Discuss about the Pathophysiology of Pneumothorax for Thoracic Disease.
The existence of air inside the pleural space is known as pneumothorax (Lichtenstein, 2016). Usually, air do not get inside the pleural space since the amount of the incomplete gas pressures in the tube blood is about 93.9KPa (Hobbs et al., 2014). Thus, the net movement of gasses into the pleural space from the capillary blood requires that the pleural pressures be lower than 54mmHg. This hardly ever occurs under normal circumstances. Therefore, there are there critical factors that may result in the occurrence of air in the pleural space, namely; direct or indirect interaction amid the air as well as the pleural space; interaction taking place between pleura and the alveolar; as well as the occurrence of a gas producing organism in the pleural space (Hobbs et al., 2014). Clinically, pneumothorax is classified as primary, secondary, catamenial, non-iatrogenic and traumatic pneumothorax (Boskovic et al., 2014). These different types have been briefly highlighted below. This paper discusses this condition, pneumothorax, using Leigh Richard’s case. The case study has been described below. The paper discusses the pathophysiology of a pneumothorax as well as the USWD as a way of treating the condition. The paper also describes two signs presented by the patient.
The Case Study
The patient by the name Leigh Richards is 39 years old and he is married with three kids he is also an irrigation advisor at Murray Bridge. The patient got a serious accident and was retrained after the rally car they were in hit a tree while speeding on a dirt road. The patient was removed from the car through inline extrication after emergency services were called. When he arrived in the hospital, he was drowsy and disoriented. The patient’s left superior arm was enlarged, it was so painful that touching or moving it was not easy, and it had a distortion as well. As a result trauma X-rays were conducted, after which the patient was diagnosed to have developed left pneumothorax, fibula and left tibia, subdural hematoma, as well as left humerus. Mr. Leigh Richards was then taken to the theater for surgery since he had an ORIF for left lower leg and ORIF for left humerus. The Sub Dural hematoma is being addressed conventionally. The neurovascular assessment has obtained slight tingling of the fifth finger, as well as weakness in left leg and arm. The patient’s daughter who is a nursing student (second year) requests for an explanation of the pathophysiology of pneumothorax because she fails to understand why they develop into pneumothorax when UWSD insertion is not applied. She also requests for additional information on the UWSD insertion technique.
Classifications of Pneumothorax
The condition is classified based on the causes. The various classes are:
Primary Spontaneous Pneumothorax: This usually occurs in tall, thin, adolescent makes. Smoking has also been associated with the condition (Tschopp et al., 2015) Since the pleural compression gradient is more in the lung apex than in the lower part of the lung, in tall people, a greater mean descending pressure is subjected in the alveoli in the lung apex (Aziz, Patel, Ie & Rubio, 2016). With time, the high descending pressure may lead to the development of subpleural bleb. It has been obtained that the condition is more prevalent in heavy smokers than non-smokers.
Secondary spontaneous pneumothorax: This condition results in individuals who already have a lung condition. The occurrence of the condition is the same as that of main impulsive pneumothorax. The condition is common in old individuals.
Catamenial pneumothorax: this condition develops at the onset of or within twenty-four to seventy-two hours after the start of menses, and is recurrent (Kolos, Dzhieshev, Dikolaev & Amangaliev, 2015). The initial development does not normally occur until the female is in her thirties. The pathophysiology of catamenial pneumothorax is still not clear.
Noniatrogenic pneumothorax: this condition develops shortly after birth in about 2% of infants. The condition is twice as common is males than females. The cases of the condition are common in preterm birth as well as low birth weight. The pathophysiology of non-iatrogenic pneumothorax is linked to motorized problems of the initial increasing of the lungs.
