TENSION PNEUMOTHORAX IN THE
PERINATAL/PEDIATRIC PATIENT
by
Susan Jett Lawson
RCP, RRT-NPS
RC Educational Consulting Services, Inc.
16781 Van Buren Blvd, Suite B, Riverside, CA 92504-5798
(800) 441-LUN G / (877) 367-NURS
www.RCECS.com
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ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
COURSE DESCRIPTION
This Tension Pneumothorax course was designed for the Neonatal Intensive Care Respiratory
Therapist to provide an increased understanding of this possibly fatal occurrence. Recognition of
signs and symptoms, causes and prevention, complications, treatment, management and
monitoring of neonates at risk for or with the diagnosis of tension pneumothorax is the focus of
this module. With a more comprehensive knowledge, the Respiratory Therapist will be better
equipped when the probability of tension pneumothorax arises and, in addition, increase the
quality of care we provide these neonates.
BEHAVIORAL OBJECTIVES
UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE
ABLE TO:
1. Define tension pneumothorax.
2. List four other air leaks common in the neonate.
3. State why tension pneumothorax may be fatal.
4. List the etiology of tension pneumothorax.
5. Describe why cerebral hemorrhage can be a sequel of tension pneumothorax.
6. List the signs and symptoms of an infant with a pneumothorax.
7. Explain why it is difficult to palpate a deviated trachea on the newborn.
8. Explain why breath sounds are not the most reliable assessment tool in pneumothorax of the
infant.
9. Describe the most obvious clues in the assessment/diagnosis of tension pneumothorax in the
newborn.
10. Describe how to assess the point of maximal impulse (PMI).
11. Describe how to assess pulsus paradoxus.
12. Describe the features of a tension pneumothorax on neonatal CXR.
13. Describe how to identify a pneumothorax via transillumination.
14. Describe the procedure for needle decompression.
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15. Describe how to assess chest tube function.
16. List the suggested continuous monitoring of a neonate at risk for pneumothorax.
17. Give three examples of ways to prevent pneumothorax in the neonate.
COPYRIGHT © 2001 BY RC EDUCATIONAL CONSULTING SERVICES, INC.
TX 5-360-039
AUTHORED (2001) BY SUSAN JETT LAWSON RCP, RRT-NPS
REVISED (2004) BY SUSAN JETT LAWSON RCP, RRT-NPS
REVISED (2007) BY MICHAEL R. CARR, BA, RRT, RCP
ALL RIGHTS RESERVED
This course is for reference and education only. Every effort is made to ensure that the clinical
principles, procedures and practices are based on current knowledge and state of the art
information from acknowledged authorities, texts and journals. This information is not intended
as a substitution for a diagnosis or treatment given in consultation with a qualified health care
professional.
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TABLE OF CONTENTS
INTRODUCTION .............................................................................................................. 6
ETIOLOGY ........................................................................................................................ 7
CEREBRAL HEMORRHAGE, INTRACRANIAL HEMORRHAGE (ICH)
OR INTRAVENTRICULAR HEMORRHAGE (IVH)................................................. 8
DIAGNOSIS ....................................................................................................................... 8
PHYSICAL SYMPTOMS AND SIGNS....................................................................... 8
ASSESSMENT ................................................................................................................. 10
GENERAL ................................................................................................................. 10
ASSESSMENT OF THE POINT OF MAXIMAL IMPULSE (PMI) .................. 10
ASSESSMENT OF PULSUS PARADOXUS ...................................................... 10
CHEST X-RAY.......................................................................................................... 11
INDENTIFICATION OF TENSION PNEUMOTHORAX ON CXR ................. 11
TRANSILLUMINATION ......................................................................................... 12
INDENTIFICATION OF A TENSION PNEUMOTHORAX
WITH A TRANSILLUMINATOR....................................................................... 12
TREATMENT FOCUSES ON MANAGEMENT AND MONITORING....................... 12
TREATMENT ............................................................................................................. 12
NEEDLE DECOMPRESSION............................................................................. 13
CHEST TUBES..................................................................................................... 14
CHEST TUBE INSERTION............................................................................ 14
CONTINUOUS MONITORING ................................................................................................................... 16
MANAGEMENT.............................................................................................................. 16
PREVENTION.................................................................................................................. 16
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CLINICAL CASE SCENARIO ........................................................................................ 17
ANSWERS TO CASE SCENARIO ............................................................................ 19
SUMMARY...................................................................................................................... 20
SUGGESTED READING AND REFERENCES ............................................................ 21
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INTRODUCTION
N
ormally on expiration, air is expelled from the lungs and the pleural space remains a
potential space (Fig. 1). With a tension pneumothorax, during inspiration, air leaks
through the affected parenchymal lesion into the pleural space. The tear in the pleura
acts as a one-way valve, impeding movement of the trapped air. As respiration continues, more
air is forced into the intrapleural space. This causes a shift of the thoracic contents and a kinking
of the greater blood vessels. This causes severe complications.
