Flail Chest Flail chest describes a situation in which a portion of the rib cage is separated from the rest of the chest wall, usually due to a severe blunt trauma, such as a serious fall or a car accident. This affected portion is unable to contribute to expansion of the lungs, which creates some obvious problems for the patient (hampered breathing) and can contribute to some not-so-obvious ones. Flail chest is a serious condition that can lead to long-term disability and even death. For a person to draw a breath, the muscles around the rib cage and the diaphragm have to move to expand the chest cavity. This creates a vacuum that is filled as air enters the lungs. If this expansion is hindered, the ability to draw air into the lungs is diminished. A flail chest is a chest in which sections of broken ribs are isolated from, and interfering with, normal chest movements. That means the chest cannot expand properly and cannot properly draw air into the lungs. This is why stabilization after blunt trauma is important. Not only are the ribs themselves in need of attention, but their condition, position and inability to function properly is causing other, potentially more serious matters that must be addressed quickly. Doctors agree that it is the potential underlying injury to the lungs, and not the flail chest segment itself, that is the most pressing and life-threatening concern. Causes Flail chest is almost always linked to severe blunt trauma, such as a serious fall or car accident, in terms of cause. But it can develop as a result of less severe impacts. There are cases of flail chest occurring as a result of bone disease or deterioration in older patients, but these are very rare. Symptoms The strict requirement for a diagnosis of flail chest—at least three ribs close together broken in two or more places—can be confirmed only by taking an x-ray. But all other significant symptoms can be observed through a simple physical exam. The most telling symptom is paradoxical movement of a portion of the chest wall—that is, the affected area draws in when the patient breathes in and the rest of the chest expands, and the affected area moves outwards as the patient exhales and the rest of the chest contracts. Paradoxical movement is an obvious sign that the portion of the chest wall is not assisting with the breathing function. Other symptoms of flail chest can include: Bruises, grazes, and/or discoloration in the chest area Telltale markings from a seat belt Chest pain Difficulty drawing breath Treatment Flail chest is identified using a chest x-ray. Doctors look for evidence in the condition of the ribs themselves, but some fractures are not easily seen. So they also look at the surrounding organs and structures. A punctured blood vessel or contusions on the lungs, for example, are solid indications of flail chest. It might be necessary to take several chest x-rays to fully examine all damage to the chest area. CT (computed tomography) scans have been found to provide very little additional useful information for initial evaluations of chest wall injuries. Treatment of flail chest has changed over the years. Doctors today have a good understanding of the secondary influence of flail chest on respiratory failure and survival, compared to the more significant influence of actual injuries to the lungs (such as pulmonary contusions) on those critical outcomes. Management of chest wall injuries is now directed more toward protecting the underlying lungs. Doctors also want to prevent the onset of pneumonia, which is the most common complication of flail chest. All patients are immediately placed on 100% oxygen using a facemask. Doctors might intubate or insert a chest tube as part of critical care. Stabilization treatment options include: Mechanical ventilation to achieve chest cavity stabilization is the standard treatment for patients with both flail chest and lung damage. This treatment has a demonstrated ability to reduce mortality rates, but the possibility of developing pneumonia increases the longer it is in place. Mechanical ventilation might also be employed in severe cases where the chest cavity is unstable and threatens to collapse, or where head or abdomen injuries require its use anyway. But for most chest flail cases that are less complicated, or do not significantly involve the lungs, it is considered unnecessary. Corrective surgery currently elicits varying opinions from doctors about its advisability. Usually it is recommended on a case-by-case basis. There are issues concerning effectiveness and timing for patients on mechanical ventilation. Patients requiring prolonged ventilation may not be good candidates for early surgical stabilization. On the other hand, patients whose dependence on the ventilator doesn’t diminish even after lung injuries begin to heal might be good surgery candidates. Analgesic pain medications are a common treatment for flail chest and other rib injuries. Opioid pain medications in high does can produce respiratory depression, especially in the elderly, although they can be helpful at lesser doses. Ideally, the patient will receive a local anesthetic medication via an epidural. Page Type: Type of Injuries You may also be interested in: Find out more about your legal options You could be eligible for compensation. Find out more about your rights. 
chest chest Also found in: Dictionary, Thesaurus, Legal, Financial, Acronyms, Idioms, Encyclopedia, Wikipedia. Related to chest: chest painchest [ chest] thorax.barrel chest a rounded, bulging chest with abnormal increase in the anteroposterior diameter,showing little movement on respiration; seen in emphysema, kyphosis, and chronic airflow limitation. Barrel chest. From Herlihy et al., 2000.flail chest see flail chest.funnel chest pectus excavatum.pigeon chest pectus carinatum.chest tube a tube inserted into the thoracic cavity for the purpose of removing air or fluid, or both. Chest tubes are attached to a closed drainage system (see illustration) so that normalpressures within the alveoli and the pleural cavity can be restored. These pressures are essential to adequate expansion and reinflation of the lung. Chest tubes are indicated when the normally airtight pleural space has been penetrated throughsurgery or trauma, when a defect in the alveoli allows air to enter the intrapleural space, andwhen there is an accumulation of fluid, as from pleural effusion. The effect of excessiveamounts of air and fluid within the pleural space is collapse of the lung and the danger of mediastinal shift. Patient Care. It is important that those responsible for the personal care of a patient who haschest tubes inserted understand the basic mechanics of inflation and deflation of the lung, and the purpose of the tubes and their location in each patient. In some cases one tube is inserted higher in the thorax (usually in the 2nd intercostal space) to remove air, and a second tube is placed lower (in the 8th or 9th intercostal space) to drain off fluids. Chest tubes may be connected to a variety of closed drainage systems: a water-sealdrainage system with one, two, or three bottles; and a self-contained system such as Pleur-evac. Whatever the type, the purpose of the system is to allow for drainage from the pleuralcavity to the outside and at the same time prevent the entry of atmospheric air into the pleuralcavity. Precautions that must be taken in the maintenance of the drainage system are: 1. The bottles and collection apparatus of the system must be kept below the level of thechest to prevent backflow. 