Section 1: Anatomy and Physiology

Fx conchae Humidify, clean, warm air

Paranasal sinuses Mucus production, resonating chamber
Protective 1. Coarse hair and mucus traps microorganism
mechanism of nasal 2. Cilia brushes pathogens into the pharynx to be digested in the
cavity stomach
3. Sneeze reflex by trigeminal nerve carries action potential to medulla
oblongata (Aka ACHOO – autosomal-dominant-compelling-helio-
ophthalmic-outburst)
4. Pharyngeal tonsil (and other tonsils) is a lymphatic tissue which
houses WBCs
Also known as the Thyroid cartilage
“Adam’s apple”
3 pairs of cartilage Cuneiform (wedge)
where vocal folds Corniculate (horn)
attached Arytenoid (ladle)
How do vocal folds 1. Air (strumming effect produces vibration): dictates loudness
produce sound? 2. Muscles facilitate tension and length of vocal folds: dictates pitch
Trachea Aka windpipe
Anterior part is surrounded by C-shaped cartilages
Narrowing aids in cough reflex via vagus nerve
How to perform Aka abdominal thrust
Heimlich maneuver 1. Stand behind
2. Wrap arms around abdomen
3. Fist one hand, covered by the other
4. Pull backwards and upwards
Preferred opening for Cricothyrotomy (between cricoid and thyroid cartilage)
intubation
Defense mechanism Goblet cells and ciliated columnar cells
of trachea
*smoking damages columnar cells and can change them to stratified
squamous
Infection of the Bordetella pertussis
tracheobronchial tree
causing whooping Prevention: TDAP booster for 20weeks AOG
cough (high pitch on
inhalation)
Why is right bronchi More in line with trachea
more prone to
lodging?
Trace the passageway 1. Nasal cavity
of airway from nasal 2. Trachea
cavity into alveolar 3. Primary bronchioles
sacs 4. Secondary/lobar bronchioles
 5. Terminal/segmental bronchioles
6. Bronchioles
7. Terminal bronchioles
8. Respiratory bronchioles
9. Alveolar ducts
10. Alveoli
11. Alveolar sacs
Name structure and 1. Made up of simple squamous cell
components of 2. Has resident macrophage
alveoli 3. Has surfactant-secreting cells (alveolar type 2)
Function of pleural Decreases friction during lung expansion by secreting pleural fluid
cavity
Condition when Pleurisy
pleural membranes
are inflamed
Lymphatic vessels in 1. Superficial – located on visceral pleura
the lungs 2. Deep – follows bronchioles

No lymphatic vessels on alveolar walls. Phagocytic cells transport debris to

lymphatic vessels instead.
Explain process of 1. Inspiration: external intercostals and diaphragm contracts, internal
ventilation intercostals and abs relax
2. Expiration: external intercostals and diaphragm relaxes, internal
intercostals and abs contract
Changing Thoracic Volume
 Pressure
Changes and Airflow

Two factors 1. Surfactant

preventing lungs - Lipoprotein molecules attracted to each other pulling each other
from collapsing together with the alveolar walls
- IRDS due to low surfactant, mother can be given cortisol to
stimulate production
2. Pleural pressure
- Lower than alveolar pressure to keep alveoli inflated
Discuss 4 types of 1. Tidal volume: 500 mL
respiratory volumes 2. Inspiratory reserve volume: 3000 mL
3. Expiratory reserve volume: 1100 mL
4. Residual volume: 1200 mL
Formula for minute Tidal volume x RR
volume
Discuss 4 types of 1. Functional residual capacity: 2300 mL
respiratory capacity 2. Inspiratory capacity: 3500 mL
3. Vital capacity: 4600 mL
4. Total lung capacity: 5800 mL (4-5 L)
Factors affecting gas 1. Membrane thickness
exchange - Pulmonary edema
2. Surface area
- Emphysema
- Pneumothorax
3. Partial pressure
- Diffusion according to gradient
Gas exchange
Why does physical Increased muscular activity decreases O2, increases CO2, decreases pH, and
exertion cause you to increases temperature. In this condition, about 73% of oxygen in the blood is
breath rapidly consumed (normal is 23%). Rapid breathing tries to fill the percentage of O2
removed from the blood.
3 way CO2 is 1. Dissolved in plasma
transported 2. Bound to hemoglobin
3. In form of bicarbonate