There exists a potential space
between the visceral and
parietal pleura.
Figure 1
A pneumothorax is the most common of the air leaks that occur in newborns. Occurrence
statistics range from 1-10% of healthy, term neonates to 15-45% of ill mechanically ventilated
neonates. The incidence of air leaks is higher in newborns with respiratory distress syndrome
(RDS), meconium aspiration and transient tachypnea of the newborn (TTN or TTNB). Air leaks
include pneumomediastinum, pneumopericardium, pulmonary interstitial emphysema (PIE),
pneumothorax and pneumoperitoneum. Where the air accumulates after it leaks from the alveoli
determines what kind of air leak will develop.
Pneumothoraces are divided into two categories; open and tension. We will be discussing
tension pneumothorax.
In tension pneumothorax (Fig. 2), the intrathoracic pressure changes induced by increasing
pleural space volumes can affect the entire chest. Initially, increased pressure adversely affects
the ipsilateral (meaning affecting the same side of the body), then contralateral (meaning
affecting the opposite side of the body) lung volumes and gas exchange. Increasing mediastinal
pressure may distort the caval (vena-cava)-strial (band of tissue) juncture and impede blood flow
or compresses mediastinal venous structures, thereby decreasing venous return to the heart and
subsequent cardiac output. In other words, a tension pneumothorax has profound affects on all
the structures in the thoracic cavity.
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Absence of lung markings in
potential pleural space
Figure 2
ETIOLOGY
A
ll perinatal/pediatric air leaks usually develop from a common event. The initial event is
generally a rupture of the alveoli, usually secondary to uneven aeration in the alveoli.
The pediatric/perinatal patient who fits any of these listed situations should be monitored
closely for the development of a pneumothorax:
Stiff lungs with low compliance
•
Respiratory Distress Syndrome (RDS) is considered a predisposing factor due to a
marked decrease in respiratory compliance, which in turn, necessitates high
mechanical ventilatory pressures for lung inflation.
•
Victims of blunt trauma have a high incidence of air leaks.
Hyperinflated lungs
•
Meconium aspiration syndrome (MAS) result in airway obstruction, air trapping
and alveolar over distension.
•
Pneumonia due to mucus plugs and consolidation, which may bring about uneven
aeration of the alveoli.
Iatrogenic causes
•
Resuscitation measures, specifically with bagging done by inexperienced
personnel.
•
Mechanical ventilation in its entirety can cause misdistribution of ventilation and
result in overinflation of some lung units.
•
Traumatic intubation and aggressive airway suction technique causes bronchopleural
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fistula.
•
Endotracheal intubation of right main stem bronchus.
•
A complication of invasive thoracic surgical procedures.
Cerebral Hemorrhage, Intracranial Hemorrhage (ICH) or Intraventricular Hemorrhage
(IVH)
When there is a sudden rise in cerebral capillary pressure, as a result of a pneumothorax, cerebral
hemorrhage can occur. Intrathoracic pressure increases with a pneumothorax. This causes the
decrease of venous blood returning to the right atrium, which can lead to over perfusion of the
periventricular cerebral circulation. Due to the fragility of capillaries in the premature infant and
autoregulatory mechanisms, which control vascular tone being immature, capillaries can rupture
easily. A pneumothorax accelerates this process by suddenly and dramatically increasing
intrathoracic pressure.
DIAGNOSIS
PHYSICAL SYMPTOMS AND SIGNS
•
Any infant that demonstrates rapid respiratory or cardiopulmonary decompensation.
