Pneumothorax or collapsed lung is caused by air leaking into the pleural cavity. In a normal lung, negative pressure exists between the visceral and parietal pleura or the pleural space. This pleural space contains minimal fluid that serves as lubrication when the tissues move. When air enters the pleural space, changes to the pressure will cause the lungs to partially or completely collapse.
Types of Pneumothorax
Pneumothoraces are divided into the following categories:
- Spontaneous pneumothorax occurs when there is a rupture of air-filled sacs on the lung surface.
- Primary spontaneous pneumothorax (PSP) occurs without an evident cause.
- Secondary spontaneous pneumothorax (SSP) occurs due to an underlying condition, such as COPD, asthma, tuberculosis, cystic fibrosis, and other lung diseases.
- Iatrogenic pneumothorax occurs due to a puncture or laceration of the lungs during a medical procedure like a lung biopsy, tracheostomy, or catheter insertion.
- Tension pneumothorax occurs when the air enters the pleural space and cannot escape. This often results from trauma such as from a stab or gunshot wound or internally from a fractured rib.
Nursing Process
Since patients with a pneumothorax may exhibit respiratory distress, the patient’s ABCs (airway, breathing, circulation) and hemodynamic stability should be considered in managing the condition. If the patient is stable and has minimal air or fluid accumulation in the pleural space, no treatment may be necessary as the condition will resolve spontaneously. With severe pneumothorax, immediate medical care is required. Treatment often includes the insertion of a chest tube connected to suction monitored by the nurse.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to pneumothorax.
Review of Health History
1. Determine the causative factor.
Causative factors of pneumothorax include the following:
- Chest trauma/injury
- Ruptured blebs or bullae (collection of air or fluid)
- Underlying lung disease
- Recent surgical or invasive procedures
2. Obtain the patient’s medical history.
Note any existing lung disease. The following conditions are associated with SSP:
- Chronic obstructive pulmonary disease (COPD)
- Asthma
- Cystic fibrosis
- Lung cancer
- Sarcoidosis
- Tuberculosis
- HIV/AIDS with pneumonia
3. Identify the patient’s risk.
Risk factors for a PSP include:
- Male gender
- 20-30 years of age
- Tall, thin body type
- Smoking
- Pregnancy
- Marfan syndrome
- Family history of pneumothorax
4. Consider genetics for PSP.
Patients with Marfan syndrome, homocystinuria, and Birt-Hogg-Dube (BHD) syndrome are linked to primary spontaneous pneumothorax. Consider genetic testing for patients with PSP.
5. Note a previous incidence of pneumothorax.
Recurrent pneumothoraces occur within the first six months to three years and are more common in patients who smoke, are younger, are taller and thinner, and have a history of COPD, AIDS, and pulmonary fibrosis.
6. Review past medical procedures.
Transthoracic needle aspiration (often used for biopsies) is the main factor contributing to iatrogenic pneumothorax. Other medical procedures that may lead to iatrogenic pneumothorax include:
- Thoracentesis
- Central venous catheter insertion
- Tracheostomy
- Cardiopulmonary resuscitation
- Acute respiratory distress syndrome with positive pressure ventilation
- Nasogastric feeding tube placement
7. Inquire about the patient’s lifestyle and occupation.
Identify the following factors that are associated with lung collapse:
- Use of inhaled drugs (marijuana or cocaine)
- Activities or occupations that have drastic air pressure changes (such as flying, scuba, or deep-sea diving)
Physical Assessment
1. Assess the patient’s general symptoms.
Sudden chest pain and dyspnea are the primary presenting symptoms of pneumothorax. Patients with PSP may only be mildly symptomatic. Patients may describe the pain to be sharp, severe, and worse with inspiration that radiates to the ipsilateral shoulder. Dyspnea may be more severe in those with secondary pneumothorax.
2. Monitor the vital signs.
Vital signs may reveal increased respiratory and pulse rate and decreased blood pressure and oxygen saturation. Closely monitor for changes in vital signs for hemodynamic instability.
