Atelectasis, PE, Pneumothoracies, Flail chest

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What is flail chest the result of?

Double fractures of three or more adjacent ribs


What happens to the ribs during inspiration?

they cave in as a result of the generated sub-atmospheric intrapleural pressure


Is Flail chest restrictive or obstructive?



What are some major pathologic changes that result from flail chest?

  • Lung volume restriction
  • Lung contusion (from trauma
  • Secondary Pna (from weak cough due to pain)

How can someone get flail chest?

  • MVA
  • Falls
  • blast injury
  • direct compression by a heavy object
  • occupational/industrial accidents

How do you manage Mild Flail chest?

  • Analgesia
  • Routine bronchial hygiene

How do you manage Severe Flail chest?

  • Stabilization of the chest (allow bones to heal)
  • Mechanical Ventilation (w/ PEEP to stabilize)
  • Paralytics (help control breathing/fighting the vent)

How many days on mechanical ventilation is sufficient for bone healing to occur?

5-10 days


Why is O2 therapy used for flail chest?

  • To treat hypoxemia
  • Decrease WOB
  • Decrease myocardial work load

What would cause a patient to not respond to O2 therapy? (refractory hypoxemia)

Capillary shunting and alveolar atelectasis caused by the disorder


Why is lung expansion therapy used to treat flail chest?

to prevent alveolar consolidation and atelectasis


When would mechanical ventilation be needed for a patient with flail chest?

  • To maintain adequate ventilatory status
  • When a pt presents with Acute ventilatory failure
  • to overcome refractory hypoxemia (using PEEP)

What settings would you use on the vent to treat flail chest?

A/C or SIMV with PEEP


What mechanical ventilation intervention would be needed for a patient who continues to decline with flail chest?



When would independent lung ventilation be necessary with a flail chest patient?

Only for patients with severe unilateral contusion when there is severe shunting or cross-over bleeding affecting the good lung


What would fractured lower (floating ribs) put the patient at risk of?

  • Diaphragmatic tears
  • trauma to the Liver or spleen

How would you appropriately diagnose injuries caused by broken floating ribs?

Abdominal ultrasound or CT scan


What are common clinical signs seen in patients with flail chest?

  • tachypnea
  • hypoxemia
  • Tachycardia
  • cyanosis

Describe paradoxical movement of the chest wall?

  • on Insp. fractured ribs are pushed inward
  • on Exp. the flail area bulges outward

How does the abnormal chest/lung movement affect gas exchange?

Causes gas to be shunted away from one lung to another (pendelluft)


What problems does pendelluft cause the patient?

  • pt will re-breathe dead space gas
  • leads to lung compression, atelectasis, and decreased V/Q ratio leading to intrapulm. shunting and venous admixture

What are common Chest assessment findings with flail chest?

  • Diminished breath sounds on both affected and unaffected sides

What are common CXR findings with flail chest?

  • Increased opacity (White) in atelectatic areas
  • Rib fractures
  • density in affected lung may be more white

What would a PFT look like in a flail chest patient?

  • Restrictive
  • all Lung volumes and capacities are reduced

What would an ABG look like if a patient has Mild to Moderate Flail chest?

Acute Respiratory Alkalosis w/ hypoxemia


What would an ABG look like if a patient has Severe Flail chest?

Acute Respiratory Acidosis w/ hypoxemia


What are some blood tests recommended with flail chest patients?

  • CBC
  • Hct, Hgb (will be low if pt is bleeding)
  • Coagulation

What is a pneumothorax?

Gas that enters the pleural space which can lead to the separation of the visceral and parietal pleura


What is a closed pneumothorax?

Gas in the pleural space that is not in direct contact with the atmosphere


What is an open pneumothorax?

The pleural space is in direct contact with the atmosphere such that the gas can move freely in and out


What is a tension pneumothorax?

the opening to the pleural space in the lung acts as a one-way valve, permitting air to enter the space but not exit. Trapped air increases pressure on the mediastinum to the unaffected side and pressure compresses the heart decreasing Cardiac output


What can cause a pneumothorax?

