crackles

37. DIAGNOSTIC EVALUATIONS • History Collection • Physical examination • CT Scan • MRI • Chest X-ray • Sputum culture • Pleural fluid and blood culture • Bronchoscopy

38. MEDICAL MANAGEMENT Antibiotics given for a prolonged period ( up to 2-4 months) are usually the primary method of treatment. Penicillin has historically been the drug of choice because of the frequent presence of anaerobic organisms. According to the recent studies Clindamycin has been shown to be superior to penicillin, and is the standard treatment for anaerobic lung infection.

39. SURGICAL MANAGEMENT Drainage: when the abscess is 6 centimeters or more in diameter. Doctor will use a CT scan to guide him as he inserts the drain through the chest wall into the abscess. Surgery: It's rare, but some people need surgery to remove the part of the lung (segmentectomy) with the abscess. Sometimes the entire lung has to come out (pneumonectomy) to get rid of the infection.

40. NURSING MANAGEMENT Ineffective breathing pattern related to decreased lung expansion as evidenced by dyspnea. Impaired gas exchange related to capillary membrane changes as evidenced by cyanosis, shortness of breath. Activity intolerance related to hypoxemia as evidenced by gasping. Imbalance nutrition less than body requirement related to less intake of food as evidenced by weight loss

41. COMPLICATIONS Chronic abscess : That’s lasts for more than 6 weeks. Empyema: This is when an abscess breaks into the space between the lungs and chest wall and fills the space with pus. Bleeding: It's rare, but sometimes an abscess can destroy a blood vessel and cause serious bleeding. Broncho-pleural fistula: This is an opening between the tubes of lungs and layers that cover them.

42. PATIENT EDUCATION The patient must be aware of the importance of continuing the medication for the prescribed period. The patient must know about the side effects that need to be informed to the health care members. Sometimes patients are asked to come for routine check ups. The patient should be taught how to cough effectively, and how chest physiotherapy and postural drainage are helpful in their disease process. Rest, good nutrition and adequate fluid intake are all supportive measures to facilitate recovery.

43. DEFINITION Pneumothorax is an abnormal collection of air or gas in the pleural space separating the lung from the chest wall which may interfere with normal breathing, causing the lungs to collapse.

44. TYPES Spontaneous pneumothorax Traumatic pneumothorax Tension pneumothorax

45. Spontaneous pneumothorax Primary: It occurs in young healthy individuals without underlying lung disease. It is due to the rupture of apical subpleural bleb. Secondary: occurs in the presence of pre-existing lung pathology. Ex : Cystic fibrosis, COPD, Asthma, pneumonia, Lung cancer.

46. Traumatic pneumothorax Open: Chest wall is damaged by any wound, outside air enters pleural space and causes lungs to collapse. Usually associated with hemothorax. E.g. Penetrating trauma: stab wound or gun shot injury. Closed: nonpenetrating chest trauma such as rib fracture can lacerates the lung or a ruptured bronchus cause air to leaks into pleural space. Iatrogenic: Postoperative Mechanical ventilation, Thoracocentesis & Central venous cannulation.

47. Tension pneumothorax It is life threatening condition. The pleural pressure is more than the atmospheric pressure. It occurs when site of air leak acts as one way valve, air enters pleural space during inspiration but cannot escape during expiration. Volume of air and intrapleural pressure increasingly elevated results in compression of lung on the affected side. Mediastinal shift towards the unaffected side, compressing the good lung which further compromises oxygenation.

48. Cont.. Possible shift of trachea, pressure on the heart and great vessels, resulting in decreased venous return and cardiac output. Associated with clinical manifestations of circulatory collapse (tachycardia, hypotension & sweating). It is more common with Positive pressure ventilation & Traumatic pneumothorax.

49. RISK FACTORS Sex : men are far more likely to have a pneumothorax than are women. Smoking. Age: The type of pneumothorax caused by ruptured air blisters is most likely to occur in people between 20 and 40 years old, especially if the person is very tall & underweight man. Genetics. Lung disease Mechanical ventilation. A history of pneumothorax.

50. PATHOPHYSIOLOGY In normal people, the pressure in pleural space is negative during the entire respiratory cycle. Two opposite forces result in negative pressure in pleural space (outward pull of the chest wall and elastic recoil of the lung). The negative pressure will be disappeared if any communication develops between an alveolus or other intrapulmonary air space and pleural space. Air will flow into the pleural space until there is no longer a pressure difference or the communication is sealed.

51. CLINICAL FEATURES Predominant symptom is acute pleuritic chest pain Dyspnea results form pulmonary compression Breath sounds may be diminished on the affected side Percussion of the chest may be perceived as hyperresonant . Other signs include: Tachypnoea, Hypoxemia, Cyanosis, Hypercapnia.

52. Presentation of pneumothorax P-THORAX P leuritic pain T racheal deviation H yperresonance O nset sudden R educed breath sounds (and dyspnea) A bsent fremitus X -ray shows collapse

53. DIAGNOSTIC EVALUATIONS History Collection Physical examination CT Scan: to identify underlying lung lesions. Chest X-ray: The characteristics of pneumothorax (Pleural line, lung markings) Chest ultrasound

54. TREATMENT Goals To promote lung expansion. To eliminate the pathogenesis. To decrease pneumothorax recurrence. Treatment options : Simple aspiration Intercostal tube drainage Trocar tube thoracostomy Surgical treatment: pleurodesis, pneumonectomy

55. Simple aspiration The aspiration can be done by needle or catheter A volume of < 2.5 L has been aspirated on the first attempt Repeated aspiration is reasonable for primary pneumothorax when the first aspiration has been unsuccessful.

56. Trocar tube thoracostomy Insertion of trocar into the pleural space. Insertion of the chest tube through the trocar

57. Intercostal tube drainage A common site of chest tube insertion is in the 2 nd ICS in midclavicular line. An alternative site now commonly used is midaxillary line of 4th and 5th intercostal space for cosmetic reason and also for when pleural effusion.

58. Observation of drainage No bubble released The lung re-expansion The chest tube is obstructed by secretion or blood clot The chest tube shift to chest wall, the hole of the chest tube is located in the chest wall. If the lung re expanded, removing the chest tube 24 hours after re expansion. Otherwise, the chest tube will be inserted again or regulated the position

59. NURSING MANAGEMENT Ineffective breathing pattern Impaired tissue perfusion Risk for infection Activity intolerance Anxiety Imbalanced nutrition Knowledge deficit

60. THANK YOU