Respiratory Study Guide for the CCRN

Thoracic Events

Disruption or injury to the thoracic cage or internal components can have significant patient outcomes. Some of these outcomes can be used to improve overall survival and quality of life, whereas others may be traumatic and decrease the patient’s quality of life. Review the following events that occur regarding the thoracic anatomy and pulmonary system in preparation for your test.

Thoracic Surgery

Thoracic surgery may be indicated in patients who have had extensive pulmonary trauma or who have chronic conditions that have remodeled the lungs beyond repair. The goal of pulmonary surgery is to improve lung compliance and reduce complications from restricted pulmonary expansion. Two primary pulmonary surgeries include lung volume reduction surgery and pneumonectomy and lung surgery.

Lung Volume Reduction Surgery

This may be indicated if a patient has approximately \(20\%\) to \(35\%\) of their lung tissue that does not work appropriately. In the procedure, surgeons remove the ineffective lung tissue to allow better expansion of the healthy lung tissue. Some patients may qualify for minimally invasive advancements such as using bronchoscopy and placing one-way valves in the affected areas. This reduces the workload of the functioning lung structures. This therapy is most commonly performed for patients with chronic emphysematous COPD. Chronic emphysematous COPD generally affects both lungs, so removal of the diseased lung tissue is performed bilaterally. Patients with cardiac disease or unilateral emphysema may only qualify for removal of the most affected lung tissue.

Long-term outcomes for patients who undergo lung volume reduction surgery are generally high, especially if their surgical risk is low and their emphysematous lung tissue is in the upper lobes. The procedure also reduces the need for a lung transplant in these patients.

Lung Removal

In some patient cases, removal of an entire lung may be indicated. This procedure is known as a pneumonectomy. Pneumonectomy procedures may be either simple or extrapleural. In a simple pneumonectomy, the entire lung is removed without any additional structures. An extrapleural pneumonectomy involves removal of the lung, part of the diaphragm, and the pericardium on the same side.

Because this is a high-risk surgery, pre-op screening and diagnostics are important to ensure the patient is a good fit for surgery. These include imaging, pulmonary function tests, metabolic stress tests, and thorough cardiac evaluation. Surgery is typically contraindicated for those with extensive cardiac dysfunction. Specific surgical precautions must be taken to avoid contamination or damage to the remaining lung. Patients should be positioned prone throughout the surgery and/or have bronchus blockers to the remaining lung. Indications for pneumonectomy include most commonly cancerous lesions, but also severe bronchiectasis, severe hypoplasia, unilateral lung destruction, pulmonary hemorrhage, lobar emphysema, and chronic pulmonary infections with destruction. Following a pneumonectomy, patients should be monitored for pulmonary infection, decreased compliance of the remaining lung, dyspnea, hypoxia, and shortness of breath.

Lung Tissue Removal

In some cases, a patient may not need a total lung pneumonectomy but rather just partial removal of lung tissue. A lobectomy is the removal of one or more lung lobes. Indications for this partial lung removal include tubercular lesions, abscesses or cysts, cancer, traumatic injury, or bronchiectasis. Patients should be monitored for postoperative hemorrhage, infection, and pneumothorax. Nurses will be in charge of managing the patient’s chest tube(s) following this procedure. The chest tubes may be placed to prevent the accumulation of air into the newly opened space or to reduce fluid buildup that may constrict or collapse the remaining lobes.

Resections

Segmental resections and wedge resections may also be used to remove smaller portions of the pulmonary tissue. In segmental resection, the patient may have a bronchovascular segment or small lesions removed. Patients who have wedge resections have a wedge of tissue removed. This procedure is used primarily for removal of small peripheral lesions, granulomas, or blebs. Just like with any pulmonary trauma or surgical intervention, nurses must monitor the patient for worsening respiratory symptoms, infection, and pneumothorax.

Thoracic Trauma

Thoracic trauma refers to any injury involving the thorax, the region between the neck and abdomen that houses vital organs such as the heart, lungs, airways, and major vessels. The thorax region is protected by the ribs, sternum, and thoracic spine, but significant force can still overcome these structures and lead to injury. These injuries are significant and can impact not only the respiratory system, but also multiple organ systems. The conditions discussed below can involve direct lung damage, damage of nearby structures, disruption of airway integrity, and bleeding.

Pulmonary Hemorrhage

Pulmonary hemorrhage is an acute, often deadly event when the pulmonary vessels are ruptured due to either a blunt or penetrating trauma. It is important to note pulmonary hemorrhage can also arise from nontraumatic etiologies. These include autoimmune diseases such as lupus, infections such as tuberculosis, blood-clotting disorders, tumors, and drugs/ toxins, such as cocaine or pesticides. This is considered a medical emergency and immediate intervention is required to repair the injured vessel. Even with immediate treatment, the mortality and complication rate is high.