2. The lumens of the tubes must be kept open to allow for drainage. If they are obstructedthere will be no fluctuation of the fluid level in the glass tube that is connected to the chesttube at one end and kept under water in the bottle at the other end. In the Pleur-evac, theliquid in the chamber should rise on the right side and fall on the left side. If there is evidencethat the system is not working properly, this must be attended to immediately. Occlusion of the tubes can lead to a buildup of air and fluids in the pleural cavity and creation of a tensionpneumothorax. 3. The system must be a closed (airtight) system. There can be no leaks aroundconnections, and the lower end of the glass tube must remain under water in the bottle. The amount, color, and consistency of the fluid drainage should be checked at least onceeach hour for the first 24 hours after surgery. The chest tubes should be milked and strippedevery one to two hours to assure patency and adequate drainage. The amount of air beingremoved is indicated by occasional bubbling in the water-seal chamber. Excessive bubblingmay indicate air leaks in the tubing. An important aspect of patient care is proper positioning to maintain adequate drainage. Thepositions allowed and the amount of mobility permitted will depend on the patient's surgicaldiagnosis, the placement of the tube (s), and preference of the attending physician. Frequentturning, coughing, and deep breathing are instituted on a regular basis to avoid seriouspulmonary complications. An exception to the rule of turning is the pneumonectomy patient,who is placed in high Fowler's position and not turned for at least 24 hours after surgery. Chest physical therapy and intermittent positive pressure breathing (IPPB) treatments usuallyare ordered for all patients with chest tubes. Some patients may require a ventilator duringthe immediate postoperative period. The patient is observed for signs of respiratory distress and a buildup of air and fluid within thepleural cavity. Early correction of this condition can prevent mediastinal shift. Other signalsthat demand immediate attention are persistent bubbling in the underwater seal (fluid shouldfluctuate in the tube as the patient breathes), a drainage through the tube that accumulates at a rate of more than 100 ml per hour, leakage of air at the junctions of the chest tube andtubing and bottles or self-contained unit, and a “putty” appearance caused by the leakage of air into subcutaneous tissues in the upper chest and neck. After a chest tube is removed, thewound is promptly sealed with a sterile petroleum jelly dressing to occlude the opening andprevent entry of air into the pleural space. One-, two-, and three-bottle methods for providing a closed drainage system. A, In theone-bottle system the drainage via the chest tube enters the bottle through the glass tubewhich has one end submerged under water to form a seal. This provides a one-wayvalve that prevents a backflow of air into the pleural cavity, which could collapse thelung. As fluid and air from the pleural cavity enter the drainage bottle, the air that is displaced in the bottle is vented through the short tube above water level. B, The secondbottle in the two-bottle system acts as a trap to control and decrease the amount of suction within the chest tube. Otherwise, the suction might be too forceful and damagethe pleural membrane. No drainage enters this bottle. Its only purpose is to control theforce of suction applied. C, The third bottle in the three-bottle system also is used to regulate the amount of suction. This can be done by adjusting the length of the glass tubethat is under water. Pleur-evac Ⓡ Adult/Pediatric Chest Drainage Model A-6000. The Pleur-evac Chest Drainage Systems have been the world's most popular units since theirinception in 1967. (Courtesy of Deknatel, Inc., Fall River, MA. )Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.chest ( chest ), 1. The part of the body between the neck and the abdomen, enclosed by the ribs and thesternum. See also: thorax.2. Colloquially, the anterior wall of the thorax. Synonym (s): pectus [A. S. cest, a box]Farlex Partner Medical Dictionary © Farlex 2012chest ( chest) thorax. flail chest one whose wall moves paradoxically with respiration, owing to multiple fractures of the ribs.funnel chest pectus excavatum.pigeon chest pectus carinatum. Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.chest (chĕst)n. The part of the body between the neck and the abdomen, enclosed by the ribs and thebreastbone; the thorax. The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.chest Etymology: AS, box1 See thorax.2 the outside front part of the basic thoracic structure. See also thoracic cage, thoracic cavity. Lateral chest landmarks Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.thorax The region between the neck and abdomen, which contains the heart, lungs (and thevarious veins, arteries, valves and tubules needed for their maintenance and functionality), thymusand oesophagus. Segen's Medical Dictionary. © 2012 Farlex, Inc. All rights reserved.chest Thorax A popular term for the region between the neck and abdomen, which containsthe heart and lungs plumbing and wiring. See Barrel chest, Dirty chest of Simon, Flail chest. Mc Graw-Hill Concise Dictionary of Modern Medicine. © 2002 by The Mc Graw-Hill Companies, Inc.chest ( chest) The anterior wall of the thorax. See also: thorax Synonym (s): pectus [TA]. [A. S. cest, a box]Medical Dictionary for the Health Professions and Nursing © Farlex 2012chestsee thorax, thoracic, flail chest.chest compressiona means of external cardiac massage; most likely to be effective in small dogs and cats,but very difficult in large animals.chest woundcommon in horses and cattle, damage to the underlying chest wall with communication to the pleural cavity and pneumothorax is the main danger. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved Patient discussion about chest Q. I was in the ER because of a chest pain and the doctor there said its costochondritis. What does it mean? I am a 42 years old man. Last night i went to the ER because of a chestpain. The doctors there did many test and in the end they said its costochondritis. What does it mean? Can someone elaborate about the risk factors that can cause this symptom? A. It seems that you are suffering from a traumatic injury to the skeleton that is near the heartwhich is called costochondritis. It can be a result of a simple trauma to the area or (as in my case, I am a rower) due to repetitive use of the muscles of the thorax and arms Q. I still have chest pain after 5 angioplasties/stents. Does anybody else still have thatmuch angina? A. my uncle had the same problem. went through several catheterization at several differentcardiologist (some are well known), but couldn't get this annoying pain off his chest. the weirdpart was that it didn't even reacted to effort. but eventually (i don't remember the stent amount)one of the cardiologist solved the problem. so don't give up and continue searching the cause!Q. What is the differential diagnosis of chest pain in a 35 year old woman? I am a 35 yearsold woman. I suffer from chest pain for about 24 hours. I just came back from a trip to Europe, and i feel really bad. I smoke and I take anti contraceptive and i know that I am at a risk for pulmonaryembolism or costochondritis. Cat it be something else? A. The differential diagnosis of chest pain is very wide. It can start in costochondritis if u carried a lot of luggage or might be pulmonary embolism if youdidn't move from the chair all the flight. But it can also be a sign for an acute coronary syndrome (even at the age of 35) or a pericarditis. To be sure you need to consult with your GP. More discussions about chest This content is provided by i Medix and is subject to i Medix Terms. The Questions and Answers are not endorsed or recommended and are made available by patients, not doctors. Want to thank TFD for its existence? Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content . Link to this page: Facebook Twitter  Flailupdate Flailupdate From Wikipedia (Redirected from Crook and flail)For other uses, see flail (disambiguation). A flail is an agricultural tool used for threshing to separate grains from their husks. It is usually made from two or more large sticks attached by a short chain; one stick is held and swung, causing the other to strike a pile of grain, loosening the husks. The precise dimensions and shape of flails were determined by generations of farmers to suit the particular grain they were harvesting. For example, flails used by farmers in Quebec to process wheat were generally made from two pieces of wood, the handle being about 1.5 m long by 3 cm in diameter, and the second stick being about 1 m long by about 3 cm in diameter, with a slight taper towards the end. Flails for other grains, such as rice or spelt, would have had different dimensions. Flails have generally fallen into disuse in many nations because of the availability of technologies such as combine harvesters that require much less manual labour. But in many places, such as Minnesota, wild rice can only be harvested using manual means, specifically through the use of a canoe and a flail that is made of smooth, round wood no more than 30 inches long. [1]Non-agricultural uses See also: Flail (weapon)As with most agricultural tools, flails were often used as weapons by farmers who may have lacked better weapons. The French Revolution was mostly fought with agricultural tools. The flail is proposed as one of the origins of the two-piece baton known in the kobudo weapon system as the nunchaku. The first known use of a flail as a weapon was by farmers under the leadership of Jan Žižka during the Hussite Wars in Bohemia. The flail is depicted alongside the shepherd’s “crook” as symbols of office for the crowned Egyptian Pharaoh. The flail symbolises the Pharaoh's role as provider of food for his people and the crook symbolises his role as the shepherd of his people. Both crook and flail also serve to link the Pharaoh with Osiris. Depictions of Anubis, the jackal-headed god of the embalming, also include the flail as attribute. References↑ "Minnesota Wild Rice Harvest regulations". Minnesota Department of Natural Resources. External links Antique Farm Tools Agriculture in Victorian Times Picture of one kind of rice flail"Flail". Encyclopædia Britannica (11th ed.). 1911.pdc: Fleggel  Pneumothorax (Collapsed Lung) Pneumothorax (Collapsed Lung)Health Guide More What Is It? A pneumothorax is commonly known as a collapsed lung. Normally, the outer surface of the lung sits next to the inner surface of the chest wall. The lung and the chest wall are covered by thin membranes called pleura. A collapsed lung occurs when air escapes from the lungs or leaks through the chest wall and enters the space between the two membranes (pleural cavity). As air builds up, it causes the nearby lung to collapse. A collapsed lung is most often caused by an injury to the lungs or chest wall, such as: A penetrating injury, such as a knife or gunshot wound Blunt trauma from a fall or car accident Medical procedures, such as removal of fluid from the pleural cavity with a needle (thoracentesis) or a lung biopsy Occasionally, a lung will collapse without any direct injury to the lung or chest. This is called a spontaneous pneumothorax. This is more likely to happen in people with lung disease. It is particularly common in emphysema, which causes air-filled sacs, called blebs, to form. When one of these sacs bursts, air is released into the pleural cavity, causing the lung to collapse. It also occurs in people with asthma, cystic fibrosis and pneumonia. A spontaneous pneumothorax also can develop in people who don't have any obvious lung disease. It's most common in tall, thin men between the ages of 20 and 40 and smokers. In most cases of pneumothorax, some air can move in and out through the tear in the lung or chest wall. If air can only move into the chest cavity, but not out, pressure builds up inside the pocket of trapped air. This is called a tension pneumothorax. A tension pneumothorax can cause complete collapse of the nearby lung and can push the heart and major blood vessels to the other side of the chest. This is a life-threatening emergency. Tension pneumothorax most commonly occurs in people with penetrating chest injuries. Symptoms Symptoms of a collapsed lung include: Sudden shortness of breath Painful breathing Sharp chest pain, often on one side Chest tightness Diagnosis Your doctor may suspect you have a collapsed lung if you suddenly develop shortness of breath or chest pain, especially if you have had trauma to the chest. He or she will ask about your symptoms, your medical history and your smoking habits. Your doctor will examine you, focusing on your general appearance, your vital signs (temperature, pulse, breath rate, blood