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Pneumothorax An Abnormal Collection Of Air In The Pleural Space

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Question:

Discuss About Pneumothorax An Abnormal Collection Of Air In The Pleural Space?

 

Answer:

Introduction

Pneumothorax is an abnormal collection of air in the pleural space, causing an uncoupling of the lung from the chest wall. It leads to collapsing of lungs. As the level of air in the space between lung and chest wall increases, the pressure against lung also increases, which causes the lungs to collapse. There are several reasons, which may leads to pneumothorax. Thus, it is important to identify the cause of the disease along with the pathophysiology (Volpicelli 2011). In this essay, the focus is Leigh Richards, whose daughter needs to know the pathophysiology of pneumothorax and the rationale for the available pharmacology of the disorder. Thus, the essay would include the description of pathophysiology of the case patient, i.e. the role of UWSD insertion, signs and symptoms of pneumothorax and its effects on cardiac and respiratory system.

 

Pathopysiology of pneumothorax

Pneumothorax is the condition with the presence of gas within the pleural space. Normally, lungs are fully inflamed within the cavity as the alveolar pressure is greater than the intrapleural pressure, while the intrapleural pressure is less than the atmospheric pressure. Instead of low pressure in the pleural space air is unable to enter it due to the absence of air-containing passage and the pressure of gases in the bloodstream is low to forcefully enter into the pleural space. Therefore, if air is allowed to enter, via damaged chest wall or impaired lung or due to gas producing microbes present in the pleural space, pneumothorax can only develop (Grundy et al. 2012). Upon establishment of a link between pleural space and alveolus or within atmosphere and pleural space, gases follow the pressure gradient and flows into the pleural space, until the pressure gradient disappears or the abnormal communication is have been sealed. When the condition develops, as the thoracic cavity is usually below the resting volume and lung is above its resting volume, lung becomes smaller and thoracic cavity enlarges. In minority of cases the air volume within the chest increases, when a one-way valve is developed by an area of damaged tissue, which develops tension pneumothorax.

This condition is referred to a medical emergency and occurs when a he intrapleural pressure goes beyond the atmospheric pressure, especially at the time of expiration, as a result of a ball valve mechanism, which influences the inspiration accumulation of pleural gases. The development of pressure within pleural space results in hypoxaemia and leads to respiratory collapse due to compression of lung. The body compensate for the condition by increasing respiratory rate and tidal volume, thereby worsening the problem. This medical condition is caused due to a steadily worsening oxygen shortage along with low blood pressure (Subotic and Van Schil 2011). The condition may also lead to death by hypoxia and respiratory arrest, if not managed properly. However, in very rare cases, both of the lungs get affected by a pneumothorax, the condition known as atelectasis or collapsed lung.

The primary pneumothorax is the condition occurring without apparent cause, in the absence of significant lung disease, whereas the secondary pneumothorax is referred to the condition when the other lung diseases are already present. The damage to chest wall can arise as a result of injury to chest wall like stab or bullet wounds. In secondary spontaneous pneumothoraces, a diverse range of disease process can lead to vulnerabilities in the lung tissue by rupturing of bullae in cases of severe emphysema (Zarogoulidis et al. 2014). The areas, where the necrosis occurs may facilitate pneumothorax. From many years it has been thought that small air filed lesions under pleural surface, which are known as blebs, are contributing in increasing the risk of pneumothorax.

 

Pharmacology of pneumothorax

Immediate needle decompression can be done for tension pneumothoraces. Continuous monitoring with regular X-ray for primary spontaneous pneumothoraces can also be a significant treatment. However, underwater seal drainage has a high potential to resolve the progression towards secondary spontaneous pneumothorax development (Nelson et al. 2013).

UWSD and effects

An underwater seal and chest tube, which is also known as chest drain, thoracic catheter, intercostals drain or thoracostomy, is a  hollow, fexible and long tube, which is inserted through the chest wall within ribs and into the pleural space or mediastinum. This process is used for removing air, in case of pneumothorax from the intrathoracic space. It is a canister device, used for collecting chest drainage (Roberts et al. 2015). This drainage canister uses three chambers, based on three bottle system. The first chamber collects the fluid from chest. The second chamber plays the role of a “water seal”, acting as one way valve that allows the gases to excape, instead of allowing gases to re-enter chest. The third chamber is the suction control chamber. The water height in the chamber controls the negative pressure on the system.

Chest drains usually remains in as long as the air remains in the pleural space. Leigh Richard will undergo a regular chest X-ray to monitor the progress in recovery of the heath issue. There may be complications, associated with chest drainage; minor problems include bruising, anxiety, breathing shortness and cough. However, major complications like bleeding, infection, re-expansion pulmonary edema, injury to liver, spleen or diaphragm may happen, though the frequency is low. Inappropriatee management can also cause thoracic aorta and heart injury. Chest tube clogging is the most common complication, caused by thrombus formation within the chest tube (Brown et al. 2014). The process can be used for other conditions like pleural effusion, referred to the condition related to accumulation of fluid in pleural space. The process is crucial for cease the development of tension pneumothorax, as tension pneumothorax is the condition, which is the result of progressive increase in intrapleural pressure to such levels that become positive all through the respiratory cycle and collapses the lung, shifts the mediastinum as well as impairs venous return to the heart. Therefore, untreated primary pneumothorax can lead to tension pneumothorax (Puri and Dingemann 2011). This condition, if treated with UWSD, can restore the previous normal lung structure and reduce the chance of systematic hypotension, respiratory and cardiac arrest.