Traumatic pneumothorax: This condition results from either a penetrating injury or blunt trauma to the walls of the chest. The condition may happen simultaneously with the injury, immediately after the injury, or later on. Apart from penetrating trauma, the condition can result from the secondary laceration of the visceral pleural after dislocation or rib fracture. The abrupt compression increases the pressure in the alveoli, which may result to rupture of the alveoli. Blunt trauma can also cause the rapturing of the alveoli. When a penetrating trauma occurs, the air gets into the pleural space directly via the wound on the wall of the chest. This class of pneumothorax is further divided into; open, simple and pull pneumothorax. The meek pneumothorax is where the air coming from the destroyed lungs enter the pleural space. In case the wound is big enough to allow air to freely pass freely into and outside the pleural space, then the condition is referred to as open pneumothorax. In the open pneumothorax case, the atmospheric stress is in balance with the intrapleural stress (Aziz, Patel, Ie & Rubio, 2016). This blocks the lung inflation as well as the ventilation of the alveoli. As a result, the air moves with sped via the wound into the wall of the chest, as usually produces a lapping sound. In many cases, the lungs collapse. This makes it critical to seal the open wound using a Vaseline gauze and put a chest tube, as an emery measure.
Tension pneumothorax usually results from the injury of the lungs or the chest walls. In this case, on way valve mechanism results, where the air goes into the pleural space and gets trapped inside, making it impossible to expel during expiration (Roberts et al., 2014). In such a case, the inter-thoracic pressure rises making the lungs to collapse (Ianniello, Di Giacomo, Sessa & Miele, 2014). The collapse of the walls shifts the mediastinum away from the injured side, leading to reduced venous return to the heart, hypoventilation, as well as development of obstructive shock (Roberts et al., 2014). The patient in the case study, Leigh Richards, suffer from this condition.
The General Pathophysiology of a Pneumothorax
In normal individuals, due to the inherent tendencies of the lungs to collapse as well as the chest wall to expand, the stress inside the pleural space is less in relation to the atmospheric stress. An interaction amid the alveoli as well as the pleural space causes airflow down the stress gradient until the attainment of equilibrium or until the interaction is sealed. As the pneumothorax expands, the lungs reduce in size. The major physiologic result of this occurrence is a reduction in the vital capacity and the oxygen’s partial pressure (Ianniello, Di Giacomo, Sessa & Miele, 2014). The young and healthy individuals can tolerate these changes effectively with minimal changes in crucial symptoms. However, those individuals having lung diseases may experience respiratory distress. The decrease in the vital capacity cases respiratory insufficiency as well as respiratory acidosis and hypoventilation of the alveoli. Many individuals with the condition have increased alveolar-arterial oxygen tension difference and reduced arterial PO2 (Ianniello, Di Giacomo, Sessa & Miele, 2014).
Pharmacology of Pneumothorax
The tension pneumothorax in the case study requires rapid treatment using anesthetics and analgesics. However, these analgesics and anesthetics should be administered when the patient is not in distress. The aim of the pharmacotherapy is to reduce the level of mobility and stop further complications (Stoelting & Hillier, 2012). The local anesthetics are applied for analgesia during thoracentesis and placement of the chest tube. The local anesthetic like Lidocaine Hydrochloride is easily absorbed into the mucous membranes after being applied topically. The rate of absorption is based on the site of application, duration of exposure, and the total dosage. The drugs mode of action is through reduction of the permeability of sodium ions in the neuronal membranes, leading to inhibition of depolarization as well as blocking the transmission of nerve impulses (Stoelting & Hillier, 2012). The known adverse effect of using the local anesthetic is allergic reactions.
The opiate analgesics agents are also used for the purpose of reducing or controlling pain (Trang et al., 2015). Reduction of pain is a good for patient care as it improves the comfort of the patient. The mode of mot analgesics is through sedation, benefiting individuals with painful skin lesions. The drugs are crucial when placing the chest tubes and for controlling pain following the procedure (Trang et al., 2015).
Signs and Symptoms
The patients was experiencing pain, was drowsy and disoriented. These conditions are closely linked with the abnormal functioning of the respiratory system. On performing UWSD, it was obtained that the lower part of the chest channel was fluctuation and draining small amounts of severe fluid while the upper part of the chest tube was swaying and intimately sparkling with no draining. This indicates that the pneumothorax had been forming on the chest region. Pneumothorax entail formation of both fluid and air in the pleural space. As such the upper region may had only air while the lower region had both air and fluid.