•
Vital signs:
Increasing systolic blood pressure above baseline
Hypotension
Increasing heart rate above baseline
Increasing pulse pressure above baseline
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Bradycardia
•
Gradual or very rapid deterioration (depending on the severity of the air leak)
•
Severe respiratory distress:
Retractions
Dyspnea
Tachypnea
Grunting
•
Unusual irritability
•
Restlessness
•
Cyanosis
• Periods of apnea
•
Distant cardiac tones
•
Asymmetric chest excursion
•
PMI movement from the original location of the point of maximal impulse
•
Deterioration after an initial good response to ventilation
•
Fails to respond to resuscitative efforts
•
Unilateral decrease in chest expansion
•
In the newborn, its size makes it almost impossible to palpate a deviated trachea.
•
Sounds are easily transmitted through the infant’s chest, so it is difficult to assess
breath sounds or the absence thereof.
In addition, the pediatric patient may exhibit:
•
Distended neck veins
•
Contralateral tracheal deviation
•
Chest pain
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ASSESSMENT
GENERAL
•
Severe hypoxemia
•
Tachycardia/bradycardia
•
Hyperresonance to percussion on the affected side
•
Decreased chest expansion
•
Diminished intensity or altered pitch of breath sounds on the side of the injury,
particularly evident during positive pressure ventilation (PPV).
•
Severely compromised systemic perfusion as the mediastinum shifts to contralateral
side, twisting the superior and inferior vena cava and obstructing venous return to the
heart.
•
Profound hypotension
•
Inflated hemithorax with reduced thoracic excursion noted on the affected side.
•
Elevated pulsus paradoxus
•
Increased central venous pressure (CVP)
•
Increased resistance to hand ventilation (bagging)
Assessment of the Point of Maximal Impulse (PMI)
The PMI is normally heard in the fifth intercostal space, midclavicularly on the left chest wall.
The apical pulse is evaluated at this point on the chest as the heart sounds are heard the loudest
here. During the initial assessment of an infant, the PMI is often marked and used as future
reference. Three main problems cause the PMI to shift: pneumothorax, atelectasis and increased
heart size.
Assessment of Pulsus Paradoxus
Pulsus paradoxus is a notable decrease in pulse strength during inhalation. A positive
assessment of pulsus paradoxus may indicate obstructive pulmonary disease, status asthmaticus,
or a sign that there is a mechanical restriction on the heart’s pumping action as can occur with
constrictive pericarditis, cardiac tamponade or tension pneumothorax. The assessment of pulsus
paradoxus is best assessed by actual blood pressure measurement.
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CHEST X-RAY
Identification of Tension Pneumothorax on CXR
Widened Intercostal Spaces
Displaced
Mediastinum
Area Of Black/Absence
of Lung Markings
Depressed Diaphragm
Collapsed Lung
AP View
Chest x-rays should be taken during expiration in both anteroposterior and lateral views.
A pneumothorax is identified on the chest x-ray as an area of black, without vascular markings,
indicating air that surrounds the collapsed lung. To differentiate between a pneumothorax and a
skin fold, look for lung markings in the air filled space and the edge of the lung. If lung
markings are absent, it is a pneumothorax. Although skin folds may appear as the border of the
lung, the space surrounding the line will have lung markings, which is inconsistent with a
pneumothorax. The skin fold may also be seen beyond the confines of the pleural cavity and into
the soft tissues of the chest wall. In a tension pneumothorax, the diaphragm on the effected side
will be depressed and the intercostal spaces will be widened. The mediastinum may also be
displaced away from the pneumothorax. If the air is under sufficient pressure to shift the lung
and mediastinal structures to the opposite side it is called a tension pneumothorax.
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TRANSILLUMINATION
Identification of a Tension Pneumothorax with a Transilluminator
Transillumination showing a normal
pattern of reflected light on the surface
of the thorax.
Transillumination showing fingerlike projection pattern seen in
pneumothorax.
Figure 3
Transillumination to identify air leak in the newborn has been used as a diagnostic tool for at
least 15 years. Following the clinical signs and symptoms of a pneumothorax, transillumination
should be the next step in diagnosing the neonate.
Transillumination is done with a high-intensity light source, usually fiberoptic, on the thoracic
surface. When the light is placed against the thorax of a neonate with normal lungs, the light is
reflected to the surface of the thorax by the lung tissue, forming a uniform circle around the light.