  • Traumatic pneumo
  • Spontaneous Pneumo
  • Iatrogenic pneumo

Which is more critical an open or closed pneumothorax?



What can cause a spontaneous pneumo?

  • previous trauma
  • ruptured bleb between the visceral pleura (usually upper lobe) causing air to escape into the chest cavity

What patients are at higher risk of developing a spontaneous pneumo?

  • tall, thin males (15-35 y/old)
  • COPD pts due to bullous disease or bleb rupture

What can cause a traumatic pneumo?

  • broken ribs (MVA)
  • Puncture wounds (stab, bullet)

What can cause an iatrogenic pneumo?

  • Dignostic therapy/procedures
  • Needle biopsy
  • thoracentesis
  • PPV (esp w/ high volumes or pressures)

How is the negative pull on the lung lost in a patient with a pneumo?

Gas enters the lungs through perforation (or gas-forming microorganisms in empyema) enter the pleural space and the negative pressure becomes atmospheric


How is a tension pneumo treated?

pressure is relieved from the pleural space by a needle insertion into the 2nd or 3rd intercostal space


What are some signs and symptoms of a pneumothorax?

  • Chest pain
  • dyspnea
  • decreased/absent BS over affected lung
  • Hyperresonant percussion over affected lung
  • Asymmetric chest excursion
  • tachypnea (severe)
  • cyanosis (severe)

What gives a definite diagnosis of a pneumothorax?

Chest x-ray


What are some common CXR findings with a pneumo?

  • hyperlucency
  • Heart, trachea & mediastinum to unaffected side
  • lung collapse
  • atelectasis
  • depressed diaphragm

What will a PFT show with a pneumothorax?

  • Restrictive disorder
  • Everything decreased

What will an ABG look like with a small pneumo?

Acute Resp. Alkalosis


What will an ABG look like with a large pneumo?

Acute Resp Acidosis


When is it a good idea to perform a needle aspiration?

immediately if a tension pneumo is suspected


What should the negative pressure suction not exceed when using a chest tube?

  • 12 cmH2O
  • It usually only takes 5 cmH2O

What is the procedure after a lung has re-expanded and the bubbling in the chest tube has stopped?

Clamp the tube and leave it placed for 24-48 hours and then remove it


Why is oxygen therapy used in treating a pneumo?

  • low saturation
  • treat hypoxemia, WOB, and to decrease myocardial workload

What is a pleural effusion?

Excessive fluid in the pleural space


What is Empyema?

The accumulation of pus in the pleural cavity


What is a chylothorax?

The presence of chyle in the pleural cavity?


What is chyle?

A milky liquid produced from the food in the small intestine during digestion


What is a hemothorax?

presence of blood in the pleural space


How does a pleural effusion develop?

Fluid accumulates in the pleural space as a result of an imbalance between the formation of the fluid and how much is absorbed (increased fluid or decreased absorption)


How does a transudative pleural effusion develop?

  • fluid from the pulm. capillaries moves into the pleural space. (imbalance btwn trans capillary pressure and plasma oncotic pressure)
  • Thin/watery; contains few blood cells and little protein

What medical conditions can contribute to transudative pleural effusions?

  • CHF
  • cirrhosis of the liver
  • kidney disease
  • nephrotic syndrome
  • Pulm. embolism

How does an exudative pleural effusion develop?

  • develops when the pleural surfaces are diseased (increased capillary permeability; inflammation)
  • has a high protein content and large amounts of cellular debris

What medical conditions can contribute to an exudative pleural effusion?

  • Infection
  • Trauma
  • Surgery
  • Tumor
  • Pulm. edema

How are transudative and exudative pleural effusions differentiated?

  • Comparing the chemistries of the pleural fluid with those of the blood

When is a PE considered to be exudative?

(One or more of the following)

  • Pleural fluid protein >2.9 g/dL
  • Pleural fluid cholesterol >45 mg/dL
  • Pleural fluid lactate dehydrogenase >60% of upper limit for serum

What is the most common cause of pleural effusion?

CHF: both left and right sided Heart failure


How does left sided HF contribute to a pleural effusion?

