TENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT
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 T 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 2 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 3 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 4 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT CLINICAL CASE SCENARIO ........................................................................................ 17 ANSWERS TO CASE SCENARIO ............................................................................ 19 SUMMARY...................................................................................................................... 20 SUGGESTED READING AND REFERENCES ............................................................ 21 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 5 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 6 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 7 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 8 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 9 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 10 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 11 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 12 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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: This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 13 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 14 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT • 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 15 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 16 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 17 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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? This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 18 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 19 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 20 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT 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. This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 21 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT POST TEST DIRECTIONS: IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS ON THE ANSWER SHEET PROVIDED AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE – PLEASE DO NOT MAIL OR FAX BACK. 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 22 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 23 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 24 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 25 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT ANSWER SHEET NAME____________________________________ STATE LIC #_______________________ ADDRESS_________________________________ AARC# (if applic.)___________________ DIRECTIONS: (REFER TO THE TEXT IF NECESSARY – PASSING SCORE FOR CE CREDIT IS 70%). IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE – PLEASE DO NOT MAIL OR FAX BACK. 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 This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law. 26 T ENSION PNEUMOTHORAX IN THE PERINATAL/PEDIATRIC PATIENT EVALUATION FORM NAME:____________________________________________ DATE:______________ AARC # (if applic.)________________________ STATE LICENSE #:______________ RC Educational Consulting Services, Inc. wishes to provide our clients with the highest quality CE materials possible. Your honest feedback helps us to continually improve our courses and meet CE regulations in many states. Please complete this form and return/submit it with your answer sheet. Thank you. YES NO Were the objectives of the course met? Was the material clear and understandable? Was the material well-organized? Was the material relevant to your job? Did you learn something new? Was the material interesting? Were the illustrations, if any, helpful? Would you recommend this course to a friend? 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