pressure), and your lungs. The following signs can indicate that you have a collapsed lung: Low blood pressure Rapid heart rate Low levels of blood oxygen Loss of normal breath sounds in the part of the chest where the lung is deflated A hollow sound when the fingers are tapped on part of the chest A chest X-ray is the best way to confirm that you have a collapsed lung. The X-ray will show the collapsed lung as a dark area in the chest. A computed tomography (CT) scan may be needed to find a small collapsed area of a lung or for people with extensive lung disease. Your doctor may check the oxygen level in your blood with a handheld device called a pulse oximeter or may draw blood from an artery in the wrist (an arterial blood gas test) to directly measure the levels of oxygen and carbon dioxide in your blood. He or she also may order an electrocardiogram (EKG), an electrical test of the heart. Expected Duration Once the cause of a collapsed lung is treated, it usually will return to normal within 48 to 72 hours. Recovering from a collapsed lung may take up to several weeks. Prevention Most cases of collapsed lung cannot be prevented. Quitting smoking can reduce your risk of developing the types of lung disease associated with this problem. Wearing your seat belt in the car and avoiding other activities that put you at risk of chest injuries can help you to avoid a collapsed lung caused by trauma. Treatment A collapsed lung can be treated in several different ways. Your doctor will choose the right treatment based on several factors, including the size and location of the collapsed lung and your medical condition. Treatment options include: Careful observation by a doctor to see if the condition corrects itself on its own Removal of the air from the pleural cavity with a needle and syringe Removal of the air from the pleural cavity by inserting a hollow plastic tube, called a chest tube, between the ribs and attaching it to a suction device If you need to be admitted to the hospital for treatment, you will likely receive oxygen by nasal prongs or a mask for the first couple days. You may be treated or observed for several days to make sure the collapsed lung re-expands completely. If you have had a serious chest injury or treatment does not expand your lung, your doctor will discuss the possibility of surgery to repair the lung and pleura. Sometimes damaged or scarred portions of lung are removed to allow the collapsed lung to heal. Traditional surgery requires the chest to be opened. But newer techniques using tiny cameras (thoracoscopy) cause less scarring and result in faster recovery times. People with who keep developing a collapsed lung may need treatment to prevent it from happening again. Options include: Surgery that removes blebs or areas of scarring or attaches the lung permanently to the chest wall A chemical injection that fuses the lung and chest wall together (pleurodesis)When To Call A Professional Call your doctor if you have symptoms of a collapsed lung, especially if you have lung disease or have had a collapsed lung before. Even if your symptoms seem to improve, call your doctor. Some people with a collapsed lung notice that chest pain and shortness of breath improve in the first 24 hours, but the lung is still collapsed. Prognosis Once a collapsed lung has re-expanded and healed, there is usually no long-term effect on your health. However, up to 50% of people have a lung collapse again, especially within a few months of the first one. To decrease the risk of a second collapsed lung again: Stop smoking. Avoid changes in air pressure, such as from flying in unpressurized aircraft or scuba diving. External resources National Heart, Lung and Blood Institute (NHLBI) 6701 Rockledge Drive P. O. Box 30105 Bethesda, MD 20824-0105 Phone: (301) 592-8573 http://www.nhlbi.nih.gov/American Lung Association 1740 Broadway New York, NY 10019 Phone: (212) 315-8700 Toll-Free: (800) 586-4872 http://www.lungusa.org/Disclaimer: This content should not be considered complete and should not be used in place of a call or visit to a health professional. Use of this content is subject to specific Terms of Use & Medical Disclaimers.  pneumothorax Correct all you're your grammar errors instantly. Try it now.pneumothorax Also found in: Dictionary, Thesaurus, Acronyms, Encyclopedia, Wikipedia. Related to pneumothorax: Tension pneumothorax Pneumothorax Definition Pneumothorax is a collection of air or gas in the chest or pleural space that causes part or all of a lung to collapse. Description Normally, the pressure in the lungs is greater than the pressure in the pleural space surroundingthe lungs. However, if air enters the pleural space, the pressure in the pleura then becomesgreater than the pressure in the lungs, causing the lung to collapse partially or completely. Pneumothorax can be either spontaneous or due to trauma. If a pneumothorax occurs suddenly or for no known reason, it is called a spontaneouspneumothorax. This condition most often strikes tall, thin men between the ages of 20 to 40. In addition, people with lung disorders, such as emphysema, cystic fibrosis, and tuberculosis, are at higher risk for spontaneous pneumothorax. Traumatic pneumothorax is the result of accident or injury due to medical procedures performed to the chest cavity, such as thoracentesis or mechanical ventilation. Tension pneumothorax is a serious and potentially life-threateningcondition that may be caused by traumatic injury, chronic lung disease, or as a complication of a medical procedure. In this type of pneumothorax, air enters the chest cavity, but cannot escape. This greatly increased pressure in the pleural space causes the lung to collapse completely,compresses the heart, and pushes the heart and associated blood vessels toward the unaffectedside. Causes and symptoms The symptoms of pneumothrax depend on how much air enters the chest, how much the lungcollapses, and the extent of lung disease. Symptoms include the following, according to thecause of the pneumothorax: Spontaneous pneumothorax. Simple spontaneous pneumothorax is caused by a rupture of a small air sac or fluid-filled sac in the lung. It may be related to activity in otherwise healthypeople or may occur during scuba diving or flying at high altitudes. Complicated spontaneouspneumothorax, also generally caused by rupture of a small sac in the lung, occurs in peoplewith lung diseases. The symptoms of complicated spontaneous pneumothorax tend to be worse than those of simple pneumothorax, due to the underlying lung disease. Spontaneouspneumothorax is characterized by dull, sharp, or stabbing chest pain that begins suddenlyand becomes worse with deep breathing or coughing. Other symptoms are shortness of breath, rapid breathing, abnormal breathing movement (that is, little chest wall movementwhen