3. Assess the respiratory status.
Follow the IPPA (inspection, palpation, percussion, and auscultation) sequence when conducting a respiratory assessment.
- Inspection: respiratory discomfort, airway patency, tracheal deviation
- Palpation: decreased tactile fremitus, asymmetrical lung expansion
- Percussion: hyperresonance
- Auscultation: decreased or absent breath sounds
4. Assess the cardiovascular status.
Tension pneumothorax may affect the cardiovascular status. Note the following findings:
- Increased heart rate (more than 134 bpm)
- Decreased blood pressure
- Jugular vein distension
- Cyanosis
- Cardiac arrest
Diagnostic Procedures
1. Prepare the patient for a chest X-ray.
Chest radiography is used to diagnose a pneumothorax, evaluate the severity of the pneumothorax and potential causes, and provide a baseline to assess the effectiveness of the treatment plan.
2. Consider other imaging scans.
Plain radiographs may not detect thoracic damage, so computed tomography (CT) should be utilized for significant chest injuries. Ultrasound is gaining traction as a bedside tool in the ICU and ED settings. When used by a competent operator, it has a high sensitivity and specificity rate.
3. Obtain ABGs.
ABG analysis is vital for patients with respiratory distress or underlying lung disease to assess for hypoxemia, hypercarbia, and acidosis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with pneumothorax.
Assists with Pneumothorax Management
1. Administer medications as ordered.
Prior to chest tube insertion, administer prophylactic antibiotics to prevent infection from skin flora. Administer analgesics or prepare the patient for a nerve block to reduce pain.
2. Prepare for decompression.
Needle decompression treats a pneumothorax by inserting a large-bore catheter into the chest wall to draw out excess air. This is usually done in emergent settings by EMS or in the ED when a pneumothorax is identified.
3. Assist in thoracostomy tube insertion.
The treatment involves placing a thoracostomy tube (chest tube) following needle decompression. Heimlich valves are one-way valves that allow air to escape without using suction. SSP typically requires suction.
4. Consider a watchful approach for small pneumothoraces.
For a small PSP where the patient is asymptomatic, observation is advised with oxygen administration as the pneumothorax will likely resolve on its own.
5. Apply supplemental oxygen.
Administer oxygen at a flow rate of 3 L/min via a nasal cannula or higher to treat hypoxemia and enhance air absorption.
6. Prepare for possible surgical intervention.
Surgical treatment can be required if the patient has experienced multiple pneumothoraces or if the lung has not expanded after five days with a chest tube in place. Options may include:
- Thoracoscopy
- Electrocautery
- Laser treatment
- Resection of blebs or pleura
- Open thoracotomy
- Video-Assisted Thoracoscopic Surgery (VATS)
7. Decrease pneumothorax recurrence.
Perform pleurodesis (sclerotherapy) on patients with recurrent pneumothoraces who are not good surgical candidates. Pleurodesis reduces the possibility of pneumothorax recurrence. This procedure creates scar tissue between the layers of the pleura, effectively sticking them together to prevent the reaccumulation of fluid or air in the pleural space.
Educate on Prevention
1. Encourage smoking cessation.
Evaluate the patient’s willingness to stop smoking and provide education and resources on smoking cessation.
2. Avoid activities with drastic changes in air pressure.
Patients with occupations like scuba diving or piloting planes should be cautioned against diving or flying until the pneumothorax has undergone definitive surgical treatment.
3. Limit air travel.
Inform the patients with pneumothorax that they should avoid flying for several weeks after treatment for pneumothorax.
4. Promptly treat respiratory infections.
Prompt recognition and treatment of bronchopulmonary infection decreases the risk of progression to a pneumothorax.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pneumothorax, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pneumothorax.
Acute Pain
Symptoms of pneumothorax typically include sudden chest pain and dyspnea. The pain is described as sharp and worsens with deep breathing or coughing.