Diagnosis

Symptoms of pulmonary hemorrhage include hemoptysis, dyspnea, fever, hemodynamic instability, and acute respiratory failure. When suspected, the nursing staff should immediately place a large-bore IV to replace fluid. Assess for hemorrhagic shock and replace fluids as necessary. Type and screen labs should be performed to match the replacement blood product to the patient. If the patient is stabilized, CT scans may be used to identify the source of the bleeding, allowing for a more focused repair.

Patients may also have a hemothorax or pneumothorax, often evidenced by mediastinal shift (movement of the central chest compartment), in the event of pulmonary trauma and hemorrhage. Additional symptoms of these include severe respiratory distress, decreased breath sounds, and dullness on auscultation due to the presence of air or blood in the pleural space. The patient may be prepared for chest tube insertion.

Treatment

Nurses may be responsible for managing some of the patient’s needs. Bronchoscopy may be used to visualize the airway, suction blood, and administer medications such as epinephrine to control bleeding. Interventional radiology can sometimes embolize the bleeding artery. Surgery is generally reserved for uncontrolled hemorrhage. Keep the patient as calm as possible to reduce stress on the respiratory system, use suctioning modestly to avoid aspiration, prepare the patient for intubation (if indicated), and maintain appropriate intravenous (IV) access. Use fluid and blood replacement as indicated through a large-bore IV.

If the patient has a chest tube, monitor for severe, acute blood loss and exsanguination which is characterized by more than 1500 mL of blood initially drained or by continuous bleeding of the patient of more than 200 to 300 mL/hr. In this case, the patient will likely be prepared for an emergency thoracotomy.

After the initial stabilization, treatment is tailored based on the cause. In trauma cases, management focuses on supportive care, pain control, and address of any other associated injuries. Autoimmune-related hemorrhage is typically treated with immunosuppressive therapy and corticosteroids. For infections, appropriate antimicrobial therapy is utilized and for blood-clotting disorders, the treatment of the underlying coagulopathy is indicated.

Pulmonary Contusion

Pulmonary contusion occurs when the lung is injured via direct force. It occurs when the parenchymal structures (functional tissues of the lung) are injured, resulting in bleeding and edema. If there is a tear in the lung parenchymal, it is referred to as a pulmonary laceration. The patient may experience intrapulmonary shunting and fluid-filled alveoli and interstitium as a result of the injury. The pulmonary system suffers as the lungs experience decreased compliance and ventilation due to the injury.

Diagnosis and Treatment

Diagnosis of pulmonary contusion is best assessed with a CT scan. However, sometimes a chest X-ray is used initially due to its convenience, but it can underestimate the extent of the injury especially within the first few hours. The patient may also have other pulmonary concerns, such as broken ribs or pneumothorax, that may make diagnosis more difficult. Symptoms with pulmonary contusion include mild dyspnea progressing into severe dyspnea, hemoptysis, chest pain, shallow or painful breathing, and acute respiratory failure. Treatment measures include supportive care such as supplemental oxygen, monitoring for respiratory failure via arterial blood gases and frequent respiratory assessments, intubation and mechanical ventilation with PEEP for severe respiratory distress, fluid management, and respiratory physiotherapy to mobilize excess fluid and clear secretions. It is also essential to prevent complications such as pneumo/hemothorax, atelectasis, pneumonia, and other lung conditions. Most contusions heal within a week or two, while lacerations take about one to two months.

Fractured Rib

Fractured ribs generally occur from severe trauma. Common traumas that result in rib fractures include motor vehicle accidents and physical abuse. These fractures can also occur in athletes, falls, and post cardiac arrest with CPR. The biggest concern with fractured ribs involves the concern for underlying structure damage. In particular, if the upper two ribs are fractured, the trachea, bronchi, and great vessels should be assessed for injury. Right-sided ribs below rib eight may induce liver injury, whereas left-sided ribs below rib eight may involve splenic injury.

Diagnosis

Side or rib pain is the primary symptom of rib fractures. Bruising or discoloration and tenderness in the area can occur as well. Patients may also experience shallow breathing due to chest compression or increased pain. Complications of shallow breathing include atelectasis and pneumonia. Chest X-ray or CT is standard for diagnosing rib fractures. Occasionally, MRI may be used as well. Most rib fractures will heal with supportive care and rest. Pain should be controlled with an analgesic; supplemental oxygen may be given to support respiratory effort; and splints may be fitted to help support the respiratory cage. If patients have underlying injury or severe fractures , surgical fixation (ORIF) may be indicated.