Why is breathing Chemoreceptors of medulla oblongata (respiratory center) are sensitive to

more stimulated with low pH such as in case of hypercapnia
high CO2 rather than
low O2?
Generation of rhythmic breathing

Section 2: Assessment
Conditions you would - Pneumothorax
suspect in acute - Obstruction
dyspnea (tends to be - MI
worse than chronic) - Allergic reaction
- PE (if immobilized)
Dyspnea and ARDS
tachypnea then
hypoxemia
Wheeze vs stridor Inspiration, expiration (respectively)
Dry, irritative cough is Viral
usually a sign of what *might be taking ACE inhibitor
type of infection
Sputum is thick, Bacterial infection
yellow/green/rusty in
color
Pink-tinged mucoid Lung tumor
sputum
Frothy, pink sputum Pulmonary edema
Pleuritic pain is Lying on affected side
reduced in what
position?
Why is wheezing Airway normally narrows during exhalation (asthma)
heard during Airway already narrowed even inspiration (bronchitis)
inspiration in
bronchitis, and
expiration in asthma
Blood from lungs vs Lungs: bright red, frothy, alkaline
from stomach Stomach: coffee ground, acidic
FDA-approved Nicotine gum/patches/lozenges/nasal spray/oral inhalants
nicotine alternatives
Physical assessment - Clubbing: chronic hypoxia
- Cyanosis: late sign (appear at 5 mg/dL Hgb)
- Nose/sinus: pale/swollen (allergic rhinitis), hyperemic (common
cold)
- Sinusitis: tenderness + light cannot pass through
- Trachea: palpate with thumb and index
- Chest: arms crossed, hands on opposite shoulder, supine for
better breast displacement
- Barrel chest: hyperaeration
- Funnel chest: depression (Marfan/Rickets), tendency to compress
the heart
- Pigeon chest
- Kyphoscoliosis
Palpation technique Fingertips: superficial, subcutaneous masses
Ball of hand: deeper mass
Thoracic excursion Anterior: thumbs on costal margin
Posterior: 10th ribs, medial
Tactile fremitus 99, using palm to feel vibration
Air = low conduction
Dense = high conduction