breathing), and cough. Tension pneumothorax. Following trauma, air may enter the chest cavity. A penetrating chestwound allows outside air to enter the chest, causing the lung to collapse. Certain medicalprocedures performed in the chest cavity, such as thoracentesis, also may cause a lung to collapse. Tension pneumothorax may be the immediate result of an injury; the delayedcomplication of a hidden injury, such as a fractured rib, that punctures the lung; or the result of lung damage from asthma, chronic bronchitis, or emphysema. Symptoms of tensionpneumothorax tend to be severe with sudden onset. There is marked anxiety, distendedneck veins, weak pulse, decreased breath sounds on the affected side, and a shift of themediastinum to the opposite side. Diagnosis To diagnose pneumothorax, it is necessary for the health care provider to listen to the chest (auscultation) during a physical examination. By using a stethoscope, the physician may notethat one part of the chest does not transmit the normal sounds of breathing. A chest x ray willshow the air pocket and the collapsed lung. An electrocardiogram (ECG) will be performed to record the electrical impulses that control the heart's activity. Blood samples may be taken to check for the level of arterial blood gases. Treatment A small pneumothorax may resolve on its own, but most require medical treatment. The object of treatment is to remove air from the chest and allow the lung to re-expand. This is done by inserting a needle and syringe (if the pneumothorax is small) or chest tube through the chestwall. This allows the air to escape without allowing any air back in. The lung will then re-expanditself within a few days. Surgery may be needed for repeat occurrences. Prognosis Most people recover fully from spontaneous pneumothorax. Up to half of patients withspontaneous pneumothorax experience recurrence. Recovery from a collapsed lung generallytakes one to two weeks. Tension pneumothorax can cause death rapidly due to inadequateheart output or insufficient blood oxygen (hypoxemia), and must be treated as a medicalemergency. Prevention Preventive measures for a non-injury related pneumothorax include stopping smoking andseeking medical attention for respiratory problems. If the pneumothorax occurs in both lungs or more than once in the same lung, surgery may be needed to prevent it from occurring again. Key terms Electrocardiagram — A test that provides a typical record of normal heart action. Mediastinum — The space between the right and left lung. Pleural — Pleural refers to the pleura or membrane that enfolds the lungs. Thoracentesis — Also called a pleural fluid tap, this procedure involves aspiration of fluid fromthe pleural space using a long, thin needle inserted between the ribs. Resources Organizations American Association for Respiratory Care. 11030 Ables Lane, Dallas, Texas 75229. (972) 243-2272. http://www.aarc.org. American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872.http://www.lungusa.org. Other"Spontaneous Pneumothorax." Health Answers.com. http://www.healthanswers.com. Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.pneumothorax [ noo″mo-thor´aks] accumulation of air or gas in the pleural cavity, resulting in collapse of the lung on the affected side. The condition may occur spontaneously (spontaneous pneumothorax), as in the course of a pulmonary disease, or it may follow perforating trauma to the chest wall or lung parenchyma (traumatic or open pneumothorax). Spontaneous Pneumothorax. This condition occurs when there is an opening on the surface of thelung allowing leakage of air from the airways or lung parenchyma into the pleural cavity. Mostoften it occurs when an emphysematous bulla or other weakened area on the lung ruptures. Normally the pleural cavity is an airtight compartment with a negative pressure. When air entersthe pleural cavity the lung collapses, producing shortness of breath and mediastinal shift towardthe unaffected side (see also mediastinal shift ). Other signs and symptoms are a sudden sharpchest pain, fall in blood pressure, weak and rapid pulse, and cessation of normal respiratorymovements on the affected side of the chest. A small spontaneous pneumothorax may require no specific treatment beyond rest andadministration of oxygen for relief of dyspnea. Chest x-rays should be obtained. The patientusually is more comfortable if allowed to sit up. A larger spontaneous pneumothorax may require a more aggressive approach such as aspiration to allow for reexpansion of the lung. If aircontinues to leak from the defect in the lung surface a continuous closed-drainage apparatus is set up (see chest tube ). As soon as the lung lesion heals and the lung is reexpanded, the patient is allowed to resume usual daily activities. Guidelines for the treatment of spontaneouspneumothorax have been published by the American College of Chest Physicians and areavailable on their web site at http://www.chestnet.org. Tension pneumothorax. This is a particularly dangerous form that occurs when air escapes intothe pleural cavity from a bronchus but cannot regain entry into the bronchus. As a result,continuously increasing air pressure in the pleural cavity causes progressive collapse of the lungtissue. Emergency aspiration of air from the pleural cavity is necessary in this disorder. If untreated, increased pressure within the pleural cavity will cause lung collapse and mediastinal shift. Pneumothorax. Air within the pleural cavity has entered some of the spacenormally occupied by the lung, thus preventing its expansion and causing partialcollapse. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.pneu·mo·thor·ax ( nū'mō-thōr'aks ), The presence of free air or gas in the pleural cavity. [G. pneuma, air, + thorax]Farlex Partner Medical Dictionary © Farlex 2012pneumothorax/pneu·mo·tho·rax/ ( -thor´aks) air or gas in the pleural space, usually as a result of trauma (traumatic or open p.) or some pathological process.tension p. pneumothorax in which the pressure within the pleural space is greater thanatmospheric pressure; as a result, the mediastinum is displaced to one side, which interfereswith breathing. Tension pneumothorax. Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.pneumothorax (no͞o′mō-thôr′ăks′, nyo͞o′-)n. Accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or sometimes induced to collapse the lung in the treatment of tuberculosis and other lungdiseases. The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.pneumothorax [no̅o̅′mōthôr′aks]Etymology: Gk, pneuma, air, thorax, chestthe presence of air or gas in the pleural space, causing a lung to collapse. Pneumothorax may be the result of an open chest wound that permits the entrance of air, the rupture of an emphysematous vesicle on the surface of the lung, or a severe bout of coughing. It may alsooccur spontaneously without apparent cause.observations The onset of pneumothorax is accompanied by a sudden sharp chest pain,followed by difficult, rapid breathing; decreased breath sounds and cessation of normal chestmovements on the affected side; tachycardia; a weak pulse; hypotension; diaphoresis; an elevated temperature; pallor; dizziness; and anxiety.interventions The patient is assured that the condition can be treated, is urged to remainstill, and is placed in bed in Fowler's position. Oxygen is administered through a nasalcannula, unless contraindicated, and the air in the pleural space is immediately aspirated. A chest tube is inserted and attached to an underwater seal; a waterless, disposable system; or a mobile chest drain; the tube is not removed until air is no longer expelled through the sealand a radiographic examination shows that the lung is completely expanded. Pain may be controlled by administering appropriate analgesics, but the use of respiratory depressants is avoided. Intermittent positive-pressure breathing may be administered.nursing considerations The patient is taught how to turn, cough, breathe deeply, andperform passive exercises and is told to avoid stretching, reaching, or making suddenmovements. The patient is advised not to smoke but to drink fluids copiously, to exercise, to avoid fatigue and strenuous activity, and to report any symptoms of recurrence, such as chestpain, difficult breathing, fever, or respiratory infection. Pneumothorax Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.pneumothorax Lung collapse Pulmology The presence of air in the pleural space, whichmay be 1º–seen in tall, thin, young ♂, characterized by subpleural apical blebs, 2º–asthma, COPD,PCP, trauma, TB, iatrogenic–due to thoracentesis, subclavian line placement, PEEP, bronchoscopy Clinical Pleural pain, dyspnea, ↓ breath sounds, percussion hyperresonance, ↓ tactile fremitus Management Small blebs may heal spontaneously, larger pneumothoraces require chest tubedrainage, pleurodesis. See Spontaneous pneumothorax. Mc Graw-Hill Concise Dictionary of Modern Medicine. © 2002 by The Mc Graw-Hill Companies, Inc.pneu·mo·thor·ax ( nū'mō-thōr'aks) The presence of air or gas in the pleural cavity. [G. pneuma, air, + thorax]Medical Dictionary for the Health Professions and Nursing © Farlex 2012pneumothorax (noo?mo-thor'aks?, nu?) (-thor'a-sez?)plural. pneumothoraces plural. pneumothoraxes [ pneum- + thorax] PNEUMOTHORAXPNEUMOTHORAXPNEUMOTHORAXA collection of air or gas in the pleural cavity. The gas enters following a perforation throughthe chest wall, e.g., due to traumatic or iatrogenic injury, or the pleura, e.g., from therupture of an emphysematous bleb or superficiallung abscess. Some tall, slender young menand women suffer repeated episodes of spontaneous pneumothorax. illustration;Symptoms The onset is sudden, usually with a severesharp pain in the side of the chest, anddyspnea. The physical signs are those of a distended unilateral chest, increased resonance,decrease in or absence of breath sounds, and, if fluid is present, a splashing sound on succussion (shaking) of the patient. Patientsoften report chest pain is worsened by coughing,deep breathing, or movement. Diagnosis Chest x-rays confirm the diagnosis, revealing air in the pleural space, often identified as a lineseen outlining a partially collapsed lung. A shift of the mediastinum toward one side of the chest or the other may be seen in tensionpneumothorax. See: tension pneumothorax Treatment Treatment varies according to type and amount of lung collapse. Traumatic or iatrogenicpneumothorax requires chest tube insertion to closed (water-sealed) chest drainage for lung re-expansion. Surgical repair also may be required. Spontaneous pneumothorax may be treatedconservatively with bedrest if there is no sign of increased pleural pressure, less than 15% lungcollapse, no dyspnea or other indication of physiological compromise. If the patient'scondition worsens or if more than 15% of thelung is collapsed, a thoracostomy tube may be placed anteriorly in the second intercostal spaceand attached to a Heimlich flutter valve or chest-drainage unit. If fluid is present in the pleuralspace, a thoracostomy tube is placed in thefourth, fifth, or sixth intercostal space moreposteriorly to drain it. Patient care The patient's vital signs, chest expansion,oximetry and/or blood gases are monitored andoxygen administered to prevent hypoxia. Thepurpose and process for placing a chest tubeare explained to the patient to allay anxiety andfoster cooperation with the procedure. After thesurgeon prepares and drapes the patient in sterile fashion, and administers localanesthesia, a small incision is made. A thoracostomy tube is attached to a water-sealeddrainage device. The patient is placed in thesemi-Fowler position to promote drainage,comfort, and ease of breathing. Vital signs andventilatory status are monitored. Once the tube is placed, deep breathing (incentive spirometry)and coughing are encouraged (at least hourly) to promote lung expansion, with prescribedanalgesics provided to control pain anddiscomfort (due in part to the tube itself). Ambulation is encouraged to facilitate fullinspiration and enhance lung expansion. Thethoracostomy tube site is kept sealed, generally by using a purse-string suture and occlusivedressing. Care is taken to avoid tension on thetubing, and all connections also are sealed to avoid air leaks. If the tube is accidentallydislodged, an occlusive (petroleum gauze)dressing is placed over the opening immediately to prevent lung collapse. When chest x-raydemonstrates adequate lung re-expansion thatremains stable without suction, thethoracostomy tube is carefully removed, and theincision is covered with an occlusive dressing. The importance of follow-up examination, x-ray,and any needed care is explained prior to discharge. Patients who smoke are urged to stop smoking and exercise is increasedgradually as determined by follow-up evaluation.artificial pneumothorax An intentionally and artificially induced pneumothorax, used to facilitate transcutaneous mediastinalbiopsy and, infrequently, to treat pulmonary tuberculosis and pneumonia. Pneumothorax allows thediseased lung to rest temporarily. The lung collapses when the air enters the pleural space. Scattered adhesions may afford only a partial collapse. Effusion may occur in about one third of thecases. Hazards include pain, infection, and respiratory distress.catamenial pneumothorax Pneumothorax that occurs during menses and resulting from endometrial implants in the chest, e.g.along the diaphragm or in the pleural space.extrapleural pneumothorax The formation of a pneumothorax by introducing air into the space between the pleura and the inside of the rib cage.occult pneumothorax A pneumothorax that is not detected by