Nursing Diagnosis: Acute Pain
Related to:
- Chest injury
- Pneumothorax
As evidenced by:
- Distraction behavior
- Expressive pain behavior
- Guarding behavior
- Positioning to ease pain
- Hesitancy to take a deep breath/shallow breathing
Expected outcomes:
- Patient will report a reduction in pain when breathing.
- Patient will demonstrate an even respiratory rate without expressions of pain.
Assessment:
1. Conduct a comprehensive pain assessment.
Chest pain in pneumothorax is described as a sudden, severe, stabbing pain that radiates to the shoulders and worsens with inspiration. Pneumothorax can happen with or without visible signs of injury to the chest.
2. Monitor the effectiveness of analgesics.
Patients may be reluctant to take normal breaths due to pain with inspiration. Assess pain control following the administration of medications to ensure adequate ventilation.
Interventions:
1. Encourage the use of a chest splint when breathing or coughing.
Chest pain in pneumothorax can negatively affect the patient’s breathing. With the use of a chest splint or pillow, the chest is supported making breathing more comfortable.
2. Assist the patient in a position of comfort.
Allow for lung expansion by supporting a high-Fowler’s position.
3. Administer analgesics as indicated.
Pain medication can help alleviate pain in pneumothorax. Anticipate pain such as prior to movement or breathing exercises and premedicate accordingly.
4. Provide diversional activities.
Rest is required when recovering from a pneumothorax. Offer the patient other activities such as reading, visiting with friends or family, music, and movies.
Impaired Gas Exchange
When air enters the pleural space this causes positive intrapleural pressure and lung compression, which ultimately results in impaired gas exchange.
Nursing Diagnosis: Impaired Gas Exchange
Related to:
- Ventilation-perfusion imbalance
- Decreased functional lung tissue
- Pain
- Chest trauma
- Ineffective breathing pattern
As evidenced by:
- Abnormal arterial pH
- Altered respiratory depth
- Altered respiratory rhythm
- Cyanosis
- Bradypnea
- Hypoxemia
- Hypoxia
- Nasal flaring
Expected outcomes:
- Patient will exhibit improved ventilation and adequate oxygenation with ABGs within normal parameters.
Assessment:
1. Assess lung sounds.
Pneumothorax will often present as decreased or absent airflow on one side of the chest, decreased chest wall movement on the affected side, and hyperresonance when the chest walls are percussed.
2. Assess respiratory rate and rhythm.
Alterations in respiratory rate and rhythm can indicate the progression of respiratory distress and more severe lung involvement.
3. Evaluate imaging studies.
A chest x-ray can confirm pneumothorax and the severity of the condition. CT scan or ultrasound may also be used.
Interventions:
1. Apply oxygen as ordered.
Air can reabsorb into the pleural space and supplemental oxygen can increase reabsorption.
2. Monitor ABG levels.
This enables healthcare providers to monitor the progress of the condition and determine the patient’s respiratory status.
3. Assist with chest tube thoracostomy.
Chest tubes are essential as they help drain air and fluid from the pleural space. This will help reduce lung compression.
4. Encourage deep breathing exercises.
Patients with a pneumothorax will need to relieve pressure on the lungs to enable optimal lung expansion. While it may be painful, encourage the patient to perform deep breathing exercises and use a device such as an incentive spirometer to inflate the lung and prevent atelectasis.
Impaired Spontaneous Ventilation
A pneumothorax may become life-threatening or fatal with a continued air leak or if treatments prove ineffective.
Nursing Diagnosis: Impaired Spontaneous Ventilation
Related to:
- Respiratory muscle fatigue
- Limited lung expansion
- Comorbid conditions
- Hemodynamic instability
As evidenced by:
- Dyspnea
- Decreasing SpO2
- Increased accessory muscle use
- Restlessness
- Fatigue
Expected outcomes:
- Patient will exhibit clear lung sounds and SpO2 within normal limits.
- Patient will demonstrate an absence of complications from pneumothorax.
Assessment:
1. Monitor the ABCs.
Airway, breathing, and circulation are priorities with a pneumothorax. Closely monitor the respiratory status and vital signs for abnormalities.