In the presence of free air in the thorax, the light is reflected at odd angles due to the collapse of
the lung. The result is an irregular-shaped reflection in the chest wall, with fingers of light
possibly appearing away from the light source (Fig. 3). It is best to darken the room as much as
possible and position the light perpendicular to the chest. Avoid tape and change the location of
chest leads, which obscure the light beam, to the shoulder. Gross edema of the chest wall can
lead to a false negative. A negative transillumination does not rule out a pneumothorax. Hourly
transillumination of the high-risk neonates as a monitoring tool is common in the Neonatal
Intensive Care Unit.
TREATMENT FOCUSES ON MANAGEMENT AND MONITORING
TREATMENT
T
reatment depends on the severity of the newborn’s symptoms. The infant in severe
distress should have the trapped air removed through needle aspiration. This is an
emergency procedure to be used until a chest tube can be inserted. Needle decompression
should even precede confirmatory chest x-ray if signs of respiratory distress or shock are present,
as without this procedure, the tension pneumothorax could be fatal.
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Needle Decompression
Recommended site for needle
decompression: 3rd intercostal
space, anterior axillary line.
Figure 4
Needle decompression creates an open pneumothorax, equilibrating the affected side to the
atmosphere and providing a temporary reduction in thoracic pressure.
•
Prep the chest aseptically
•
Insert an over the needle catheter, 18-20 (23-25) gauge. Some references state that the
puncture be made through the second intercostal space on the midclavicular line, just
above the third rib. The Pediatric Advanced Life Support (PALS) recommendation, and
ours, is the third intercostal space in the anterior axillary line (Fig. 4).
•
A gush of air will be heard or felt after successful needle decompression.
•
This may be attached to a 3-way stopcock and a 10-20 ml syringe.
•
Vent to atmosphere until chest tube is inserted.
Positions for needling chest for pneumothorax and for chest tube position:
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CHEST TUBES
Chest Tube Insertion
Recommended sites for chest tube insertion:
2nd intercostal space, midclavicular line.
3rd intercostal space, midclavicular line.
Laterally-6” intercostal space.
Figure 5
Standard sharp and blunt surgical dissection is the preferred insertion method in the neonate. To
remove air, the tube is usually placed high in the chest in the second or third intercostal space in
the midclavicular line, but it may also be placed laterally (Fig. 5).
A chest tube should be attached to a one-way valve, water seal or suction. Suction level should
range from –15 cmH2 O for small leaks to –25 cmH2 O for larger.
Chest tubes can be removed when the patient’s respiratory distress is resolved, there has been no
leakage from the tube for 24 to 48 hours and the extrapulmonary air has been resolved for 24-48
hours. Often, the tube is clamped for 24 hours before removal to assure complete resolution of
the air leak.
Obtain a chest X-ray to assure proper placement and air evacuation.
Assess the drainage system in a systematic way:
•
Assess the tube insertion site:
Airtight (sterile dressing covered sparingly with adhesive tape/Op-Site or
Tegaderm)
•
Assess tubing patency:
Not a problem in the patient with a pneumothorax as it is only evacuating air.
Manipulate tubing only when absolutely necessary.
Position the tubing so there are no dependent loops. If there is drainage, coil
the tubing and rest it on the bed.
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•
Clamp only to simulate tube removal to determine patient tolerance for 12-24
hours before anticipated removal and obtain a chest x-ray just prior to removing
the tube.
•
Monitor the collection chamber for the rate and nature of drainage.
There is minimal drainage expected with pneumothorax.
•
Evaluate the water seal chamber:
If there is bubbling in the water seal chamber and this is inconsistent with the
patient’s condition, there probably is an air leak somewhere. Determine
whether the leak is from the lung or the system. Use a booted hemostat or
tubing clamp to clamp the chest tube momentarily proximal to the chest wall and
look at the water seal chamber. If the bubbling stops, the leak is from the lung.
If the bubbling continues, the leak is between the chest wall and the chest
drainage unit. Often the leak is the connector between the chest tube and
the patient tubing of the drainage unit. Place the clamp on the patient side
of the connector and look for bubbling. Then place it on the unit side of the
connector and look at the water seal chamber. If bubbling vanishes when
the clamp is placed on the unit side of the connector, the leak is at the
connector.
•
Water level:
This reflects actual pressure changes in the pleural space.
If there is no vigorous bubbling, water movement with respirations should be
visible. Spontaneous respirations water should move up the column with
inspiration on exhalation, the water should go back down to baseline.