Under Water Sealed Drains (UWSD)
These are chest drains implanted to permit draining of fluid, air, and blood out of pleural spaces (Zarogoulidis et al., 2014). The draining permits lungs expansion as well as restores the bad pressure in the thoracic opening. The operation is as well executed with the aim of preventing air backflow and fluid (Huang et al., 2014). There are three basic components of the chest drain systems. The first one is the chest tube that is introduced in the pleural space to permit air as well as fluid to get out. The system has six-foot long patient elastic pipes connecting the chest tube and the chest drain structure (Zarogoulidis et al., 2014). The other component is the drainage system that has; a collection chamber for collecting fluids and measurement if the drainage volume; a one-way water seal section or valve that allows the air or fluid inside to leave while preventing entry of the outside air; and a suction for controlling the amount of negative pressure subjected to the chest (Zarogoulidis et al., 2014).
There are two main types of chest tubes namely; the thoracotomy and the trocar chest tubes. These tubes are different in their design but perform similar functions in an almost similar manner (Zarogoulidis et al., 2014). There is a specific procedure for using the UWSD technique, which begins with strategic positioning of the patient to allow for high oxygen flow (Kirmani & Page, 2014). Aseptic techniques are used to fill the syringe with 5ml of normal saline or water. The next step entails location of a landmark and cleaning the area using a disinfectant (Kirmani & Page, 2014). The needle is, then, perpendicularly inserted above the third rib while drawing the syringe back causing the solution to bubble. Once this is done, the syringe is inserted further 5mm, after which the catheter is advanced into the pleural space. The stylette is then placed into a sharps container, and a one-way-valve is attached to the IV Catheter. Strappings are used to secure the Catheter and the valve. The last step is the reassessment of the chest for improvement, and when o improvement is determined then insertion of another needle close to the initial one is done.
Pneumothorax is a condition where air, blood or fluid occurs in the pleural space (Ouellette et al., 2014). The condition is a result of the rupture in the pleura or the visceral. Even though the pathophysiology of the condition is not fully established, it is known that the negative pleural pressures contribute to the manifestation of the condition. If the interaction between the alveoli and the pleura develops, air flows into the pleural space till an equilibrium stress is attained or until the interaction is stopped (Ouellette et al., 2014). The elastic recoil feature of the lungs may cause them to fall if there is no negative intrapleural pressure to hold the lungs together. The major physiologic consequences of the condition include a reduction in the vital capacity as well as a reduction in the unfinished pressure of the arterial oxygen. The condition can be well-tolerated in healthy individuals (Panigrahi & Pradhan, 2016). However, when an individual’s lungs had been compromised before the development of the condition, the development of the condition leads to respiratory insufficiencies, respiratory acidosis, as well as hypoventilation of the alveoli.
The pathophysiology of tension pneumothorax is similar to the one-way regulator course, where the valve opens for inspiration but fails to open for respiration. In case the extrathoracic pressure continues to be greater than the stress in the pneumothorax for a while, then the air occupies similar to the single-way regulator procedure, where the valve opens for inspiration but fails to open for respiration. In case the extrathoracic pressure continues to be greater as compared to the pressure in the pneumothorax for a while, after which the air occupying the pleural space as well as the ambient atmosphere will start to get close to equilibrium (David, Pompeo, Fabbi & Dauri, 2015). This stage may cause shifting of the mediastinal, and solidity of the contralateral lung and the superior vena cava. The reduced volume returning to the heart results in reduced volume stroke, and thus, reduced cardiac output. This ultimately causes obstructive shock and hemodynamic collapse. The diagnosis of the condition can be through assessment of the patient’s history, physical examination as well as through x-ray scanning. The condition is managed either conservatively, use of UWSD or surgical procedures (Porpodis et al., 2014)
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