2. Assess CT results.
A CT scan is utilized for significant chest injuries, though treatment should not be delayed if clinical signs indicate pneumothorax.
Interventions:
1. Administer oxygen.
Supplemental oxygen should be administered at 3L to prevent hypoxemia and aid in air absorption.
2. Prepare for needle decompression.
Especially in tension pneumothorax, prompt recognition and intervention through needle decompression is essential to prevent deterioration and cardiac arrest.
3. Prepare for surgical intervention.
If the lung remains unexpanded after 5 days with a chest tube, surgical options like thoracoscopy, electrocautery, resection of blebs or pleura, or open thoracotomy may be advised.
4. Implement mechanical ventilation.
If the patient displays respiratory muscle fatigue, hypoxemia, acidosis, or changes in mental status, prepare for mechanical ventilation.
Ineffective Airway Clearance
The patient with a pneumothorax may be unable to maintain a clear airway.
Nursing Diagnosis: Ineffective Airway Clearance
Related to:
- Underlying lung disease (COPD, asthma, pneumonia)
- Tracheal deviation
- Ineffective cough
As evidenced by:
- Altered respiratory rate and rhythm
- Abnormal breath sounds
- Dyspnea
- Orthopnea
- Restlessness
- Cyanosis
Expected outcomes:
- Patient will maintain clear, open airways as evidenced by normal breath sounds, and respiratory rate and depth within normal limits.
- Patient will demonstrate ABG results within acceptable limits.
Assessment:
1. Monitor and measure the rate and depth of respirations, chest movement, and the use of accessory muscles.
Monitor for changes in the respiratory status, like tachypnea, bradypnea, accessory muscle use, asymmetrical breathing, and decreasing Spo2 levels.
2. Assess lung sounds.
With a pneumothorax, lung sounds may be decreased or absent on the side of collapse. Adventitious sounds like crackles and wheezes are also possible.
Interventions:
1. Encourage coughing and breathing.
Deep breathing and coughing promote drainage and re-expansion of the lungs. The patient may also use an incentive spirometer.
2. Position the patient upright.
Upright positioning promotes better lung expansion and improved air exchange while enhancing drainage.
3. Administer analgesics.
Patients may be reluctant to ambulate, cough, or deep breathe due to pain, inhibiting airway clearance. Administer pain medication as necessary to promote pulmonary hygiene.
4. Monitor ABGs and SpO2.
Closely monitor ABGs and SpO2 levels for hypoxia and acidosis that may be related to worsening respiratory distress.
Ineffective Breathing Pattern
Pneumothorax causes the build-up of air in the pleural space, adding unnecessary pressure to the lungs. This can lead to ineffective breathing patterns as the lungs are unable to expand normally when breathing.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Pain
- Asymmetrical lung expansion
- Body position that inhibits lung expansion
As evidenced by:
- Abdominal paradoxical respiratory pattern
- Altered chest excursion
- Altered tidal volume
- Bradypnea
- Decreased expiratory pressure
- Decreased inspiratory pressure
- Accessory muscle use
Expected outcomes:
- Patient will maintain an oxygen saturation of 94% or greater.
- Patient will demonstrate an effective breathing pattern evidenced by respiratory rate and depth within expected limits.
Assessment:
1. Assess the chest tube drainage system.
The nurse should regularly assess the chest tube and drainage system. Assess for dislodgement, leaks, or kinks in the tubing.
2. Assess the patient’s respiratory function.
Closely monitor for changes in the patient’s breathing pattern which would signal respiratory distress or the development of infection such as pneumonia.
3. Review imaging tests.
Patients may receive routine chest x-rays to monitor the progress of the pneumothorax. If the nurse feels there has been a change in the patient’s respiratory status, a chest x-ray can be requested.
Interventions:
1. Assist with thoracentesis.
The healthcare provider may perform a thoracentesis by inserting a needle in the pleural space to drain air or fluid. This can aid in improving the patient’s breathing pattern.