  • decreases the rate of pleural fluid absorption through the visceral pleura
  • fluid movement through the visceral pleura into the pleural space

How does right sided HF contribute to a pleural effusion?

  • Increases the hydrostatic pressure in the systemic circulation which increases the rate of pleural fluid formation.
  • decreases the lymphatic drainage from the pleural space

What is a hepatic hydrothorax?

  • pleural effusion (>500 mL), in patients with cirrhosis and without primary cardiac, pulm. or pleural disease
  • Very hard to manage

What side does hepatic hydrothorax usually present itself, and why?

  • Right side
  • liver location

How are pleural effusions and empyema treated?

  • Drain fluid by thoracentesis
  • chest tube drainage in chronic cases and with large PE's
  • Supplimental O2 as needed for hypoxemia

What are some clinical assessments of a patient with pleural effusions?

  • Tachypnea (may lead to increased ventilatory rate)
  • Increased HR and BP
  • Pleuritic Chest Pain
  • Cyanosis, cry cough
  • Tracheal shift

What does auscultation/palpation usually present with PE's?

  • Decreased tactile/vocal fremitus
  • Dull percussion
  • Dim BS
  • Pleural friction rub

What are common CXR finding with PE's?

  • Blunting or costophrenic angles
  • Fluid level on affected side
  • depressed diphragm
  • mediastinal shift to unaffected side
  • Atelectasis
  • Meniscus sign

What does a PFT show for PE's?

Restrictive disease


What does an ABG look like with a small PE?

Acute Resp. Alkalosis


What does an ABG look like with a large PE?

Acute Resp Acidosis


What is atelectasis?

Partial or complete collapse of alveoli(us)


What lobes can be involved with atelectasis?

  • Small localized areas
  • a lobe
  • or entire lung

What is absorption atelectasis and how can it be caused?

  • prevent gas flow and air from reaching the alveoli for gas exchange
  • obstructions or high concentrations of O2

What are some common obstructions that can cause atelectasis?

  • mucus plugs
  • secretions
  • tumors
  • aspiration of something

How can a loss of negative pressure cause atelectasis?

any condition that results in a loss of this pressure causes the lung to collapse


What are some examples of loss of negative pressure causing atelectasis?

pneumothorax and pleural effusion


How can a right main-stem bronchus intubation lead to atelectasis?

No gas will enter the left lung and result in no gas flow


Can deficiency or loss of surfactant cause atelectasis, why or why not?

  • Yes
  • O2 toxicity caused by high O2 concentrations can damage the alveolar type 2 cells that produce surfactant

What are some medical conditions that can lead to surfactant deficiency?

  • ARDS
  • near downing
  • premature birth

How can hypoventilation/decreased VT cause atelectasis?

people that have chest injuries/abdominal pain dont want to deep breathe


What types of patients are at risk for atelectasis caused by hypoventilation/decreased Vt?

  • thoracic surgery patients
  • high level spinal cord injuries
  • inadequate ventilator tidal volumes

How can decreased pulmonary blood flow lead to atelectasis?

if a PE is blocking blood flow to the alveoli the lungs will compensate by reducing volume to that specific area


What are some common signs and symptoms of atelectasis?

  • Asymptomatic to mild atelectasis
  • hypoxemia
  • dyspnea
  • cough
  • dull percussion note
  • late inspiratory crackles in lung base
  • Dim or absent BS
  • tracheal deviation toward affected side (severe)

What are findings seen on a CXR with atelectasis?

  • Increased density (white)
  • elevated diaphragm
  • displaced interlobar fissures
  • mediastinal shift
  • altered bronchial/carinal angles

What are common treatment strategies for atelectasis?

  • prevention of post-op atelectasis (IS or IPPB FVC >10-15 mL/kg IBW)
  • Adequate pulm hydration to prevent mucous plug and mobilize secretions
  • Treat with deep breathing (IS or IPPB)
  • O2 therapy as needed

When would you initiate CPAP if a pt has atelectasis?

if pt has hypoxemia with the use of 50-60 % O2


When would you use PEEP in a patient with atelectasis?

If they are receiving mechanical ventilation