74 | Caring for pneumothorax patients: how to use your skills as a veterinary nurse
In episode 74, we’re diving straight into pneumothorax - what it is, how it presents, and most importantly, how you can help manage it as a veterinary nurse.
We see these patients commonly, and they’re usually a real nightmare to manage. From big dogs with ruptured pulmonary bullae, to post-RTA patients with continuous air leakage, they’re a real test of our nursing skills - but in reality, there’s so much we can do to help them.
So, let’s go through everything you need to know to feel more confident nursing a pneumothorax patient.
Time for a quick refresher - what is a pneumothorax?
A pneumothorax occurs when air enters the pleural space.
As a reminder from last week’s episode, the pleural space is usually a vacuum - under negative pressure - and when air enters, that negative pressure is lost.
This causes the lungs to collapse inward, depending on the severity and amount of air present.
And as you can imagine, this reduces the amount of oxygen getting to the alveoli and puts our patients in serious respiratory distress.
But not every pneumothorax is the same.
There are a few different types, and understanding them will help you anticipate what kind of care your patient might need.
Our patient could have a traumatic, spontaneous or iatrogenic pneumothorax.
Traumatic pneumothorax
This is one of the most common types we see in practice. It occurs due to blunt or penetrating trauma, like a dog attack, a road traffic accident (RTA), or even a fall from height (especially in cats - think high-rise syndrome cases where cats fall out of high windows).
These patients often have other injuries too, so keep your eyes peeled for fractures, uroabdomen, haemorrhage or other signs.
Spontaneous pneumothorax
These are seen less commonly, but are equally essential to recognise.
It usually happens when a pulmonary bulla or bleb ruptures, often in deep-chested dog breeds like Huskies or German Shepherds.
Pulmonary bullae are small, air-filled spaces within the lung tissue caused by alveolar damage, destruction and enlargement due to emphysema, traumatic damage or even pulmonary inflammation. If these rupture, the air the patient breathes in continues to ‘leak’ through the ruptured bullae, despite thoracic drainage.
Spontaneous pneumothorax can recur and may eventually require surgical intervention via a lung lobectomy, removing the affected area.
Iatrogenic pneumothorax
These occur due to something either we do in the process of caring for the patient, or perhaps the patient does themselves.
It might be after thoracocentesis, excessive manual ventilation during anaesthesia, or even a fine needle aspirate of a thoracic mass.
We also see this in patients who damage indwelling chest drains, which is why preventing patient interference is so key in chest drain patients! And patients with oesophageal foreign bodies can also develop pneumothorax if the oesophagus perforates during foreign body removal.
We can also classify pneumothorax based on how the air enters the space, as either an open, closed or tension pneumothorax.
In an open pneumothorax, the chest wall is breached, and air enters directly from the outside environment. Think of a penetrating bite wound or deep laceration. This is an emergency because air continues to enter the space with every breath.
With a closed pneumothorax, there are no external wounds, but air leaks from the lung tissue itself into the pleural space. This is what we see with ruptured bullae or lung trauma.
Lastly, we have a tension pneumothorax. This is the most dangerous (not that any pneumothorax isn’t dangerous!) because with a tension pneumothorax, the air gets in but can’t get out, creating a one-way valve effect. This rapidly increases the pressure within the chest, collapsing the lungs and compressing the heart and major vessels, reducing cardiac output. A classic example of when we see tension pneumothorax is during oesophageal foreign body removal, if the oesophagus ruptures - and if you’ve ever seen one, you’ll know how poor the prognosis is if this happens.
Ok, so those are the types of pneumothorax we see - but what do these patients look like when they arrive? What clinical signs do we need to look out for?
Most patients with pneumothorax are going to present with respiratory distress.
The severity of their signs will vary depending on how much air has accumulated and how quickly it happened, but here are the common ones:
Tachypnoea,
Restrictive breathing pattern with rapid, shallow breaths,
Abdominal effort,
Orthopnoea with their elbows abducted and their neck extended to improve airflow (sometimes they are referred to as looking ‘air-hungry’).
Open-mouth breathing,
Cyanosis (in cases of severe hypoxaemia)
Lethargy, weakness and collapse,
Evidence of other injuries or changes associated with trauma, such as external wounds, haemorrhage or fractures.
On your physical exam (because no, you do not need to have an MRCVS to do a ‘proper’ patient examination), you may notice:
Muffled lung sounds, especially dorsally (as air rises),
Hyper-resonant (low, loud and hollow) sounds on percussion of the dorsal thorax,
Evidence of hypovolaemia if the patient has concurrent circulatory compromise, such as weak pulses, bradycardia, prolonged CRT and pale mucous membranes.
Regardless of whether you’re assessing these patients on initial presentation or if they’ve decompensated in the ward, a calm, quick but thorough approach is vital. Put the patient on oxygen, alert the vet to your findings, and prepare equipment for thoracocentesis ASAP.
After that? It’s time to talk diagnosis.
These really are some of our truest respiratory emergencies, and stabilising them promptly is essential.
Just like we discussed in episode 73, a hands-off, oxygen and ‘leave them to chill’ approach will only get us so far, because it’s that pleural air compressing the lungs and interfering with ventilation.
