Do all symptomatic pneumothorax need chest tubes?

Esme12, ASN, BSN, RN · Aug 21, 2014

YOU wouldn't necessarily know if someone had an asymptomatic pneumo....because why? because they are asymptomatic. It is usually an incidental finding after a CXR for something else....like a MVA and a patint hasd anterior bruising from the seat belt and sir bag deployment. Sometimes the EDMD will do a CXR and the pneumo is an incidental finding.

How do you know someone has crossed the line?....they develop symptoms.

Guests · Aug 21, 2014

The question asks what assessment findings indicate a need for chest tube - all I can find is large pneumothorax and symptomatic pneumothorax.

Also, a hemothorax. That is, the lungs and chest wall may be intact but there may be bleeding into the chest cavity which needs to be removed by a chest tube.

I have also read that small pneumothorax can be treated with O2 and elevating the head of the bed and observation.

Yep, if the patient is in no distress, the docs may let it ride. Here's my question for you: Why give them oxygen if they're not hypoxic?

If symptomatic pneumothrorax is treated and assymptomatic are not, how would you even know a pt had a pneumothorax if they didn't have any symptoms? Other maybe noticing subcutaneous emphysema?

Without imaging, you wouldn't... but nearly all trauma patients get a CXR, as do chest painers and SOBers... and many trauma patients also get a CT chest and CT spine... that's how occult pneumos are found... it's often a clinical diagnosis, though.

Two, does everyone who has symptoms of pnemothorax get treated with a chest tube (or thoracentesis) or do you ever just use watchful waiting for these cases too?

Pretty much anybody with a symptomatic pneumo is going to get a chest tube...

Point of clarification... it's not a thoracentesis (which is when they're drawing fluid out of the pleural space), it's a needle thoracostomy... or if you want to sound cool, just getting "needled" or "needling them." Needling is generally a pre-hospital procedure... in the hospital, they just get a chest tube... unless it's a small hospital and the doc isn't comfortable doing the chest tube and the patient is getting transferred. That said, hospitals don't come much smaller than my first one and even there, it was a chest tube rather than a needle.

How can you tell when someone has crossed that line? I would assume request an order chest x-ray right away? BUT how do you know when a person can't wait on a chest x-ray?

They start to develop distress.

I know you're doing this for school but trust me, in the real world, you'll never miss somebody needing a chest tube... and you'll never forget the first time you feel subcutaneous emphysema (or bony crepitus for that matter).

tsm007 · Aug 21, 2014

YOU wouldn't necessarily know if someone had an asymptomatic pneumo....because why? because they are asymptomatic. It is usually an incidental finding after a CXR for something else....like a MVA and a patint hasd anterior bruising from the seat belt and sir bag deployment. Sometimes the EDMD will do a CXR and the pneumo is an incidental finding.
How do you know someone has crossed the line?....they develop symptoms.

Thank you. That makes so much more sense if a asymptomatic one you wouldn't know in the first place without incidentally finding it.

akulahawkRN, ADN, RN, EMT-P · Aug 21, 2014

Symptomatic pneumos will usually get a chest tube. The reason is quite simple: they've gotten big enough to cause symptoms. Asymptomatic ones don't because they're not causing symptoms, but they'll be watched to ensure they're not getting worse.

How do you know they're getting worse? The asymptomatic ones aren't and the symptomatic ones begin having more problems. Could be a problem if the pneumo develops into a tension pneumo.

I've been fortunate enough to not have to dart someone's chest. That's a temporary measure anyway as all that's being relieved is some excess pressure.

SubQ emphysema and bony crepitus are definitely memorable...

tsm007 · Aug 21, 2014

Yep, if the patient is in no distress, the docs may let it ride. Here's my question for you: Why give them oxygen if they're not hypoxic?

THAT is why I was confused. Honestly don't know why they'd need oxygen if they weren't hypoxic. I just couldn't figure out why textbooks would say to raise head of bed and give O2.

Point of clarification... it's not a thoracentesis (which is when they're drawing fluid out of the pleural space), it's a needle thoracostomy

Thank you. I didn't realize they were different.

I know you're doing this for school but trust me, in the real world, you'll never miss somebody needing a chest tube... and you'll never forget the first time you feel subcutaneous emphysema (or bony crepitus for that matter).

I didn't just want to know this for school. I wanted to know it period.

Thank you so much! You really have helped this click and everything makes so much more sense now. I had the ideas of what everything was, but was just missing a few pieces to connect the dots. I really appreciate you (and anyone else) that takes the time to answer these questions.

tsm007 · Aug 21, 2014

Also, a hemothorax. That is, the lungs and chest wall may be intact but there may be bleeding into the chest cavity which needs to be removed by a chest tube.

Ugh! Realized I misread the question too which is partially why I was having so much trouble with this. I thought it said what assessment findings of a pneumothorax indicate the need for a chest tube? The word pneumothorax was not in the question just assessment findings in general. Duh, hemothorax and tension pneumothorax symptoms should also be included. Thank you again.

Guests · Aug 22, 2014

Yep if the patient is in no distress, the docs may let it ride. Here's my question for you: [i']Why give them oxygen if they're not hypoxic?
[/i]
THAT is why I was confused. Honestly don't know why they'd need oxygen if they weren't hypoxic. I just couldn't figure out why textbooks would say to raise head of bed and give O2.

Worry not... three years in to nursing and I didn't know until a trauma surgeon came to check on my patient with a small, closed pneumo - from whom I'd removed the cannula since she didn't like it and was satting fine. The doc put the cannula back on and said, "Let's leave the O's on her."

The answer is one of those "of course" things...

The body absorbs oxygen about 4-5 times faster than it does air. If she's got a small leak from the lung into the chest, you want it to be oxygen rich to enhance absorption, especially if you're not pulling it out via a chest tube.

Guests · Aug 22, 2014

Thank you so much! You really have helped this click and everything makes so much more sense now. I had the ideas of what everything was, but was just missing a few pieces to connect the dots.

It's really tough to form understanding until you see it for real.

I find that textbooks are generally long on text and fluff but deficient in details.

tsm007 · Aug 22, 2014

The answer is one of those "of course" things...
The body absorbs oxygen about 4-5 times faster than it does air. If she's got a small leak from the lung into the chest, you want it to be oxygen rich to enhance absorption, especially if you're not pulling it out via a chest tube.

Oh my gosh, that is awesome! I feel smarter now :)