In the event that at least three or more adjacent ribs are fractured on both the anterior and posterior side, the patient will experience flail chest. The ribs, having no connecting bone, then float free of the rib cage. Paradoxical respirations are an abnormal breathing pattern where the chest wall moves inward during inspiration and outward during expiration, the opposite of normal respiration. This occurs due to the inability of the chest wall to support changes in intrathoracic pressure during breathing. This decreases the ability of the lungs to inflate and deflate properly, causing respiratory distress.

Treatment

Treatment of flail chest is similar to the treatment of fractured ribs. The chest should be stabilized on one side to strengthen the chest wall and promote appropriate ventilation. It is stabilized by applying gentle, direct pressure to the flail segment with a thick dressing or pillow. Analgesics should be given for pain. Pulmonary clearance interventions, such as physiotherapy, should be used to prevent atelectasis. If the patient is unable to maintain adequate gas exchange, mechanical ventilation may be needed. Surgical fixation is only recommended in the event of underlying tissue injury and thoracotomy.

Tracheal Perforation

Tracheal perforation may result due to external, penetrating injury or as a complication of intubation or percutaneous dilation tracheostomy (DPT). Occasionally, aspirated foreign objects may erode the tracheal structures. Early diagnosis and intervention is key to preventing death from this injury.

Diagnosis and Treatment

Nurses should assess patients at risk for severe respiratory distress, hemoptysis, stridor, progressive dysphonia, pneumothorax, pneumomediastinum, and subcutaneous emphysema. Diagnosis may be achieved via CT scan, chest X-ray, or bronchoscopy. If the perforation was caused by foreign objects, bronchoscopy may be utilized to remove it. Treatment of tracheal perforation includes intubation to facilitate rest and healing of small lacerations or surgical repair for larger lacerations or severe respiratory distress. It is important to note that intubation may be difficult if perforation is present, and techniques such as fiberoptic intubation may be needed for direct visualization. If possible, the ETT cuff should be inflated distal to the injury to avoid worsening the tear and to maintain adequate ventilation.

Transfusion-Related Acute Lung Injury (TRALI)

Patients experiencing anemia, severe hemorrhage, hemodynamic instability, and shock may require the use of blood products to help stabilize their condition. Transfusion-related acute lung injury (TRALI) is an adverse reaction following an infusion of blood product(s). All blood products that include plasma have a risk of causing TRALI. TRALI is life threatening and can cause severe respiratory compromise, increased mortality, and prolonged recovery. A patient experiencing TRALI will start to develop symptoms within six hours following the transfusion of one or more blood units. Symptoms of TRALI include acute hypoxemia (\(\text{O}_2\) < 90% on room air), pulmonary edema, dyspnea, tachypnea, hypotension, and fever.

Diagnosis

There are two categories of TRALI, one caused by an immune-mediated response and one with no immune-mediated response. In immune-mediated TRALI, the injury is due to a response of anti-HLA antibodies present in the blood of either the donor or recipient. These antibodies activate in the event of foreign presence recognition and react with leucocytes, causing damage to the surrounding tissues. Immune-mediated TRALI accounts for \(65\%\) to \(85\%\) of TRALI events. In non-immune mediated TRALI, there is no antibody involvement. Instead, biologically active compounds accumulate, causing a cascading bodily reaction of inflammation, endothelial damage, pulmonary capillary fluid leakage, and pulmonary edema.

Risk factors for TRALI include being female or receiving blood from a female donor, older age (65+), increased age of blood products, alcohol and/or tobacco use, end-stage liver disease, cardiovascular surgery, frequent transfusions or massive blood transfusion protocol, sepsis, and current respiratory compromise, such as being on mechanical ventilation. Diagnosis of TRALI can be determined based on the presence of recent blood transfusion with acute symptoms and radiographic imaging. Chest X-ray and/or CT may show bilateral pulmonary infiltrates without cardiac compromise or fluid overload.

Treatment

Nurses should monitor closely for both subtle and significant symptoms of TRALI. If TRALI is suspected during active transfusion, the nurse must first stop the transfusion and initiate supportive measures such as oxygen administration. The blood product and tubing should not be thrown away but rather returned to the facility’s blood center for further investigation of the product and testing of potential donor antibodies. If respiratory compromise is severe, intubation may be required for appropriate ventilation management. Prone positioning may be used to improve oxygenation and reduce additional pulmonary injury from increased mechanical ventilatory pressures. Extracorporeal membrane oxygenation (ECMO) may also be required if mechanical ventilation is inadequate and the patient advances into severe acute hypoxemic respiratory failure. Unlike traditional pulmonary edema, diuretics are generally avoided as TRALI is non-cardiogenic and fluid removal does not improve oxygenation.

Decreased time on mechanical ventilation can improve patient outcomes. Nurses should advocate for daily sedation holidays to assess the patient’s pulmonary status and potential for extubation. Most patients heal with supportive treatment within a few days. Discontinuation of mechanical ventilation should be performed as soon as determined safe to help prevent any additional pulmonary compromise.