Once your patient can handle interventions, prioritise a thoracic point-of-care ultrasound and thoracocentesis. These will tell you what you need to know to begin with.
Look for an absent glide sign on ultrasound - this is diagnostic for pneumothorax. The glide sign is a shimmering line that moves back and forth on ultrasound, representing the movement of the lungs against the chest wall. No glide sign? Something is sitting between the lungs and chest wall - and if there’s no pleural fluid, then that can only really be one thing: air.
Confirm this by tapping the chest (or assisting with a centesis, depending on your local legislation) and draining as much air as the patient will allow before going on to other diagnostics once the patient is stable.
And those other diagnostics?
Well, they include:
Thoracic radiographs or CT: which show a black space between the lung and chest wall, retracted lung lobes, and an elevated heart (lifted away from the sternum)
Bloodwork: such as a haematology, biochemistry and/or blood gas analysis in suspected trauma patients or if you suspect concurrent disease
Abdominal ultrasound: to look for further evidence of traumatic damage and assess the abdominal organs where needed (eg, in cases where diaphragmatic rupture is suspected).
Like we said last week, these patients are on a knife-edge and can struggle to tolerate diagnostics, even once they’ve been initially stabilised. Always have oxygen ready, and restrain any conscious patients minimally. If your patient won’t tolerate diagnostics, stop and reassess. You can always come back to them when they’re more stable.
Ok, so we know our patient has a pneumothorax. How do we manage it?
Now, onto the crucial part: what we can do to support these patients as nurses and technicians.
This starts at initial stabilisation by providing appropriate oxygen therapy (depending on the patient’s size, condition, and degree of hypoxaemia), minimising stress, and keeping the patient in sternal recumbency to aid lung expansion as much as possible.
Next, there’s thoracocentesis.
This is the first line of treatment for pneumothorax. Depending on your location, you’ll either be performing this yourself or assisting the vet with the procedure.
But even if you’re not performing this skill independently, this doesn’t mean you can’t know how it works, or what the risks are for your patient.
When performing a thoracocentesis on a pneumothorax patient:
Adhere to strict septic technique throughout.
Tap the dorsal third of the thorax, usually around the 7th to 9th intercostal space, ensuring your needle enters off the cranial border of the rib (since nerves and vessels run along the caudal aspect).
Use a butterfly needle or over-the-needle catheter connected to a three-way stopcock and syringe.
Withdraw air slowly to avoid re-expansion injury and minimise pleural trauma.
Monitor the patient closely during and after the procedure.
You’ll need to repeat this procedure if air continues to accumulate.
What about chest drain placement?
If thoracocentesis isn’t enough, for example, if the pneumothorax is recurring and repeated thoracocentesis is needed, chest drains are the next step.
These allow for repeated intermittent or continuous drainage but require general anaesthesia for placement, and they must be managed carefully once in situ.
Once the drain is in place, our role as nurses and technicians is:
To follow careful aseptic technique when handling and using the drain
To clean, inspect and redress the site at regular intervals
To carefully empty the drain every 2-4 hours (depending on the individual patient) or use a continuous drainage device where needed
To prevent patient interference causing drain damage and iatrogenic pneumothorax.
Along with chest drain management, we also need to provide analgesia.
Chest drains are painful themselves, and patients with traumatic pneumothorax or after thoracic surgery will be particularly uncomfortable.
Assess pain levels regularly in these patients and utilise opioids alongside appropriate multimodal analgesia where indicated, taking care with NSAIDs in trauma patients at risk of haemorrhage, or hypotensive/hypovolaemic patients at increased risk of AKI.
How else do we nurse these patients?
Our role isn’t just about managing the chest drain and removing that air. We also need to prioritise:
Intensive patient monitoring, particularly of their cardiorespiratory parameters
Identifying sudden changes or declining trends in the patient’s status
Recumbency care
Fluid balance
Nutritional support
Supporting mobility
Managing eliminations
Wound management (if present) and much more.
How well our pneumothorax patients do depends on the cause and severity of their disease. Traumatic pneumothorax often has a good outcome with prompt stabilisation and supportive care, spontaneous pneumothorax often requires surgery, but patients can do well with thorough post-operative care, and tension pneumothorax is critical, but can resolve with early detection and aggressive treatment.
So there you have it - a look at the most common pleural space disease we see, and how to successfully care for these patients as nurses and technicians. Yes, they’re challenging, and yes, sometimes they really do test our skills - but they’re also an excellent opportunity for us to learn and do more.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Gilday, C. et al. 2021. Spontaneous pneumothorax: pathophysiology, clinical presentation and diagnosis. Topics in Companion Animal Medicine, 45.
King, L.G. and Boag, A., 2007. Textbook of Small Animal Emergency Medicine. Iowa: Wiley-Blackwell.
Merrill, L. 2012. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell.
Nelson, R.W. and Couto, C.G., 2020. Small Animal Internal Medicine. 6th ed. Missouri: Elsevier.
Sharp, CR. 2015. Approach to respiratory distress in dogs and cats [Online] Today’s Veterinary Practice. Available from: https://todaysveterinarypractice.com/respiratory-medicine/approach-to-respiratory-distress-in-dogs-and-cats/