•
Positive pressure ventilation should be just the opposite. These water movements are
called “tiding”. Tiding may be damped in patients on PEEP and those whose lungs are
fully re-expanded.
•
Monitor the suction control chamber for the water level and the amount of bubbling. The
amount of negative pressure transmitted to the pleural space is determined by the water
level in this chamber, NOT by the amount of suction set on the suction regulator. Adjust
the suction so that gentle bubbling appears in the chamber.
Two Types of Dry Suction Chambers:
1. Principle of restricted orifice. Adjusting the size of the orifice through which airflow sets the
amount of suction. The disadvantage of this type is that although they accurately reflect the
amount of suction desired at the time of set-up, as changes in patient pressures occur, the
actual suction imposed on the pleural space may change, without a change on the unit.
2. Spring-loaded, self-regulating. Automatically compensates for changes in wall suction or
patient pressures and maintains suction level originally set as long as there is sufficient
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suction pressure to support the device. The Pleur-evac neonatal chest drainage unit is one
such device.
CONTINUOUS MONITORING
•
Arterial blood pressure
•
Heart rate
•
Pulse pressure
•
Transcutaneous oxygen
•
Mark the PMI and auscultate every hour for movement
•
Transcutaneous CO2
MANAGEMENT
•
Keep intrathoracic pressures as low as possible by:
During mechanical ventilation, keep peak airway pressure and mean airway
pressures as low as possible.
Another consideration is that spontaneous breaths contribute negative pressure in
the thorax and can help keep the mean intrathoracic pressure down, but an infant
fighting the ventilator will increase intrathoracic pressures. Synchronizing
ventilator and spontaneous breaths (SIMV mode) may assist in the prevention of
this problem.
•
Use of surfactant replacement therapy in RDS decreases the incidence of
pneumothorax and intraventricular hemorrhage (IVH).
•
Keep infant’s head straight and slightly elevated.
PREVENTION
Fibrin glue has been used in neonates to seal cannulation sites in ECMO and to seal
postoperative thoracic duct leaks. Fibrin glue is made of fibrinogen and factor XIII combined
with thrombin and calcium forming a coagulum. It stimulates the formation of a fibrin clot
within second after administration. In a recent study, infants with persistent pneumothorax had
fibrin glue inserted into their pleural air pocket. The chest tube(s) was briefly clamped.
The study concluded that this form of treatment was effective for infants unresponsive to
standard therapy for persistent pneumothorax.
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CLINICAL CASE SCENARIO
5-week-old neonate in the NICU born at 30 weeks gestation.
Survanta X 1
Developed RDS
Mechanical ventilation since birth
Slow weaning process, not at minimal settings
Following suctioning, the infant suddenly showed signs and symptoms of respiratory distress
with retractions, nasal flaring and tachypnea. Bradycardia, peripheral and central cyanosis
become evident.
1. What are the pertinent positive findings in this subjective data?
2. What are the probable diagnoses given the above information?
3. What assessments would you like to perform to differentiate the diagnosis?
Observation:
Central and peripheral cyanosis
HR 80 and decreasing
SpO2 68% on FIO 2 of .48
Ventilator parameters were not changed
Rate 35BPM
PIP 22 cmH 2 O
PEEP 4 cmH2 O
IT 0.4 sec
Quick examination of the ventilator circuit reveals no obvious disconnection or occlusion.
Chest excursion greatly diminished bilaterally
Breath sounds decreased on the right side
Heart sounds muffled
PMI shifted slightly left
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4. What tests should now be performed?
Transillumination shows a large atypical light reflection on the right superior thoracic area.
5. What is your diagnosis at this point?
6. What would be your treatment plan for this patient?
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ANSWERS TO CASE SCENARIO
1. Positives in history:
Diagnosis of RDS
Mechanical ventilation with fairly high levels of support
A sudden change in status with respiratory distress, cyanosis and bradycardia.
2. Probable diagnoses:
Dislodged endotracheal tube
Vagal stimulation
Tension pneumothorax
3. Assessments to differentiate the diagnosis:
Physical examination
Breath sounds are decreased on the right
PMI is shifted to the left
4. Diagnostics:
Immediate (life-threatening) - Initial transillumination
Chest radiograph
5. Positive transillumination in the right thoracic area confirms the diagnosis of tension
pneumothorax.
