Discuss about the Pathophysiology of Pneumothorax.
Pneumothorax can be defined as the accumulation of air bubbles in between the pleural cavity that disconnects the lungs from the chest wall. General pneumothorax is not fatal and be treated easily unless it approaches tension pneumothorax (Tschopp et al., 2015). Tension pneumothorax is a critical manifestation when the air bubble increases in size forming a one way valve damaging the surrounding tissue exponentially (Porpodis et al., 2014). This report attempts to assess the case of Mr. Leigh Richards, who had a terrifying car crash that resulted into clinical complexities such as a traumatic pneumothoax rapidly escalating towards the tension stage. In this report the pathophysiology of his case will be explained with detailed description of his condition and treatment.
The patient in this case study has suffered form an unfortunate accident, while being restrained to a rally car. He was driving a dirt road on high speed when the tree hit a tree and he was trapped inside the car by an intrusion that pinned his leg (Porpodis et al., 2014). The patient soon approached trauma and was unconscious, and the car needed to be cut in order to free his pinned leg, and provide inline extrication. The patient was addressed by SAAS ambulance officers, a CFS crew and MedStar trauma team.
In the initial stages the symptoms diagnosed by X-ray and computed tomography, of the patient included,
Pneumothorax is characterized by the presence of air in the pleural cavity, it usually cause sharp pleurotic pain. The pain is due to the pressure exerted by the air on the lungs and collapsing the lungs (Porpodis et al., 2014).
The presence of an air bubble in the pleural cavity interferes with the normal flow of oxygen within the lung, in order to supply enough oxygen, the body compensates by increasing the respiratory rate (Tschopp et al., 2015).
In case of a traumatic pneumothorax rapidly approaching tension phase, the jugular venous distention can create hyper resonant lung sounds (Porpodis et al., 2014).
due to the rapidly distorting lung functions, the neck vein can appear distorted by the pressure.
Deviated trachea can also be a part of the symptoms, due the distortion of the wound and the pressure generated in the lungs can deviate the trachea around the injury site (Porpodis et al., 2014).
The inflammation caused by pneumothorax can lead to asymmetry in the chest.
After the initial observations the patient was recommended immediate UWSD insertion to stabilize his medical condition. The pleural space cavity is a particular that is present as an outer covering to the lungs. The two types of pleura membranes are known as Visceral and the Parietal (Alrajhi, Woo & Vaillancourt, 2012). The pleura membrane folds back for forming a two-layered membrane structure. The space in between the two different types of pleural membranes is known as Pleural cavity. It contains the pleural fluid that helps the allowance of the pleurae for sliding effortlessly during ventilation. The insertion of the chest tube can cause difficulty in breathing as well (Alrajab et al., 2013). For the draining of both the fluid and the air,. the number of chest tube increases in number. But in the case of transplantation of lungs, one may require 4 chest tubes for the drainage purpose.
The chest tube normally remains as long as it required for draining the fluids from the chest of the patient and it remains attached for monitoring the regular X-rays of the chest for the resolution of the problem (Russo et al. 2015). The patient was suffering from pneumothorax, and for liberating out the gas present inside the pleural membrane of the lungs. He was being given the chest tube so that he does not develop the chronic pneumothorax (Ianniello et al., 2014)
An underwater seal drain also known as UWSD is a type of drainage canister device that is mainly used for the collection of the drainage material from the thoracic cavity, such as pus, excess water or air. This type of drainage canister consists mainly of three broad chambers that act as a three bottled chamber (Edaigbini et al., 2014). The first chamber mainly collects the fluid only from the chest. The second chamber acts as a valve and does not allows the water to flow to the backward direction back to the chest. It only allows the discharge of the gas to the backward direction that also prevents the entry of it. The third chamber is known as the suction control chamber. The height of the water present here regulates the pressure that is negative in nature that is applied to the system (Benns et al. 2015).
The chest tube is a long, hollow, flexible tube that is inserted through the wall of the chest, in between the ribs and the space just inside the pleural or mediastium of the lungs is known as Intercoastal Catheter. It is generally used for removing the fluid or the excess air or the pus from the part of intrathoracic space. It is also known as Intercoastal Catheter (Allen & Ganti, 2016).
The bubbling through the water column minimizes the rate of the evaporation of the fluid which indicates the suction is in the regulation for the height of the given water column. The newer canisters of the drainage help in the elimination of the waste using a mechanical check valve, in which a mechanical regulator is attached to it for the regulation of the suction pressure (Woodrow, 2013). Systems that follow both the employs are known to be the Dry system, whereas the system that helps in retaining the water is known to be the Wet-dry systems.