Emphysema: reduced
Pneumonia: increased
Percussion Dull: solid/fluid (pneumonia, pleural effusion)
Resonant: air (hyper in pneumothorax, COPD)
Section 3: Diagnostic Evaluations
Thoracentesis - Aspiration of pleural fluid
- Can be therapeutic and diagnostic (C&S, cell count, cytology)
Thoracoscopy must - Report SOB immediately
know - Mainly used for pleural conditions and
- Performed OR
Bronchoscopy must - NPO 4-8 hrs
know - Remove oral prostheses
- Moderate sedation/local anesthesia (lidocaine)
- NPO until cough reflex returns
- Blood-tinged sputum normal within 24 hrs
- Can be bedside
PFTs are generally Respiratory therapists
performed by?
PFTs purpose - Extent
- Effectivity
- Exposure screening
- Preoperative evaluation
PFT for measuring Maximal voluntary ventilation
exercise tolerance
Common site for ABG Radial, brachial, femoral
drawing
Performed if ABG not Venous blood gas
possible. Measures
oxygenation of blood
returning to the right
heart. Sample is
drawn from
pulmonary artery
catheter.
Possible sites for Fingertips, forehead, earlobes, nose bridge
pulse oximetry
Conditions that may Hypothermia, hypoperfusion, hemodynamic instability
alter oximetry *no nail polish!
Most reliable Capnometry (ETCO2)
indicator of proper ET
tube placement
Alters ETCO2 results HCO3, carbonated drinks, antacids
Best time to collect Before initiation of antibiotic therapy
specimen for culture
(throat,
nasopharyngeal)
Culture results is 48-72 hrs (prelims as early as 24hrs)
expected within?
Best time to collect Early morning before eating/drinking
sputum (rinse mouth, deep breath, then cough and expectorate)
CXR normal findings Mostly radiolucent
Instruct patient to do Full inhalation, hold
what during CXR?
Main Pregnancy
contraindication for
CXR
Safety consideration - Kidney compromise
in CT - Allergy to iodine
- Pregnancy
- Claustrophobia
- Metformin withheld 1 day prior (prevent lactic acidosis)
NPO for how many 4 hrs
hours if contrast
needed in CT?
Position in CT Supine for about 30 mins (no moving)
Expectation during Warm flushing sensation, chest pain
injection of dye in
pulmonary
angiography
Expectation during Loud thumping noise, can communicate via microphone, antianxiety may be
MRI given
CT vs MRI CT is good at spatial resolution (edges of tissues) while MRI is better at
contrast resolution (tissue make-up)
Major Pregnancy
contraindication of
radioisotope studies
V/Q lung scan result Ventilation without perfusion
in PE
Best radioisotope Gallium scan
study for tumors and
inflammation
Best in detecting PET scan
metabolic changes of
tissues
Considerations in - CXR before V/Q scan
radioisotope - NPO 4 hrs
procedures - No caffeine, alcohol, smoking 24 hrs
- Radiation safety not indicated
- Empty bladder prior to procedure
Section 4: Disorders and Diseases
Chapter 1: Restrictive vs Obstructive Lung Disorders
Differentiate RESTRICTIVE
restrictive with - Poor lung expansion
obstructive lung - Spirometry: everything is low, FEV1 to FVC is normal (>70%)
disorders - Inspiratory difficulty

OBSTRUCTIVE
- Poor airway clearance
- Spirometry: everything is high, FEV1 to FVC is low (<70%)
 - Expiratory difficulty

MIXED
- FRC low, FEV1 to FVC is also low
4 types of obstructive 1. COPD
diseases 2. Bronchiectasis
3. Asthma
4. Cystic Fibrosis

COPD Definition/Description
- Chronic, irreversible airflow obstruction due to excessive cough
production and/or saccular dilatation

Pathophysiology
Clinical Findings
Surgical Management
- Bullectomy: surgical removal of enlarged airspaces that do not
contribute to ventilation but occupy space in the thorax
- Lung Volume Reduction Surgery: removal of a portion of the
diseased lung parenchyma
 Nursing Interventions
 Pulmonary rehabilitation to reduce symptoms, improve quality of life and
increased physical and emotional participation in everyday activities
 Pursed-lip breathing helps slow expiration, prevents collapse of small
airways, and helps the patient control the rate and depth of respiration
 Instruct the patient to coordinate diaphragmatic breathing with activities
such as walking, bathing, bending, or climbing stairs
 Provide small frequent meals and offer liquid nutritional supplements to
improve caloric intake and counteract weight loss
 Administer low flow of oxygen (1-2L/min)
 Adequately hydrate the patient
 Instruct the patient to avoid bronchial irritants
 If indicated, perform CPT int the morning and at night as prescribed
 Encourage alternating activity with rest periods
 Teach relaxation technique or provide a relaxation tape for patient
 Enroll patient in pulmonary rehabilitation program where available
 Monitor respiratory status, including rate and pattern of respirations, breath
sounds, and signs and symptoms of acute respiratory distress
Bronchiectasis Definition/Description
- Irreversible dilatation of bronchioles resulting in chronic
obstruction of airway

Pathophysiology
 Tetrad Sign and Symptom
- Chronic cough
- Recurrent lung infection
- Hemoptysis
- Clubbing

Management
- CPT
- Smoking cessation
- Antibiotic therapy: macrolides (
- Nebulized mucolytics
- Nebulized hypertonic saline
- Bronchodilators
- Surgery: segmental resection, lobectomy, pneumonectomy