6. Treatment plan:
Severe distress-needle aspiration/decompression
Chest tube
Management of respiratory distress/shock
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SUMMARY
A tension pneumothorax is a life-threatening condition caused by air trapped within the pleural
space that is under pressure thereby displacing the mediastinal structures and compromising
cardiopulmonary function. A tension pneumothorax in the neonate is generally due to the
rupture of alveoli due to uneven aeration. Infants who have been manually resuscitated, those
who have respiratory distress syndrome (RDS), meconium aspiration syndrome (MAS),
pneumonia or those who are have been intubated or are being mechanically ventilated have the
highest incidence of pneumothorax. Aggressive suctioning techniques have been known to
cause tension pneumothorax in the neonate. A pneumothorax causes increased intrathoracic
pressure that, in turn, causes a sudden rise in cerebral capillary pressure that may lead to cerebral
hemorrhage.
The physical signs and symptoms of pneumothorax are fairly remarkable. Generally, especially
in those infants receiving mechanical ventilation, there is a profound and rapid cardiopulmonary
deterioration. The infant’s vital signs become abnormal; signs of severe respiratory distress are
displayed. Asymmetric chest excursion may be observed. The infant may not respond to
resuscitative efforts. Movement of the point of maximal impulse (PMI) may occur. A positive
pulsus paradoxus is of concern. Distended neck veins may be noted in the infant. Careful
monitoring and assessment of those infants at perceived highest risk is vitally important.
The chest X-ray is an acceptable means of obtaining a definitive diagnosis of pneumothorax.
Transillumination, visualizing the chest wall with a high-intensity fiber optic light source, is
often the quickest diagnostic tool available to the bedside practitioner and may be used in routine
monitoring of the high-risk neonate. The location of the pneumothorax is easily seen on chest Xray as a black area without lung markings. The two most unreliable assessment tools used to
diagnose tension pneumothorax in the neonate are palpation of a deviated trachea and breath
sounds.
Treatment of tension pneumothorax is focused on management and monitoring. Monitoring
pulse pressures, heart rate, arterial blood pressure and location of PMI is highly suggested in the
care of the infant at high risk for developing an air leak. The emergent treatment for a tension
pneumothorax is to, of course, support the cardiopulmonary system, but needle decompression or
chest tube insertion must be done to prevent death. Infants with persistent pneumothorax
unresponsive to conventional treatment may be treated successfully by the administration of
fibrin glue.
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SUGGESTED READING AND REFERENCES
American Heart Association/American Academy of Pediatrics. Textbook of Pediatric Advanced
Life Support (1987).
Brenner, B. Comprehensive Management of Respiratory Emergencies, (1985) Aspen Systems.
Burton, G.G., et al. (1997) Respiratory Care: A Guide to Clinical Practice. (4th Ed).
Philadelphia: Lippincott-Raven.
Neonatal Network Volume 10, No. 2(1991). Pneumothorax in the Newborn.
Sarkar, S., Hussain, N., Herson, V. Fibrin Glue for Persistent Pneumothorax in Neonates.
Journal of Perinatology, January 2003, Volume 23, Number 1, Pages 82-84.
Scanlan, C.L., Wilkins, R., Stoller, J. (1999). Egan’s Fundamentals of Respiratory Care. (7th
Ed). St.Louis: Mosby.
Sills, J. (1995). Respiratory Care Registry Guide. St. Louis: Mosby.
Whitaker, K. (1997). Comprehensive Perinatal and Pediatric Respiratory Care. (2nd Ed).
Albany: Delmar, ITP.
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1. The assessment of a positive pulsus paradoxus:
I.
II.
III.
IV.
V.
indicates a mechanical restriction of the heart’s pumping action
may indicate obstructive pulmonary disease
may indicate status asthmaticus
is generally not indicative of a life-threatening situation
may be the result of constrictive pericarditis, cardiac tamponade or tension
pneumothorax
a.
b.
c.
d.
V, VI, III, II
I, II, IV, V
I, II, III, V
I, II & III only
2. Transillumination:
I.
II.
III.
IV.
is the quickest way to identify an air leak in an infant
is done with a high-intensity fiberoptic light source
may be done hourly in the high-risk neonate
is only used when chest radiography is not immediately available
a.
b.
c.
d.
