Introduction
Respiratory compromise due to pneumothorax could occur due to various causes. Two types of pneumothorax were described: spontaneous and traumatic (Porter, 2008). The former was characteristic of young men who were otherwise healthy. Six times more young men had a primary spontaneous pneumothorax. Older men usually had the secondary variety associated with chronic respiratory illnesses like bronchitis and emphysema. The commonest was chronic obstructive pulmonary disease (Lobato et al, 2007). There could also be some other underlying disease or a problem with the mechanism of ventilation. Causative factors that had been identified included mostly respiratory illnesses. Bronchial asthma could limit the airflow leading to pneumothorax. A similar mechanism was attributed to bullous emphysema too. It could be induced by positive pressure ventilation. Infections affecting the lung-like staphylococcal pneumonia and tuberculosis could produce pneumothorax. Cystic fibrosis and Marfan’s syndrome also could have been associated with pneumothorax (Porter, 2008). Traumatic pneumothorax following a chest injury has a high mortality rate. This variety is being discussed in this paper.
A 19-year-old male presented to the emergency department with extreme shortness of breath and chest pain. Having been involved in a motorbike accident, he sustained bruising to his left chest. Complaining of pain in that area and difficulty in breathing, he was pale, perspiring and generally unwell with a blood pressure of 90/50 and a heart rate of 120 beats a minute in sinus tachycardia. Chest X-ray showed a left flail chest as well as a large pneumothorax in the left lung. An intercostal catheter was inserted in the emergency department. When transferred into the intensive care unit, he became confused and disoriented with a respiratory rate of 44 breaths a minute. His condition deteriorated rapidly. Following immediate intervention and management, he was intubated and placed on mechanical ventilation.
Clinical presentation of pneumothorax and flail chest
The history and physical examination corroborated by radiological investigations provided the grounds for a diagnosis of pneumothorax (Rankine et al, 2000). The clinical presentation varied according to the causes. The comorbidities that the patient already suffered from also influenced the clinical features (Lobato et al, 2007). Typically there was a sudden onset of symptoms with severe chest pain, the difficulty of breathing which progressed and accompanying cough (Porter, 2008). Physical examination revealed lesser respiratory excursion on the involved left side. Percussion exhibited an exaggerated resonance. Lesser breath sounds were found through auscultation and their absence over the apex of the lung was significant (Porter, 2008). Pleuritic chest pain though a feature of traumatic pneumothorax became usually masked by other, perhaps greater, injuries. A blowing or sucking wound would be found on the chest. The accompanying flail chest occurred due to multiple rib fractures. The respiratory functions were severely affected in such an eventuality.
The flail portion moved in and out in correspondence with inspiration and expiration (Lobato et al, 2007). Flail chest had a high mortality rate and was accompanied by long-term pain with disability (Marasco et al, 2009). Some patients developed a paradoxical movement of the chest wall compromising respiration severely. This condition required “internal pneumatic splinting”. Mechanical ventilation was continued for long periods. The outcomes could include intermittent chronic pain preventing the patient from returning to work. The movement of the chest wall was restricted and subsequent deformity was expected. Tension pneumothorax was accompanied by extreme hypotension causing the patient to be semi-conscious. Physical examination showed prominent neck veins. The trachea has deviated. Percussion showed hyper resonance on the left side. Clinical features of other underlying co-morbidities needed to be watched for. Subcutaneous emphysema was another possible development.
The 19 years old patient who arrived after a motorbike accident had the typical features of chest pain in the area of hit and shortness of breath. The pallor, perspiration, the general feeling of being unwell, the hypotension and the sinus tachycardia could be attributed to a developing tension pneumothorax. With the history of the accident, the possibilities of internal bleeding also needed to be excluded. Lung markings were not detected in the Chest X-ray. This confirmed the diagnosis of a left-sided, large pneumothorax and a flail chest on the same side.
Clinical diagnosis: This boy had tension pneumothorax with flail chest and multiple fractures of the ribs following a blunt trauma for which he was subjected to intercostal catheterization, endotracheal intubation and intermittent positive pressure ventilation.
The physiological relationship between the pneumothorax, flail chest and his deteriorating respiratory condition – including the key issues of oxygenation at a cellular level.
The pleural space between the parietal pleura (against the chest wall) and the visceral pleura (lining the lung) normally contained fluid. The elastic property of the lung and chest wall caused the lung to move inwards and the chest wall to move outwards causing a negative subatmospheric pressure in the space (Rankine et al, 2000). This negative pressure sucked the air from the atmosphere if the pleural space was interrupted. Air had entered the boy’s pleural cavity and the lung had recoiled and collapsed. Air could enter the pleural space in a variety of ways depending on the cause of the pneumothorax. In trauma, the causes were chest wall damage and rib fractures (Rankine et al, 2000).