Notes
- Can be confused with bronchitis
- High-contrast CT shows bronchial dilatation
Asthma Definition/Description
- Bronchoconstriction and bronchial obstruction due to
hypersensitivity reaction
Features
- Allergy as strongest predisposing factor
- Type I hypersensitivity
- Attacks at night or early morning
- Mostly reversible (unlike COPD)

Pathophysiology

Triad Symptoms
- Wheezing (on expiration)
- Dyspnea (chest tightness)
- Coughing (productive/nonproductive)

Management:
1. Quick relief medications
- SABA: albuterol, levalbuterol, pirbuterol
 - Anticholinergic: ipratropium (is SABA not tolerated)

2. Long-acting control
- Corticosteroids: beclomethasone and budesonide (inhaled),
prednisone and methylprednisolone (systemic)
- LABA: salmeterol, formoterol (>12hrs duration)
- Theophylline
- Antileukotrienes: montelukast, zafirlukast

Notes:
- Bronchodilation via SABA = vasoconstriction
- Corticosteroids = hyperglycemia, immunosuppression (thrush)
- Persistent cases treated with ICS + LABA
- Daily peak flow monitoring for moderate or severe persistent
asthma (green: 80-100, yellow: 60-80, red:<60). Repeat 3x and
record personal best. Done standing up, closed lips around
mouthpiece.
- PaCO2 during acute attack should be low. Normal or elevated
level with sudden disappearance of wheezing is an impending
sign of respiratory failure.
Cystic Fibrosis Definition/Description
- Mutation in CFTR gene causing defect in chloride transporter
leading to decrease water secretion and obstruction of multiple
organ tissues

Features
- Autosomal recessive
- Diagnosed mostly by age 2
- Common in Caucasian

Pathophysiology, Assessment, and Diagnostic Findings

Parts Affected
- Small man with;
- Red nose
- Red lungs
- Blocked airways
- Blocked liver
- Blocked pancreas
- Blocked intestines
- Blocked penis/ovaries
- Salty skin

Management:
1. For infections
- Antivirals: zanamivir, oseltamivir
- Antibacterials: tobramycin +
cephalosporin/carbapenem/piperacillin tazobactam. Additional
vancomycin if MRSA.
2. Airway clearance
- CPT
- Nebulization
- Hypertonic inhalation
- Inhaled corticosteroids (for acute, asthma-like presentation)
- Bronchodilators: salmeterol tiotropium bromide
3. Pancreatic supplementation
- ADEK (taken with meals)
- Insulin
4. CFTR modulators
- Potentiators: ivacaftor
 - Correctors: lumacaftor, tezacaftor (often paired with ivacaftor)
- 2-5 y/o: lumacaftor + ivacaftor
- >6 y/o: tezacaftor + ivacaftor
5. Diet and Nutrition
- High fluid
- High calorie

Notes:
- B. cepacia complex is antibiotic resistant. Candidate for lung
transplant.
- Nebulized antibiotics or inhaled tobramycin for local effect
Chapter 2: Lung Infections

