Chapter 12: Respiratory care, CPR and blood transfusion
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Source: Adapted from Cardillo et al. ([36]), Hassan and Shaarawy ([102]).
Source: Adapted from Cardillo et al. ([36]), Tschopp et al. ([275]).
Related theory
Drainage is required for patients who are symptomatic of excess air (pneumothorax) or fluid (pleural effusion) within the pleural space. Chest drains may also be inserted to drain blood (haemothorax), lymph (chylothorax) or pus (empyema), or a combination of air and fluid (Mao et al. [144]).
Pleural effusion
The mechanisms by which pleural effusions develop are complex, but they generally occur when the rate of filtration overwhelms the rate of lymphatic clearance resulting in an excessive amount of fluid in the pleural space (Chadwick et al. [42]).
Pleural effusions are classified as either transudative or exudative. A transudative pleural effusion occurs when the balance of hydrostatic forces influencing the formation and absorption of pleural fluid is altered to favour pleural fluid accumulation. The permeability of the capillaries to proteins is normal. In contrast, an exudative pleural effusion develops when the pleural surface and/or the local capillary permeability are altered. There are many causes of transudative and exudative effusions, as outlined in Box 12.2.
Pleural effusion develops in nearly half of all patients with metastatic disease. The most common cancers that cause malignant pleural effusions are adenocarcinomas; other carcinomas of the lung, breast and ovaries; and lymphoma (Egan et al. [70]).
Patients with pleural effusion usually present with a number of symptoms and signs (Na [171], Saguil et al. [241]). Symptoms include the following:
- dyspnoea
- chest pain (may be mild or severe and is often worse on deep inspiration; it is typically described as a sharp or stabbing pain)
- cough (usually dry and unproductive).
Signs include the following:
- unequal chest expansion
- tracheal deviation may be seen with a very large pleural effusion
- decreased tactile and vocal fremitus
- dull to percussion
- diminished air entry on auscultation.
Box 12.2
Causes of transudative and exudative pleural effusions
Transudative pleural effusion
- Left ventricular failure
- Liver cirrhosis
- Nephrotic syndrome
- Peritoneal dialysis or continuous ambulatory peritoneal dialysis
- Hypoproteinaemia (e.g. severe starvation)
- Hypothyroidism
- Mitral stenosis
Causes of exudative pleural effusion
- Malignant disease
- Infectious diseases, including tuberculosis
- Parapneumonic effusions
- Pulmonary embolism
- Pancreatitis
- Collagen vascular diseases: rheumatoid arthritis, systemic lupus erythematosus, benign asbestos effusion
- Drug‐induced primary pleural disease: nitrofurantoin, amiodarone, procarbazine, methotrexate, bleomycin, metronidazole, phenytoin or beta blockers
- Injury after cardiac surgery, pacemaker implantation, myocardial infarction, blunt chest trauma or angioplasty
Pneumothorax
Pneumothorax can be defined as air in the pleural cavity that causes the lung to collapse due to a loss in negative pressure (Tschopp et al. [275]). A pneumothorax occurs as the result of the processes described in Table 12.10. Pneumothoraces can therefore be classified as iatrogenic, traumatic, primary spontaneous and secondary spontaneous (Tschopp et al. [275]).
Table 12.10 Causes of pneumothorax
| Cause | Notes |
|---|---|
| Breach of the integrity of either pleural layer, causing direct or indirect communication between the atmosphere and the pleural space | Many procedures performed in an intensive care or emergency setting can result in an iatrogenic pneumothorax. Examples of these procedures include incorrect chest tube insertion, mechanical ventilation therapy, central venous catheterization, cardiopulmonary resuscitation, lung or liver biopsy, or surgery. A blunt or penetrating trauma to the chest wall, diaphragm or bowel may cause a traumatic pneumothorax. |
| Communication between the alveolar spaces and the pleura | This can occur spontaneously and is most common in tall, thin males (primary spontaneous pneumothorax). It can also occur secondarily to underlying lung conditions such as asthma, chronic bronchitis, tuberculosis, pneumonia, cystic fibrosis or carcinoma of the lung (secondary spontaneous pneumothorax). |
| Gas‐producing organisms in the pleural space | Micro‐organisms that produce gas will cause an increase in the amount of air within the pleura and subsequent pneumothorax. |
The symptoms of a pneumothorax are proportional to its size and depend on the degree of pulmonary reserve. Common signs and symptoms are listed in Box 12.3.
Box 12.3
Signs and symptoms of pneumothorax and tension pneumothorax
| Symptoms of a pneumothorax | Signs of a pneumothorax |
|---|---|
|
|
|
Signs and symptoms of a tension pneumothorax (in addition to those listed above)
| |
Tension pneumothorax
A tension pneumothorax is the complete collapse of a lung as the intrapleural pressure becomes greater than the atmospheric pressure during both inspiration and expiration (Tschopp et al. [275]). A breach in the pleura creates a one‐way valve, which allows air to progressively accumulate within the pleural space with each inspiration (Woodrow [290]). As the amount of air in the pleural space increases, the lung becomes compressed, the mediastinum shifts and venous return to the heart decreases, causing cardiac arrest (Woodrow [290]). A tension pneumothorax is therefore a life‐threatening emergency that requires immediate treatment (RCUK [232]).
Diagnosis of a simple pneumothorax can be confirmed on a chest X‐ray, which should be taken during inspiration (MacDuff et al. [138]). However, diagnosis of a tension pneumothorax is based on clinical history and examination alone. It is a medical emergency and should be treated urgently without the need for diagnostic imaging. Ultrasound can be performed at the bedside so long as it does not delay treatment (MacDuff et al. [138], RCUK [232]). Supportive therapy should be given until needle decompression or chest drain insertion is performed. This may include sitting the patient upright and giving oxygen therapy to maintain saturations between 94% and 98% (O'Driscoll et al. [209], Woodrow [290]).
Haemothorax
Haemothorax is a collection of blood within the pleural space, usually as a result of injury to the heart, lungs or major vessels within the thoracic cavity, or in a patient who has bled on anticoagulation therapy (Patrini et al. [217]).
Haemopneumothorax
Haemothorax may also be associated with pneumothorax, in which case it is called ‘haemopneumothorax’. Depending on the amount of blood or air in the pleural cavity, a collapsed lung can lead to respiratory and haemodynamic compromise (Patrini et al. [217]).
Empyema
Empyema is defined as pus in the pleural space. It may occur following rupture of an abscess within the lung, pneumonia, pulmonary tuberculosis or an infection following thoracic surgery (McCauley and Dean [150]).
Chylothorax
Chylothorax is a collection of lymphatic fluid within the pleural space, usually resulting from disruption of the thoracic duct or its tributaries (Alamdari et al. [8]). The fluid is usually milky and contains a high level of triglycerides (>110 mg/dL), an essential feature for its diagnosis (Bender et al. [21]). Chylothorax can be split into traumatic (thoracic surgery or penetrating trauma) and non‐traumatic/spontaneous (congenital, neoplastic, infectious or obstructive) classifications (Bender et al. [21]).