 

Effect on respiratory and cardiac system

In case of tension pneumothorax, as the pressure of gas increases within the pleural space, the ipsilateral lung collapses, leading to hypoxia. Untreated condition leads to the shift of mediastinum towards the contralateral side and impinges on and compresses both the contralateral lung and impairs the venous return towards the right atrium. The effect is hypoxia, indicating that there is shortage of airflow through airtubes, leading to deceased venous return due to compression of the relatively thin walls of the atria, impairing the cardiac function (Subotic and Van Schil 2011). The condition is followed by kinking of the inferior vena cava, which has been demonstrated as the initial step in blood flow restriction towards heart. This kinds of situation has been identified in many in trauma patients, who are hypovolemic with reduced venous blood returning to the heart. Therefore, the above consequences of tension pneumothorax demonstrated that the condition, if left untreated, can rapidly progress towards respiratory insufficiency, cardiac arrest or cardiovascular collapse, which in turn leads to death. Therefore, the above discussion regarding the effect of pneumthorax on both respiratory and cardiovascular system would be helpful for Leigh Richard’s daughter to understand from the nursing perspectives.

Signs/Symptoms

The symptoms are dependent upon the size of pneumothorax. In the mild cases, the symptoms are not properly felt or understood. However, in severe cases rapid symptoms may generate, leading to shock. Symptoms of pneumothorax usually include sudden onset of one sided, sharp chest pain along with breathing shortness.  Shortness of breath or dyspnea may be mild or severe, severity of which depends upon how much the lung is collapsed. These sudden symptoms can be worsened with changes in altitudes like flying high in airplane or going underwater or underground (Volpicelli 2011). Breathing shortness or hypoxia is the manifestation of low airflow through the air tube, which is the result of respiratory arrest, whereas hypotension is the manifestation of cardiac insufficiency of proper blood flow through the blood vessels. The physical findings consist of absent tactile fremitus, hyperresonance to percussion along with decreased breath sounds on the affected side. Hypotension can also be a sign, if the pneumothorax is large and the affected side is enlarged, which causes the shift of trachea to the opposite side.

 

Conclusion

In conclusion, it can be said that pneumothorax is a significant respiratory disorder, which should be diagnosed as soon as the patient experiences visible signs and symptoms. It is because, the issue can rapidly progress towards the worsening of the condition, which may be non-curable and may led to fatal consequences. In this essay, Leigh Richard’s case study was focused, where his daughter, the second year nursing student attempts to understand the consequences of the condition and role of UWSD. The essay demonstrated the signs and symptoms, pathophysiology, pharmacology of UWSD as well the effects of the issue on both respiratory and cardiovascular system.

 

Reference List

Brown, S.G.A., Ball, E.L., Macdonald, S.P.J., Wright, C. and McD Taylor, D., 2014. Spontaneous pneumothorax; a multicentre retrospective analysis of emergency treatment, complications and outcomes. Internal medicine journal, 44(5), pp.450-457.

Grundy, S., Bentley, A. and Tschopp, J.M., 2012. Primary spontaneous pneumothorax: a diffuse disease of the pleura. Respiration, 83(3), pp.185-189.

Nelson, D., Porta, C., Satterly, S., Blair, K., Johnson, E., Inaba, K. and Martin, M., 2013. Physiology and cardiovascular effect of severe tension pneumothorax in a porcine model. journal of surgical research, 184(1), pp.450-457.

Puri, P. and Dingemann, J., 2011. Pulmonary air leaks. Newborn Surgery 3E, p.333.

Roberts, D.J., Leigh-Smith, S., Faris, P.D., Blackmore, C., Ball, C.G., Robertson, H.L., Dixon, E., James, M.T., Kirkpatrick, A.W., Kortbeek, J.B. and Stelfox, H.T., 2015. Clinical presentation of patients with tension pneumothorax: a systematic review. Annals of surgery, 261(6), pp.1068-1078.

Subotic, D. and Van Schil, P., 2011. Spontaneous pneumothorax: remaining controversies. Minerva chirurgica, 66(4), pp.347-360.

Volpicelli, G., 2011. Sonographic diagnosis of pneumothorax. Intensive care medicine, 37(2), pp.224-232.

Zarogoulidis, P., Kioumis, I., Pitsiou, G., Porpodis, K., Lampaki, S., Papaiwannou, A., Katsikogiannis, N., Zaric, B., Branislav, P., Secen, N. and Dryllis, G., 2014. Pneumothorax: from definition to diagnosis and treatment. Journal of thoracic disease, 6(4), pp.S372-S376.

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