Pneumonia Inflammation of lung parenchyma

Causative Agents:
- S. pneumoniae
- M. pneumoniae
- S. aureus
- H. influenzae
- Viral, common in children (CMV, HSV, RSV)
Why is HAP more Virulence, MDRO, comorbid
deadly than other
types?
Bacterial features Pseudomonas: weak and intubated
Staphylococcus: often sepsis, high mortality
MRSA drugs Vancomycin, linezolid
MRSA precaution - Private room
- Contact precaution (gown, gloves, hand rubs)
Why are gram- Double wall (diderm)
negative bacteria - Pseudomonas
harder to treat? - E. coli
- Enterobacter
- Klebsiella
Time frame in <96hrs>
determining VAP
from antibiotic-
sensitive bacteria and
MDRO
Prevention of adult PCV13 and PPSV23 (not co-administered)
pneumonia
Parameter for clinical 1. <=37.8C or <=100F
stability 2. <=100 bpm
3. <=24 cpm
4. >=90 mmHg SBP
5. >=90% O2sat
6. +oral intake
7. Normal mental status
Pharmacologic No MDR, monotherapy
management - Ceftriaxone, ampicillin/sulbactam, levofloxacin, ertapenem
With MDR, 3-drug combination
- Cephalosporin or Carbapenem or piperacillin/tazobactam; plus
- Fluoroquinolone or aminoglycoside; plus
- Linezolid or vancomycin
Viral pneumonia - Hydration
supportive - Antipyretic
management - Antitussive
- Antihistamines
- Moist inhalations
- Bed rest
- Oxygen therapy
How does SARS-Cov 2 Via ACE2 receptors of type 2 alveolar cells
enter host cell?
Nursing interventions Airway patency
- Hydration 2-3 L/day
- High humidity facemask
- Incentive spirometry
- Effective coughing
- CPT
Rest and Energy
- Semi-fowler
- Avoid overexertion
Nutrition
- Small, frequent feedings
- Commercial electrolytes
Pulmonary Tuberculosis

Where TB is common - Poverty

- Overcrowded
- Malnutrition
MOT Airborne
Initial infection after 2-10 weeks
exposure to
pathogen
The central portion of Ghon tuberculosis
fibrotic granuloma in
PTB seen on x-ray
Risk factors Close contact, immunocompromised, substance abuse, comorbidity,
overcrowding
Preventing Private room w/ negative pressure
transmission of TB in *air from room directly exhausted out
hospital
Pentad symptom - Low-grade fever
- Coughing (can be productive or dry)
- Night sweats
- Fatigue
- Weight loss
- *hemoptysis
Diagnostics Tuberculin test
- 0.1 cc PPD w/ 5 units tuberculin injected ID
- Form 6-10 mm bleb
- Reading after 48-72hrs
- (+) if induration >5mm w/ erythema
- Result may be active or latent
- Not confirmatory, since (-) result could mean that Px may have
been exposed but is not able to create antibody
Blood test
- Interferon-gamma release assay (IGRA)
- Result within 24-36 hrs
Sputum culture
- Nuclei acid amplification test
- Culture as confirmatory
Gerontologic Skin test
consideration - Delayed reaction up to 1 week (second test after 1-2 weeks)
- No reaction (loss of immunologic memory)
MDR Resistant to isoniazid and rifampin
XDR Resistant to iso + rif + fluoroquinolones + aminoglycosides (2nd line)
Initial phase of RIPE + B6, PO, OD for 8 weeks
treatment
Continuation Rifampin + isoniazid for 4 or 7 months
treatment
Prophylaxis for Isoniazid for 6-12 months
persons who are at
TB risk
Nursing management Airway clearance
- Positioning
- CPT
- Hydration
Medication regimen
- Take meds on empty stomach (1 hr before, 2 hrs after meals)
- Avoid tyramine-rich foods (tuna, aged cheese, soy sauce, yeast)
while taking isoniazid: can cause hypotension, palpitations,
lightheadedness
- Avoid alcohol
- Rifampin reduces potency of BB, anticoagulants, steroids,
hypoglycemics, contraceptives, CCB
Nutrition
- Small, frequent meals
Preventing transmission
- Mouth care
 - Proper disposal of used towels
- Hand hygiene
- Covering mouth/nose when sneezing

Chapter 3: Pleural Conditions

Pleurisy Inflammation of visceral and parietal pleura causing friction rub during
inspiration and knife-like pain