Had the hole in the pleura been small, it would have closed by itself and the re-expansion of the lung would have occurred. However, with a large opening, the hole started acting like a valve. During inspiration, the air had entered but had failed to escape during expiration causing trapping of air. The pneumothorax enlarged progressively and the collapsed lung remained so. The enlarging pneumothorax pushed the heart to one side also displacing the great vessels. This was leading to tension pneumothorax. The flail chest added to the severe pain. It was also moving with the movement of the chest. There could have been a paradoxical movement of the flail chest. This tension pneumothorax was an emergency. The boy’ respiratory distress was not relieved by the intercostal catheter. The tension pneumothorax was progressing and more had to be done to save the patient.
The blood gas analysis had indicated a reduction of PaO2 to critical levels. The next step would be the rise in PaCO2. Simple needle aspiration could relieve only small spontaneous pneumothoraces. Complications seen were “local emphysema, vasovagal reactions, catheter kinking, dislodgement and empyema” (Yazkan and Han). Due to his deteriorating condition, the boy was admitted to the ICU where his disorientation, confusion and tachypnoea became worse. The intercostal catheter was usually placed by the axillary method. The posteroapical or anterior approach also was common (Yazkan and Han, 2010). Trauma to the chest and viscera of the abdomen, wrong placement of the tube, empyema, bronchopleural fistula were seen rarely as complications. Other possible complications included perforation of the internal mammary artery, pulmonary edema and lung infarction (Kelly, A.M., 2007). The intercostal catheter placed in the emergency room was insufficient to correct his pneumothorax. Pleural catheters of small-bore also could be used. Pulmonary edema occurring with the re-expansion was a potentially fatal complication. The cost and hospital were the same for both the intercostal catheter and the pleural catheter (Liu, 2003).
Possible complications of his presenting condition, the most likely mode of mechanical ventilation that will be used to manage his condition and critical analysis of the mode of ventilation in relation to this presentation.
Tension pneumothorax could cause collapse due to hemodynamic compromise (Greenberg, 2005). If treatment was not offered, death could follow. Persistent pneumothorax could result. Laceration of the lung was another possible complication. Intercostal nerves or vessels could be injured. Empyema could result from the trauma or inaccurate placement of the intercostal catheter (Greenberg, 2005).
The boy was immediately intubated and mechanically ventilated. This was the usual treatment administered in the US. Internal stabilization was possible by endotracheal intubation. Patients who had flail chests were provided critical care (Gunduz, 2005). More than 40 years had passed when mechanical ventilation ruled the roost (Rodriguez, 1990). Mechanical ventilation if prolonged produced complications like lung injury. Pneumonia occurring as a hospital-acquired infection would be another complication that could end fatally (Cross, 1981). Major atelectasis also could occur. Epidural analgesia and sufficient oxygenation had been indicated by Trinkle et al (1975). Recently non-invasive positive pressure ventilation had been proposed. The boy in this case could have had CPAP (continuous positive airway pressure) through a mask because he had trauma to the chest wall and was hypoxic in addition (Boundain 2002). However, he was most likely given intermittent positive pressure ventilation as he was intubated endotracheally. Endotracheal intubation further improved oxygenation and pulmonary function.
A pulmonary function could be affected by the pain from the rib fractures. Effective pain management was critical for this patient. It permitted proper inspiration. The secretions also could be removed easily. The two techniques of epidural analgesia and the patient-controlled analgesia did not have differences in the outcomes like duration of hospital stay or intensive care or pulmonary complications. Organ failure had also not been reported (Wu, CL, 1999). Within the first two hours of admission, the Thoracic Traumatic Severity Score (25 point score) could have been used for determining the extent of injuries but this case had been excluded as he was very much compromised in his respiratory functions (Pape, 2000). Pneumonia, sepsis and septic shock, which were complications, influenced the mortality rates.
CPAP did not improve the PO2 as did the IPPV. Gunduz et al suggested CPAP as the first step in the management of flail chest caused by blunt trauma (2005). However later their effects had been considered similar. Patients with CPAP produced lesser oxygenation. The pain was supposed to be the cause of this. Analgesia was considered very significant in the management of the flail chest.
Discussion and critical analysis of the nursing and interdisciplinary assessment and diagnosis for this patient’s presentation.
Trauma could be due to a blunt instrument or surface or a penetrating injury. Differences between the two were clear. In a blunt injury, the large energy transfer to the body caused drastic complications. In the thoracic region, rupture of the alveoli and bronchial tears were injuries occurring to the respiratory system (Lobato et al, 2007). Laceration of the oesophagus was another injury possible. There was no indication whether this esophagus injury was ruled out in this case.
