pneumothorax/chest tube healing
- 0A patient asked me a question the other day that I am embarassed I have never been able to answer well enough for myself, let alone my patients (my patient's RN family member couldn't either): How does a pnemo- or hemothorax heal the hole that the chest tube was in if it was a hole of smaller or similar size that caused the pneumo in the first place? This one always eluded me!
- 2Jun 8, '09 by Be_MooreBecause when you pull the chest tube, you place a vaseline gauze over it which creates an air-tight seal in the skin until it heals on it's own. Without the gauze, there is high risk for a pneumo.
Since the tube merely goes into the pleural space, not into the lung, the only place for air/blood to come through back into the system is through the hole where the chest tube was...which is sealed with vaseline gauze as mentioned previous.
- 0Jun 8, '09 by KatnipBut, and correct me if I'm wrong, please.
A pneumothorax can be caused because the integrity of the pleural sac has been disrupted, causing the negative pressure that keeps the lungs from collapsing, to disappear. So The chest tube is insterted into the pleural space, also disrupting the pleural sac membrane, and when it is removed still leaves a hole in the pleural sac.
It's been a while since I've done bedside. This is going to keep me up tonight if I don't figure it out, though.
- 0That's my problem...I understand and can explain how the tube works to re-expand the lung, but not how the hole left behind doesn't cause a problem, just like the original hole did. I mean, I understand the purpose of the gauze for the exterior hole, but not the hole in the pleural sac.
Take my recent patient: suffered a pneumo after having a pacer placed. So, we're asuming something in the pacer procedure damaged the pleural sac, althogh we can't say for certain. Te patient understands all that, and after the docs explanation and my nifty dry erase board drawings, we can all understand how the lung deflated, postive and negative pressure, and how the tube will help it re-inflate. Then the family asks why there still won't be a hole in the lining when we pull the tube out. um....a miracle happens?
Most families/patients have just accepted that it works (like me), but I think the family RN who was at bedside was having the same questions I have always had and was hoping I, as the ER nurse nurse who does these more often, could answer the mystery. She read me wrong, alright!
- 2Jun 8, '09 by GilaRRTYou may be overthinking this concept. Chest tube = pneumothorax. So, even if I put a chest tube in a person without a pneumo, they will in essence have one after I penetrate the pleural cavity. However, small pneumos will typically heal without intervention. It is not uncommon to have people with 10-20% pneumos heal with rest and observation. So, chest tube comes out, we seal with the purse string and a dressing, and monitor for any problems. The remaining deficit will usually heal following chest tube removal. Of course, scarring and adhesions can occur, and that area will be prone to injury and pneumo in the future.
In addition, you need not violate the pleural lining to have a pneumo. Blunt and accel/decel injuries can easily cause a pneumo without compromising the pleural lining.
As a side note. It is not uncommon to place a chest tube for small pneumos if a patient will fly to another facility. Changes in gas volume at altitude as dictated by Boyles law may cause the pneumo to grow in size.
- 0Jun 8, '09 by Pixie.RN, BSN, RN, EMT-P Senior ModeratorThat's what I was thinking -- I had a patient recently with a 10-15% right-sided pneumo (blunt trauma, fell back against a saw horse), and we didn't do a chest tube -- he was admitted for obs/monitoring. So if you place a chest tube to help correct a larger pneumo, once you get it back into the range of where a pneumo can heal on its own, then the tube comes out and you're good (hopefully).
- 0[quote=GilaRN;3672157]You may be overthinking this concept. quote]
I agree After my last post, I got out an A&P reference, and, once I had some visual aides, it seemed simpler. I think my problem was that I was imagining additional air space between the outer surface of the body and the pleural lining. You know, in drawings, they don't always show all the layers of skin, fat, muscle and bone, and I tend to forget that they are all there when I'm concentrating on the organs! Sometimes I forget how tightly together the body fits.
I bet I even I figured this out once before, so the question is will I remember it next time?? I go to church with one of the patient's family members...maybe when I see her next I can fit this into conversation. "Singing was nice today...speaking of harmony, isn't it nice how the thoracic cavity works?"