Under water seal drain operation was vital for the patient to successfully avoid tension pneumothorax, and after effective insertion of chest tube the vitals of the patent revived gradually and the manifestation of the disease reduced drastically (Kuhajda et al., 2014). The post operative observation of the patient include after first UWSD insertion,
Immediately after UWSD,
With these observations, it is clear that the vitals of the patient improved after the UWSD, however it was not enough. The cyanosis and shallow breathing can attest to the need of another UWSD insertion in order to completely eradicate the pneumothorax (Ho, 2015). After the insertion of another UWSD, the observations of the patient are,
Studies suggest the successful insertion of UWSD followed by adequate pressure suction can help in reviving the normal functionality in the patient that had been previously hindered due to limited oxygen in the body, in case of the patient,
The treatment of choice in case of a pneumothorax is the insertion of chet tube via under water seal drain, which is explained in detail above. However the degree of such operative measures are determined by the severity of teh symptoms. In this case the patient was exhibiting symptoms taht were raidly leading to a much complicated and dangerous satge of tension pnemothorax, which can be fatal. In such cases, the UWSD operation must be carried out as soon as possible (Tschopp et al., 2015). Tension pneumothorax is a precursor to cardiac arrest and immediate insertion of a chest tube diminishes the risk of cardiac arrest to a large extent.
However, small pneumothorax do not require the intervention of a surgery, in such cases, conservatives and aspiration is the first priority (Tschopp et al., 2015). Analgesia however is the absolute necessity for both cases, to relieve the patient from severe pain. As a popular medication for analgesia, fentanyl citrate is the first choice of IV administration. Fentanyl, used as operative premedication, is used in 50-100 mcg/dose or 25/100 mcg/dose in usual. As a general anaesthesia it is used in a much lower dosage. This medication is absorbed through slow diffusion and is absorbed readily; the metabolism of fentanyl is hepatic, through production of a major metabolite. The analgesic properties of the fetanyl drug is almost twice the power of morphine, however, there are some side effects associated with the medication such as Coughing, chest pain, fever, fatigue, headache and painful urination (Hartrick et al., 2016).
Conclusion:
From the observation of the patient is can be clearly seen that the insertion of chest tube improved the condition of the patient drastically. Immediately after the insertion his pulse improved and his rapid breathing rates also deceased drastically. However with the extreme trauma that the patient underwent in the crash, the condition of the patient was already delicate and the delay in the treatment worsened the conditions further.
Hence, it a single insertion event was not sufficient for the patient in order to recover normal functionality in the lungs and eradicate the air bubble from the pleural cavity (Woodrow, 2013). All these factors propagated the need for a second insertion and that could address the symptoms of the patient and prevented his onset to tension pneumothorax that could have been fatal for him.
Reference List:
Allen, B. R., & Ganti, L. (2016). Chest Tube Thoracostomy. In Atlas of Emergency Medicine Procedures (pp. 149-153). Springer New York.
Alrajab, S., Youssef, A. M., Akkus, N. I., & Caldito, G. (2013). Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Critical care, 17(5), R208.
Alrajhi, K., Woo, M. Y., & Vaillancourt, C. (2012). Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis. CHEST Journal, 141(3), 703-708.
Benns, M. V., Egger, M. E., Harbrecht, B. G., Franklin, G. A., Smith, J. W., Miller, K. R., … & Richardson, J. D. (2015). Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions. journal of trauma and acute care surgery, 78(2), 386-390.
Edaigbini, S. A., Delia, I. Z., Aminu, M. B., Orogade, A. A., Anumenechi, N., & Ibrahim, A. D. (2014). Indications and complications of tube thoracostomy with improvised underwater seal bottles. Nigerian Journal of Surgery, 20(2), 79-82.
Hartrick, C. T., Knapke, D. M., Ding, L., Danesi, H., & Jones, J. B. (2016). Fentanyl iontophoretic transdermal system versus morphine intravenous patient-controlled analgesia for pain management following orthopedic surgery: A pooled analysis of randomized, controlled trials. Journal of opioid management, 12(1), 37-45.
Ho, S. C. (2015). Root Cause of Analysis of Peculiar Response of Pneumothorax to Chest Tube Drainage. Universal Journal of Medical Science, 3(4), 87-90.
Ianniello, S., Di Giacomo, V., Sessa, B., & Miele, V. (2014). First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography. La radiologia medica, 119(9), 674-680.
Kuhajda, I., Zarogoulidis, K., Kougioumtzi, I., Huang, H., Li, Q., Dryllis, G., … & Papaiwannou, A. (2014). Tube thoracostomy; chest tube implantation and follow up. Journal of thoracic disease, 6(4), S470-S479.
Porpodis, K., Zarogoulidis, P., Spyratos, D., Domvri, K., Kioumis, I., Angelis, N., … & Tsakiridis, K. (2014). Pneumothorax and asthma. Journal of thoracic disease, 6(1), S152-S161.
Russo, R. M., Zakaluzny, S. A., Neff, L. P., Grayson, J. K., Hight, R. A., Galante, J. M., & Shatz, D. V. (2015). A pilot study of chest tube versus pigtail catheter drainage of acute hemothorax in swine. Journal of Trauma and Acute Care Surgery, 79(6), 1038-1043.
Tschopp, J. M., Bintcliffe, O., Astoul, P., Canalis, E., Driesen, P., Janssen, J., … & Waller, D. A. (2015). ERS task force statement: diagnosis and treatment of primary spontaneous pneumothorax. European respiratory journal, 46(2), 321-335.
Woodrow, P. (2013). Intrapleural chest drainage. Nursing Standard, 27(40), 49-56.
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