- Lie on affected side to splint

- Often due to infection or trauma
- Can lead to pleural effusion
Pleural effusion
Diagnosis Lateral decubitus x-ray
- Layering out of fluid when side-lying on affected side
Tracheal deviation away from affected side seen on CXR or CT
Absent breath sounds/dull, flat
Pleurodesis Intrapleural administration of irritants to produce pleural adhesions
- Talc (hydrous magnesium silicate)
- Bleomycin
- Corynebacterium parvum
Acute respiratory Hypoxemia (PaO2 <60mmHg) + hypercapnia (PaCO2 >50mmHg) + acidosis (pH
failure is defined as? <7.35)
Causes of ARF CNS depression/dysfunction (head trauma, infection, hemorrhage,
anesthesia/sedatives)
Neuromuscular dysfunction (GBS, MS, ALS)
Musculoskeletal dysfunction (flail chest, trauma)
Pulmonary dysfunction (obstructive + restrictive lung diseases)
Manifestations Early signs
- Restless, fatigue, air hunger, high BP
Late signs
- Confusion, lethargy, central cyanosis
Endotracheal tube - Inserted orally (more common) or nasally
- Cuff inflated at 2cm above carina w/ 20-25 mmHg
- ET placement verified with CO2 level at end tidal and confirmed
with x-ray
- Max of 14-21 days. Tracheostomy for longer ventilatory support
- Concern: aspiration, vocal cord paralysis
Tracheostomy - Long term support
- Opening at 2nd or 3rd tracheal ring
- Semi-fowler
- Closed suctioning may be performed without PPE
Mechanical Positive-pressure: pushes air in, passive expiration
ventilation a. Volume cycled: fixed air volume going in
b. Pressure cycled: air in until set pressure reached
c. High-frequency oscillatory: 180-900 bpm, low tidal volume. Indicated
for closed small airways to prevent pressure injury
d. Noninvasive positive-pressure ventilation: done with mask or canula
e. CPAP: like NIPPV, Px must be able to breath independently
Ventilator modes a. Continuous mandatory ventilation: preset tidal volume and breath
rate even if PX breaths on their own
 b. Controlled mechanical ventilation: like one above but patient is
apneic
c. Intermittent mandatory ventilation: support + spontaneous to
prevent muscle atrophy
d. Synchronized IMV: support decreases as spontaneous increases
FiO2 Fraction of oxygen in a gas mixture
Room air is 21% oxygen
Nursing management Enhancing gas exchange
Airway clearance
- Lung auscultation 2-4 hrs
- Suctioning, CPT, repositioning
- Bronchodilators
- Anticholinergics
- Mucolytics
Preventing injury and infection
- Trach care q8
Mobility
- ROM as tolerated

Description Acute inflammatory process causing diffuse alveolar damage leading to

hypoxemia that is unresponsive to oxygen supplementation
Characteristics Bilateral infiltrates
 Alveolar dead space
Decreased lung compliance
Management ET and mechanical ventilation
- Monitored via ABG, pulse ox, PFTs
- PEEP to keep alveoli open
- Goal: PaO2 of >60mmHg or SpO2 >90% at room air FiO2
Hypovolemia due to third-spacing
- Inotropic drugs
- Vasopressors
Enteral/parenteral feeding
- 35-45 kcal/kg/day
Chapter 4: Pulmonary Vascular Disorders

Epoprostenol 3-minute half-life so continuous IV infusion via CVC

Iloprost Inhaled, 6-9 times/day
Selexipag BID, tablet form
Endothelin receptor Oral, hepatotoxic
antagonists
Nitric oxides Can also treat erectile dysfunction
Treprostinil SQ infusion

DX for pulmonary Right heart catheterization (definitive)

HPT 2D-echo (visualization)
Chapter 5: Occupational Lung Diseases
Features - Irreversible damage
- Not curable, but preventable
- Therapy is supportive
Most common Asbestosis: manufacturing, building materials
Silicosis: mining
Manifestations - Chronic cough; productive in silicosis
- Dyspnea on exertion; progressive and irreversible in asbestosis
- Susceptibility to lower respiratory tract infections
- Bibasal crackles in asbestosis
Management - There is no specific treatment; exposure is eliminated, and the
patient is treated symptomatically
- Give prophylactic isoniazid (INH) to patient with positive
tuberculin test, because silicosis is associated with high risk of TB
- Persuade people who have been exposed to asbestos fiber to stop
smoking to decrease risk of lung cancer
- Keep asbestos worker under cancer surveillance; watch for
changing cough, hemoptysis, weight loss, melena
- Bronchodilators may be of some benefit if any degree of airway
obstruction is present
Chapter 6: Lung Tumors