physical examination of the patient or by plain x-rays but is identified instead by other means, usually a CT scan of the chest and abdomen. The condition may be life-threatening.open pneumothorax A pneumothorax in which the pleural cavity is exposed to the atmosphere through an open wound in the chest wall.spontaneous pneumothorax The spontaneous entrance of air into the pleural cavity. The pressure may collapse the lung anddisplace the mediastinum away from the side of the lesion. Symptoms Although some patients with pneumothorax have few symptoms, most people who come to clinicalattention report the sudden onset of left- or right-sided chest pain, often accompanied by shortness of breath. Breath sounds may be absent on the affected side, or the lung percussion note on thatside may reveal increased resonance.tension pneumothorax A type of pneumothorax in which air can enter the pleural space but cannot escape via the route of entry. This leads to increased pressure in the pleural space, resulting in lung collapse. The increase in pressure also compresses the heart and vena cavae, which impairs circulation. Patient care The patient is assessed for evidence of respiratory failure or the need for immediate intervention. Thedevelopment of tension pneumothorax is a medical emergency; if it is not promptly relieved, thepatient will experience inadequate cardiac output and hypoxemia (and may die). To prevent rapiddecompensation, a large-bore needle is inserted emergently into the pleural space at the secondintercostal space, mid-clavicular line (needle decompression, needle thoracotomy). This temporizingprocedure must be followed by thoracostomy tube placement and water-sealed chest drainage unit. Medical Dictionary, © 2009 Farlex and Partnerspneumothorax The presence of air in the normally potential space between the twolayers of the PLEURA (the pleural cavity). This may occur spontaneously from the rupture of a CONGENITAL bleb on the inner layer, or may result from air access from the outside through a wound. Pneumothorax causes the collapse of the lung on the same side. In minor cases there is recovery without treatment, but the air may have to be withdrawn through a tube. Collins Dictionary of Medicine © Robert M. Youngson 2004, 2005pneumothoraxair in the pleural cavity, between the chest wall and the lungs, either by escape from damaged lungs or by entry from outside with a penetrating injury. Causes compression of lung tissue and potentially respiratory distress. Can occur spontaneously, especially in theyoung, as a complication of lung disease or in sport, most commonly as a result of direct trauma. May also occur by barotrauma in scuba diving and flying at altitude. Symptoms include sharpchest pain and shortness of breath. Diagnosis is clinical, confirmed by chest X-ray. If small, usuallyheals spontaneously but if larger and symptomatic may require the use of a chest drain to re-expand the lung. If recurrent, may require surgery. Dictionary of Sport and Exercise Science and Medicine by Churchill Livingstone © 2008 Elsevier Limited. All rights reserved.pneumothorax (nōōˈ·mō·thōˑ·raks),n an abnormal condition characterized by the buildup of air within the space between thelungs and the chest wall; as a result, the lung is unable to expand properly during respirationand eventually collapses because of the increased pressure. Symptoms include chest painand shortness of breath; although rare, it is a potential complication of acupuncturetreatments. Jonas: Mosby's Dictionary of Complementary and Alternative Medicine. (c) 2005, Elsevier.pneu·mo·thor·ax ( nū'mō-thōr'aks) Presence of free air or gas in pleural cavity. [G. pneuma, air, + thorax]Medical Dictionary for the Dental Professions © Farlex 2012pneumothorax (noo´mōthôr´aks),n an accumulation of air or gas in the pleural cavity. The air enters by way of an externalwound, a lung perforation, a burrowing abscess, or rupture of a superficial lung cavity. It is accompanied by sudden, severe pain and rapidly increasing dyspnea. Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc. All rights reserved.pneumothoraxentry of air into the pleural cavity in sufficient quantity to cause collapse of the lung andconsequent respiratory embarrassment. If it is unilateral there is a mediastinal shift withdisplacement of the heart to the other side of the chest. Breath sounds are absent from theaffected side. Pneumothorax. By permission from Ettinger SJ,Feldman E, Textbook of Veterinary Internal Medicine, Saunders, 2004closed pneumothoraxair leaks from a discontinuity in the lung into the pleural cavity.false pneumothoraxartifactual increased radiolucency of the thorax resembling free air in the pleural cavity.iatrogenic pneumothoraxmay occur following intrathoracic surgery or in association with procedures which involveentry into the pleural cavity, such as thoracentesis or placement of a chest drain.open pneumothoraxcaused by an open wound in the chest wall.spontaneous pneumothoraxdue to an unknown cause.tension pneumothoraxa particularly dangerous form of pneumothorax that occurs when air escapes into thepleural cavity from a bronchus but cannot regain entry into the bronchus. As a result,continuously increasing air pressure in the pleural cavity causes progressive collapse of the lung tissue. If not relieved, it can lead to lung collapse and mediastinal shift. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved Want to thank TFD for its existence? Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content . Link to this page:<a href="https://medical-dictionary.thefreedictionary.com/pneumothorax">pneumothorax</a>Facebook Twitter Finally, Farlex brings you all the rules of English grammar, all in one place, explained in simple terms. The Farlex Grammar Bookis available now in paperback and e Book formats.  