A flail chest occurs where there are two or more consecutive rib fractures with a resultant instability in the chest wall, it may also occur with a fractured sternum and several ribs. During inhalation, the chest wall moves in during exhalation the chest wall bulges, this is known as paradoxic movement. The movement prevents adequate ventilation.
- Movement may be observed
- Crepitus may be auscultated at fracture point
- Tachypnoea, and shallow breaths
- Airway management
- Supplemental oxygen
- Pain relief
- Possibly intubation and ventilation
- Possibly surgical intervention
A pneumothorax occurs when air enters the pleural space the air places pressure on the lung causing a collapse. The pleural space maintains a negative pressure under homeostatic conditions allowing chest expansion to draw air into the lungs. When air enters the pleural space the pressure becomes positive, and the lung can no longer hold its shape and thus collapses. This can be classified as an open or closed pneumothorax.
Open pneumothorax – Air enters via open wound to chest wall.
Closed pneumothorax – Air enters via lung injury, chest wall remains intact.
Image retrieved from http://www.fprmed.com/Pages/Trauma/Simple_Pneumothorax.html
- Absent breath sounds on affected side
A tension pneumothorax is a medical emergency death will occur if not treated. A tension pneumothorax occurs when air enters the pleural space but cannot escape. As intrapleural pressure increases, shifting of the internal structures occurs. Structures affected are the trachea, the heart, the great vessels and the inflated lung.
Tension pneumothorax may be closed due to traumatic injury occurring. Alternatively, it may be open with a flap of tissue sealing the wound and acting as a one way valve letting air in but not out.
When a lung collapses the area available for ventilation and perfusion is reduced, and the blood flow to the affected lung can no longer flow through the lung. In response to physiologic stress and rising carbon dioxide levels, chemoreceptors attempt to compensate by increasing heart rate along with ventilatory rate and depth thus exacerbating the positive pressure in the pleural cavity. Cardiac output is affected, as the heart cannot fully relax to maintain preload thus cardiac output declines with increasing pressure.
- Tracheal deviation
- Absent breath sounds on affected side
- Neck vein distension
Image retrieved from https://medcomic.com/medcomic/tension-pneumothorax-a-medcomic-emergency/
Treatment requires needle decompression followed by the insertion of a chest tube and drain. The chest tube is inserted in the second intercostal space in the midaxillary area. The patient’s head should be elevated to 30 to 60˚ in order to lower the diaphragm and avoid injury. The arm should be raised above the head on the affected side.
Chest drains attach to chest tubes and work to return the negative pressure that normally exists intrapleurally by facilitating intrapleural air to escape and preventing it to re-enter. There are several types of chest drainage systems wet, dry, and Heimlich. Heimlich is a simple system used for uncomplicated pneumothorax. A wet system provides passive suction by way of water pressure, whereas a dry system uses a dry chamber with suction controlled via a regulator. Evidence base suggests the water system reduces the days the tube must stay in place in comparison to the active suction or dry system.
Nursing considerations for chest drains:
- Ensure chest drain is below chest level, always
- Monitor connections to maintain patency
- Tubing should be loosely coiled on the bed
- Observe for tidaling in the water seal chamber, this is rising and falling of water in response to ventilation, if not occurring suspect blockage or lung re-expansion.
- If there is increased bubbling suspect air leak.
Nursing considerations for patients:
- Pain, chest drains are uncomfortable, assess and treat accordingly
- Vital signs to be monitored.
- Infection risk at site of insertion, change dressings using aseptic technique
- Auscultate lung fields to assess for changes
- Educate patient to breathe deeply, and use tools such as incentive spirometry
Other great info on chest drains:
Shackell, E., & Gillespie, M. (2009). The oxygen supply framework: A tool to support integrative learning. Canadian Association of Critical Care Nurses. 20(4), 15-19. Retrieved October 7 2016 from http://www.caccn.ca/
Mathers, D. (2010). Nursing management: Lower respiratory problems. In D. Brown & H. Edwards (Eds.), Lewis’s medical-surgical nursing: Assessment and management of clinical problems (pp.521-559). Sydney, Australia: Mosby Elsevier.