Most common cause Inhaled carcinogens (tobacco smoke, 23x in men and 13x in women compared
to non-smokers)
- Pack-year history
- Age started
- Tar and nicotine level
Genetics (2-3x higher if with close relative)
 - EGFR
- K-RAS
- ALK
Urban areas
Size classification Small cell (13%)
- Most aggressive
- Quick growth
- Starts centrally

Non-small cell (84%)

- Squamous: 20%, centrally located
- Large cell: 5%, fast-growing, peripheral
- Adenocarcinoma: 41%, peripheral, high metastases
- Bronchoalveolar: terminal alveoli and bronchioles, slow-growing
Non-specific Weakness, anorexia, weight loss
symptoms
Commonly used Dx Fiberoptic bronchoscopy
- Brushings for biopsy
Indication type for NSCLC because SCLC grows and metastasizes rapidly
surgery
Surgical techniques - Resection
- Lobectomy
- Pneumonectomy (right lung more vascular, therefore more risk)
Preoperative - Teach diaphragmatic and pursed-lip breathing
- Coughing routine (use splinting)
Postoperative - Supine then raise HOB 30-45 degrees when recovered from
anesthesia
- Hourly turning from back to operative side
- WOF complications: respiratory distress, arrhythmias,
hemorrhage, infection, shock, pneumothorax/hemothorax
- Exercise asap as tolerated to improve ventilation (shoulder
exercise)
Chapter 7: Chest Trauma
Spontaneous No trigger
pneumothorax - Primary: Tall, thin, young male who smokes (no underlying
disease)
- Secondary; w/ underlying disease (usually obstructive)
Traumatic Blunt trauma
pneumothorax - Fractures, contusions
Penetrating trauma
- Gunshot, stab wounds, surgeries

*open pneumothorax: wound large enough to cause spontaneous air entry

and exit causing mediastinal shift. PLUG THE OPENING TO STOP AIRFLOW!
Tension One-way valve trapping the air, pressure is constantly increased
pneumothorax intrathoracically
CT drainage If air only, 2nd ICS
If with blood, 4th-5th ICS

20 mmHg suction

Small bore: one way valve, 7-12 Fr

Large bore: connected to chest tube, up to 40 Fr
Emergency Close chest wound with towel, handkerchief, or ball of hand
management Instruct to strain against closed glottis

If tension
- Large bore needle 2nd ICS, MCV
Thoracotomy >1500 mL blood aspirated in thoracentesis
indication CT output is >200 mL/hr
Nursing Drainage system itself: keep system below patient’s chest
Management of a Tubing: Keep it free from kinks and make sure it is draining freely (not clots or
Chest Tube stagnate fluid) and that all connections are sealed
Drainage Collection Chamber: Monitor drainage (color, amount…..should
drain no more than 100 cc/hr and record routinely)
Water Seal Chamber: performs an underwater seal on the tube to allow air to
be removed from pleural space while preventing outside air from entering
lungs
What if it doesn’t fluctuate at all? The lung could have re-expanded or there
is a kink somewhere.
Excessive bubbling? There is an air leak somewhere
What to do if chest tube becomes dislodged? Cover the site with a sterile
dressing, and tape on three sides (this allows air to escape and prevent
tension pneumothorax) and notify physician immediately.
System breaks? Insert the tube 1 inch into a bottle of sterile water or sterile
normal saline and obtain a new system.
Clamping tubing? Increase risk of patient developing a tension
pneumothorax. Never do it without an order and follow hospital policies.
Removal: bedside, Valsalva prior to removal to prevent air coming in
Air enters Cardiac tamponade
mediastinum Subcutaneous emphysema: crackling sound upon palpation
Chapter 8: Infections of the Upper Tract

Chapter 9: Trauma and Obstruction of Upper Tract