The bruise on the chest could be attributed to a blunt injury. It was also not known whether a high velocity or low-velocity injury had occurred. The type of injury could have indicated the extent of injuries to look out for. The fracture of multiple ribs or the flail chest could have caused injuries to the soft tissue, the pleura, bone and blood vessels. No mention was made of soft tissue injuries. Penetrating trauma could be due to injuries caused at low or high velocity. The low-velocity ones could cause injuries that were anatomically affected. The high-velocity ones could cause distant injuries due to the sudden shock (Lobato et al, 2007). There was a probability of this boy going into shock as he was hypotensive with tachycardia, perspiring and becoming disoriented. The chest wall was not affected in the closed variety of traumatic pneumothorax. The pneumothorax if an open variety could communicate with the atmosphere. Open pneumothorax could be expected in this case as the pneumothorax was large and progressing. Tension pneumothorax was an emergency situation where immediate measures for relieving the tension had to be taken. In hemothorax, blood and air would have been found in the pleural space (Lobato et al, 2007).
Thoracic ultra-sound had been recommended for the detection of pneumothorax over the chest X-ray in the AP position as it was more sensitive. The absence of “pleural sliding and comet-tailed artefacts (B lines)” and the presence of the lung were the findings characteristic of pneumothorax (Wilkerson and Stone, 2010). B lines were found in alveolar edema and in some normal subjects too. The movement of the lung at the border of the pneumothorax clinched the diagnosis (Linchtenstein, 2000). Imaging using a transthoracic B-mode was done. The transducer of high or low frequency was placed at the anterior and lateral chest wall (Wilkerson and Stone, 2010). The sliding movement of the two layers of pleura against each other in respiration was indicative of a normal lung. The artifacts were hyperechoic lines that began in the pleura and were limited at the outer extent, moving with respiration. The normal pattern showed physiologic “A” line artifacts.
Studies had indicated that Chest X-ray in the AP supine position was only 36 to 48 % sensitive (Rowan et al, 2002; Neff et al, 2000). Recently the CT scan had been identified as being the superior technique of imaging for pneumothorax. It had also been indicated that patients with pneumothorax which was not seen in the Chest X-ray but seen with the CT scan, were amenable to positive pressure ventilation while other patients felt a progression of their illness (Barrios et al, 2008). Occasionally patients needed to be air-lifted for further management. Then tube thoracostomy would be helpful in controlling the respiratory distress temporarily.
Critical analysis of current treatment modalities
The usual treatment of flail chest was to do internal pneumatic splinting. This was followed by mechanical ventilation which could be continued for long periods of time (Marasco, 2009). The pain would accompany the recovery period. An active management strategy had been suggested to overcome the prolonged and painful recovery for the flail chest. Different prostheses like metallic plates, Kirschner wires and pins had been used unsuccessfully. Marasco’s study investigated the safety of absorbable prostheses in fixing the broken ribs (2009). Surgery was efficiently planned by scrutinizing the CT scans. It involved reducing the fractures and keeping the bones in place. The plates were approximated to and fixed in position to the outer surface of the reduced fractures (Marasco, 2009). The paradoxical movement of the flail portion was thus controlled. Time healed the fractures and the method was considered effective. All thirteen patients had the treatment and left the hospital after being weaned from the ventilator support. Tanaka et al discussed the costs in their study (2002). Only one study used conservative management by strapping the flail segment with Elastoplast (Granetzny et al, 2005). One group of researchers classified the patients into two: those who had contusion formed one group and those without, another group (Voggenreiter et al, 1998).
They found that the presence of contusion complicated the management. All the patients benefited from surgery but those who had the contusion benefited less. Mayberry (2003) also used absorbable prostheses for the flail chest. They were used for pain in the chest due to rib fractures and deficiencies in the chest wall addition. Marasco’s prostheses were degraded by mere hydrolysis in vivo. In the body, they were metabolized into carbon dioxide and water (2009). The prostheses remained strong by 40% even after 3 months when the fractures were healed. By three years, they were totally absorbed without producing any toxicity. The advantage of these over metallic plates was that there was no associated slowing of bone healing (Viljanen, 2001). Cost-saving was associated with this method as the necessity of removing the prostheses did not arise. The complications associated with metallic plates and screws like “migration, palpability or thermal sensibility” were not associated with the absorbable prostheses (Marasco, 2009). Stress shielding was a disadvantage of metallic plates as the plates took over the weight-bearing functions and relieved the limb or part of the body from taking loads. Sufficient stimulus for bone growth was thereby not obtained. The absorbable plates also allowed the patient to have MRI imaging. Good results had been indicated by other researchers recently (Viljanen, 2001; Bell, 2006).
Conclusion
Flail chest and pneumothorax are severe complications in blunt traumatic injury. The management strategies are still controversial researchers have different opinions. Analgesic techniques are being adopted. Ventilation should not be invasive. Fluid therapy may be used sparingly as necessary. Surgical intervention may be done as indicated. The optimal management is with prostheses after surgery. The latest material used for rib fracture management is absorbable material that remains in the body without removal. Metallic plates and nails may have to be removed. Absorbable material is not removed and is metabolized in the body without causing toxicity even after 3 years. Further research needs to be done to discover newer methods of management to reduce morbidity and mortality.
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