II, III, IV
I, II, III
I, III, IV
I, II, IV
3. The PMI refers to:
a.
b.
c.
d.
the location of the loudest breath sounds
the location of the loudest heart sounds
a notable decrease in pulse strength during inspiration
the location to perform needle decompression
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T
ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
4. A tension pneumothorax is best defined as:
a.
b.
c.
d.
air in the parenchyma
air in the pleural space
trapped air in the pleural space
leaky alveoli
5. A tension pneumothorax can lead to cerebral hemorrhage in the infant due to:
a. Increased intrathoracic pressures and subsequent sudden rise in cerebral capillary
pressure.
b. Decreased pulmonary compliance
c. Bradycardia and tachypnea
d. Hypoxemia
6. Causes of tension pneumothorax include:
I.
II.
III.
IV.
V.
rupture of the alveoli secondary to uneven aeration
grunting, dyspnea and retractions
high mechanical ventilatory pressures
air trapping and alveolar over distension
aggressive suctioning
a.
b.
c.
d.
I, II, III, IV
II, III, IV, V
I, III, IV, V
III, IV, V
7. Air leaks are more common in the neonate with:
I.
II.
III.
IV.
Respiratory Distress Syndrome (RDS)
Persistent Pulmonary Hypertension (PPHN)
Transient Tachypnea of the Newborn (TTN)
Meconium aspiration
a.
b.
c.
d.
I, III, IV
I, II, III
II, III, IV
I & IV only
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T
ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
8. The signs and symptoms of tension pneumothorax include:
I.
II.
III.
IV.
V.
severe respiratory distress
failure to respond to resuscitative efforts
bowel sounds in the chest
asymmetric chest excursion
distended neck veins
a.
b.
c.
d.
I, II, III, IV
All of the above
I, II, III, V
I, II, IV, V
9. A pneumothorax is identified on the chest x-ray as:
a.
b.
c.
d.
a darkened space with faint lung markings
an area of black with no lung markings surrounding the lung edge
diffuse, white patchy areas in the hilum
a whitened area at the base of one lung forming a meniscus
10. The PALS recommendation for a needle catheter placement in needle decompression of a
tension pneumothorax is:
a.
b.
c.
d.
fourth intercostal space, midclavicular line
second intercostal space, anterior axillary line
third intercostal space, midclavicular line
third intercostal space, anterior axillary line
11. Tension pneumothorax is considered a life-threatening event because:
a.
b.
c.
d.
systemic perfusion is severely compromised
the affected lung cannot inflate
the patient will be difficult to intubate
there is no treatment for this condition
12. The two most unreliable assessment tools for the diagnosis of tension pneumothorax are:
a.
b.
c.
d.
palpation of a deviated trachea and breath sounds
breath sounds and transillumination
palpation of a deviated trachea and chest radiography
needle decompression and breath sounds
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T
ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
13. An infant at risk for the development of air leaks should have the following continuously
monitored:
I.
II.
III.
IV.
V.
pulse pressures
heart rate
arterial blood pressure
transcutaneous O2 and CO2
location of PMI
a.
b.
c.
d.
I, II, III, IV
I, II, III, V
I & II only
All of the above
14. Prevention of pneumothorax in the neonate can best be achieved by:
I.
II.
III.
IV.
using the lowest possible ventilating pressures
adequate pulmonary hygiene to prevent of mucus plugging
bagging only by experienced personnel
proper endotracheal tube placement
a.
b.
c.
d.
I, II, III
II, III, IV
I, IV, II
I, II, III, IV
15. The following refers to the proper needle decompression procedure in the perinatal/pediatric
patient:
a. 25 gauge over the needle catheter through the 4th intercostal space at the midaxillary
line
b. 14 gauge over the needle catheter through the 2nd intercostal space at the
midclavicular line
c. 23 gauge over the needle catheter through the 3rd intercostal space in the anterior
axillary line
d. 18 gauge over the needle catheter through the 5th intercostal space at the
midclavicular line
SL: Test Version C
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T
ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
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1.
a b c d
2.
a b c d
3.
a b c d
4.
a b c d
5.
a b c d
6.
a b c d
7.
a b c d
8.
a b c d
9.
a b c d
10. a b c d
11. a b c d
12. a b c d
13. a b c d
14. a b c d
15. a b c d
SL: Test Version C
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T
ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
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