Gross anatomy of the chestGross anatomy of the chestcase studycase study

Elizabeth Kelley Buzbee Elizabeth Kelley Buzbee AAS,NPS-RRT, RCPAAS,NPS-RRT, RCP

Case study # 1Case study # 1

Your patient is an 18 year-old Latin Your patient is an 18 year-old Latin American male [LAM] who has about a American male [LAM] who has about a liter of fluid in the plural spaces secondary liter of fluid in the plural spaces secondary to renal [kidney] failure and congestive to renal [kidney] failure and congestive heart failure.heart failure.

His respiratory rate is 35 bpm.His respiratory rate is 35 bpm.His heart rate is 125 bpm.His heart rate is 125 bpm.Are his Vital Signs within normal limits?Are his Vital Signs within normal limits?

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No, his RR should be between 12-20 bpm. No, his RR should be between 12-20 bpm. He is breathing fast—tachypnic He is breathing fast—tachypnic

Nor is his heart rate normal. It should be Nor is his heart rate normal. It should be between 60-100 bpm and it also is too between 60-100 bpm and it also is too fast--tachycardiafast--tachycardia

The patient complains of pain on deep The patient complains of pain on deep breathing. Why?breathing. Why?

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The The parental pleura parental pleura is filled with pain is filled with pain receptors and the swelling irritates themreceptors and the swelling irritates them

How could this problem effect his How could this problem effect his ability to breathe?ability to breathe?

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The fluid pressing on the lung will cause it to The fluid pressing on the lung will cause it to collapse. Collapsed air sac are harder to re-collapse. Collapsed air sac are harder to re-inflate inflate

The interface between the pleura and the lung is The interface between the pleura and the lung is filled with fluid so that the lung doesn’t follow the filled with fluid so that the lung doesn’t follow the rib cage out during inspiration. To compensate rib cage out during inspiration. To compensate for this, the patient must create more negative for this, the patient must create more negative pressure in his chest. This, too, increases the pressure in his chest. This, too, increases the WOB WOB

How does increased WOB cause him to How does increased WOB cause him to have the retractions you see on his chest have the retractions you see on his chest wall?wall?

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Retractions of the soft tissue of the ribs, Retractions of the soft tissue of the ribs, and sternum and clavicles result from and sternum and clavicles result from excessive negative pressure in the thorax excessive negative pressure in the thorax created by the patient to get air into a stiff created by the patient to get air into a stiff lung.lung.

You note that this patient’s skin is cool and You note that this patient’s skin is cool and damp [diaphrotic] Why is he sweating?damp [diaphrotic] Why is he sweating?

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He is sweating because he is working hard He is sweating because he is working hard to breathto breath

Before the chest tube was placed and 500 Before the chest tube was placed and 500 ml of fluid removed from the thoracic ml of fluid removed from the thoracic cavity, this patient’s Sp02 was 88% .cavity, this patient’s Sp02 was 88% .

What is the significance of the 02 What is the significance of the 02 saturation?saturation?

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He has lower than normal 0xygen bound He has lower than normal 0xygen bound to his blood hemoglobin.to his blood hemoglobin.

He is hypoxicHe is hypoxic

What would you suggest for this What would you suggest for this condition?condition?

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Give him supplementary 02 to get his Give him supplementary 02 to get his Sp02 back to 90% Sp02 back to 90%

Do you think that the presence of this fluid Do you think that the presence of this fluid could interfere with this patient’s ability to could interfere with this patient’s ability to take a deep breath and cough?take a deep breath and cough?

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Yes, he cannot take a deep breath with all Yes, he cannot take a deep breath with all the fluid taking up space where lung the fluid taking up space where lung should beshould be

When we listen to his breath sounds, we When we listen to his breath sounds, we hear crackles in the upper lobes and hear crackles in the upper lobes and diminished breath sounds in the lower lung diminished breath sounds in the lower lung fields. fields.

Why?Why?

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We hear We hear cracklescrackles because we are hearing because we are hearing the air sac pop open on inspirationthe air sac pop open on inspiration

We hear We hear diminished breath soundsdiminished breath sounds in the in the basal areas because gravity causes the basal areas because gravity causes the fluid to move down to the lower portion of fluid to move down to the lower portion of the chest. The fluid is causing the lung to the chest. The fluid is causing the lung to collapse and the fluid is damping down the collapse and the fluid is damping down the breath sounds breath sounds

What would be your expectations What would be your expectations regarding his Sp02 and his Vital Signs regarding his Sp02 and his Vital Signs after the chest tube has been placed in his after the chest tube has been placed in his chest and the extra fluid drained off?chest and the extra fluid drained off?

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We expect that his RR to drop closer to We expect that his RR to drop closer to normalnormal

We expect the HR to drop closer to normal We expect the HR to drop closer to normal We expect the Sp02 to rise closer to We expect the Sp02 to rise closer to

normalnormalWe expect the sweating and the We expect the sweating and the

retractions to return to normalretractions to return to normal