2. Encourage ambulation.
For patients who are able to ambulate safely, doing so will result in quicker improvement and a shorter hospital stay.
3. Consult with respiratory therapy.
If observing changes in the patient’s respiratory status or concerns with a chest tube system, a respiratory therapist can assist in troubleshooting and assessing.
4. Maintain the closed-drainage system.
The chest tube drainage system must always be kept below the drainage site, usually on the floor. If suction is used, ensure it is on at the prescribed level. Document drainage as required per facility protocol. Bubbling in the air leak chamber may signal a leak. Attempt to locate and remedy the leak or notify the healthcare provider.
Nursing Diagnoses and Rationales for Pneumothorax
1. Impaired Gas Exchange
Rationale: Pneumothorax results in the collapse of the affected lung, which compromises the lung’s ability to oxygenate blood and remove carbon dioxide. This leads to impaired gas exchange. Continuous monitoring of respiratory rate, oxygen saturation, and arterial blood gases is essential to assess the patient’s respiratory status. Administering supplemental oxygen and preparing for possible interventions such as chest tube insertion can help improve gas exchange.
2. Ineffective Breathing Pattern
Rationale: The presence of air in the pleural space can cause pain and discomfort, leading to shallow and rapid breathing patterns. This can further decrease lung expansion and exacerbate respiratory distress. Pain management, encouraging deep breathing exercises, and positioning the patient in a semi-Fowler’s position can help promote effective breathing patterns.
3. Acute Pain
Rationale: Pneumothorax often causes sudden and severe chest pain, which can impact the patient’s ability to breathe deeply and effectively. Administering prescribed analgesics, providing a calm environment, and using non-pharmacological pain relief methods such as relaxation techniques can help manage the patient’s pain.
4. Anxiety
Rationale: Experiencing a pneumothorax can be a frightening event, leading to feelings of anxiety and fear. Providing clear and concise information about the condition, treatment options, and expected outcomes can help alleviate anxiety. Offering emotional support and reassurance, and involving the patient in decision-making can also improve their coping abilities.
5. Risk for Infection
Rationale: Invasive procedures such as chest tube insertion and the presence of an open wound increase the risk of infection. Strict adherence to aseptic techniques during procedures, regular monitoring for signs of infection, and providing appropriate wound care can reduce the risk of infection. Educating the patient and caregivers on signs of infection and proper hygiene practices is also essential.
6. Risk for Tissue Perfusion
Rationale: A tension pneumothorax can compromise cardiovascular function and tissue perfusion due to increased intrathoracic pressure. Recognizing signs of decreased perfusion, such as hypotension and altered mental status, and providing prompt intervention can prevent complications. Administering intravenous fluids and medications as prescribed can help maintain adequate tissue perfusion.
7. Knowledge Deficit
Rationale: Patients and caregivers may lack knowledge about the causes, treatment, and management of pneumothorax. Providing comprehensive education on the condition, including signs and symptoms, treatment options, and prevention of recurrence, is crucial. Encouraging questions and providing written materials and resources for further learning can empower patients and caregivers to manage the condition effectively.
8. Risk for Activity Intolerance
Rationale: Pneumothorax can lead to decreased lung function and endurance, making it difficult for the patient to perform daily activities. Gradual increase in activity levels, providing physical therapy, and educating patients on energy conservation techniques can help improve their tolerance for physical activity.
9. Risk for Skin Integrity Impairment
Rationale: The presence of chest tubes and the need for prolonged bed rest can increase the risk of skin breakdown. Regular assessment of the skin, using protective barriers, ensuring proper positioning, and encouraging mobility can help maintain skin integrity. Educating patients and caregivers on skin care and repositioning techniques is also important.
10. Ineffective Coping
Rationale: Adjusting to the diagnosis and treatment of pneumothorax can be challenging and may affect a patient’s coping abilities. Providing emotional support, counselling, and connecting patients with support groups can help them develop effective coping strategies and improve their quality of life.
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