flail flail Also found in: Thesaurus, Medical, Legal, Acronyms, Idioms, Encyclopedia, Wikipedia. Related to flail: flail chestflail (flāl)n. A manual threshing device consisting of a long wooden handle or staff and a shorter, free-swinging stick attached to its end.v. flailed, flail·ing, flailsv. tr.1. To beat or strike with or as if with a flail: flailed our horses with the reins.2. To wave or swing vigorously; thrash: flailed my arms to get their attention.3. To thresh using a flail.v. intr.1. To move vigorously or erratically; thrash about: arms flailing helplessly in the water.2. To strike or lash out violently: boxers flailing at each other in the ring.3. To make energetic but aimless or or ineffectual efforts: "As the end of law schoolapproached, Hill flailed briefly in numerous professional directions" (Molly Worthen).4. To thresh grain. [Middle English, from Old English flegil and from Old French flaiel, both from Late Latinflagellum, threshing tool, from Latin flagrum, whip . ]American Heritage® Dictionary of the English Language, Fifth Edition. Copyright © 2016 by Houghton Mifflin Harcourt Publishing Company. Published by Houghton Mifflin Harcourt Publishing Company. All rights reserved.flail ( fleɪl) n1. (Agriculture) an implement used for threshing grain, consisting of a wooden handle with a free-swinging metal or wooden bar attached to it2. (Arms & Armour (excluding Firearms)) a weapon so shaped used in the Middle Agesvb3. ( tr) to beat or thrash with or as if with a flail4. to move or be moved like a flail; thresh about: with arms flailing. [C12 fleil, ultimately from Late Latin flagellum flail, from Latin: whip]Collins English Dictionary – Complete and Unabridged, 12th Edition 2014 © Harper Collins Publishers 1991, 1994, 1998, 2000, 2003, 2006, 2007, 2009, 2011, 2014flail (fleɪl)n.1. an instrument for threshing grain, consisting of a staff or handle to one end of which is attached a freely swinging stick or bar.v.t., v.i.2. to beat or swing with or as if with a flail. [before 1100; Middle English fleil, Old English flighel. See flagellum]Random House Kernerman Webster's College Dictionary, © 2010 K Dictionaries Ltd. Copyright 2005, 1997, 1991 by Random House, Inc. All rights reserved.flail- Based on Latin flagellum, "whip. "See also related terms for whip. Farlex Trivia Dictionary. © 2012 Farlex, Inc. All rights reserved.flail Past participle: flailed Gerund: flailing Imperativeflailflail Collins English Verb Tables © Harper Collins Publishers 2011Flail A hand-threshing implement that consisted of two wooden sticks connected together by a flexible connection such as a piece of chain or a leather strap or thong. One of the sticksfunctioned as a handle while the other piece, the Swipple, was used to beat the grain loosefrom the stalks.1001 Words and Phrases You Never Knew You Didn’t Know by W. R. Runyan Copyright © 2011 by W. R. Runyan Thesaurus Antonyms Related Words Synonyms Legend: Switch to new thesaurus Noun 1. flail - an implement consisting of handle with a free swinging stick at the end; used in manual threshingimplement - instrumentation (a piece of equipment or tool) used to effect an end Verb 1. flail - give a thrashing to; beat hardthrash, lam, threshbeat up, work over, beat - give a beating to; subject to a beating, either as a punishment or as an act of aggression; "Thugs beat him up when he walked down thestreet late at night"; "The teacher used to beat the students"drub, lick, clobber, cream, bat, thrash - beat thoroughly and conclusively in a competition or fight; "We licked the other team on Sunday!"2. flail - move like a flail; thresh about; "Her arms were flailing"threshflap, beat - move with a flapping motion; "The bird's wings were flapping"Based on Word Net 3.0, Farlex clipart collection. © 2003-2012 Princeton University, Farlex Inc.flailverb thrash, beat, windmill, thresh His arms were flailing in all directions. Collins Thesaurus of the English Language – Complete and Unabridged 2nd Edition. 2002 © Harper Collins Publishers 1995, 2002flailverb1. To swing about or strike at wildly:thrash, thresh, toss. Idiom: toss and turn.2. To beat (plants) with a machine or by hand to separate the grain from the straw:thrash, thresh. The American Heritage® Roget's Thesaurus. Copyright © 2013, 2014 by Houghton Mifflin Harcourt Publishing Company. Published by Houghton Mifflin Harcourt Publishing Company. All rights reserved. Translations Select a language:desgranarflail [fleɪl]A. N ( Agr) → mayal m B. VT1. ( Agr) → desgranar2. (= beat) → golpear, azotar3. (= agitate) [+ arms, legs] → agitar C. VI to flail (about) [ arms, legs] → agitarse; [ person] → revolverse I tried to grab his flailing arms → intenté agarrarle los brazos que no paraba de agitar Collins Spanish Dictionary - Complete and Unabridged 8th Edition 2005 © William Collins Sons & Co. Ltd. 1971, 1988 © Harper Collins Publishers 1992, 1993, 1996, 1997, 2000, 2003, 2005Want to thank TFD for its existence? Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content . Link to this page: Facebook Twitter  Cruciform Anterior Spinal Hyperextension (CASH) Cruciform Anterior Spinal Hyperextension (CASH)Thoraco Lumbar Sacral Orthoses (TLSOs) are used mainly to treat fractures between T6 and L3. Every TLSO is designed to provide support and immobilization of the thoracic and lumbar regions following various surgical procedures/ traumatic injuries. TLSO are commonly used to help treat post-operative thoracic/lumbar fusion, laminectomy or discectomy, compression fractures, degenerative disc disease, osteoporosis, single column spinal instability immobilization, and facet syndrome. The Cruciform Anterior Spinal Hyperextension (CASH) brace features anterior sternal and pubic pads to produce a force opposed by the posterior pad and strap around the thoracolumbar region. Sternal and pelvic pads attach to the anterior, metal, cross-shaped bar, which can be bent to reduce excess pressure on the chest and pelvis. The brace is easy to don and doff, but it is difficult to adjust. It provides greater breast and axillary pressure relief than does the Jewett hyperextension TLSO. Two round upper chest pads can be used instead of the sternal pad to decrease discomfort around the breast area. Motion Restrictions: • Limits flexion and extension at T6-L1Indications: • Flexion immobilization to treat thoracic and lumbar vertebral body fractures T6-L1 • Reduction of kyphosis in patients with osteoporosis Contraindications: • Three-column spinal fractures involving anterior, middle, and posterior spinal structures • Compression fractures caused by osteoporosis • Ineffective in limiting lateral bending and rotation of the upper lumbar spine Manufacturer’s Website »Keywords: 805.2, L1, L2, L3, T10, T11, T12, T6, T6-L3 Compression Fracture, T7, T8, T9Tweet Product Categories Search Products (Ctrl+D)  Anatomy and Physiology Anatomy and Physiology Health History Current Health Status- shortness of breath- cyanosis- cough- sputum- chest pain Past Health History- prior lung disease- exposure to respiratory disease- allergies- smoking- OTC nasal sprays or medications- use of oxygen- vaccinations Examination Position: Remove all clothing to waist. Sit on an exam table or stand. Inspection: Shape of chest -A. AP Diameter - (Antero-posterior diameter)B. Barrel Chest - AP diameter compared to transverse diameter is 1:1C. Pigeon Breast (Pecus carinatum) - AP diameter is increased D. Funnel Breast - (Pecus excavatum)E. Kyphosis F. Poker Spine G. Scoliosis H. Lordosis Slope of Ribs - normally ribs are inserted into the spine at a 45E angle and inserted into the costal angle at a 45E angle. Abnormal Retraction of Interspaces During Inspiration A. Substernal retractions B. Intercostal retractions C. Suprasternal retractions Pattern of Respiration A. Men & women - breathe diaphragmatically Women - breathe thoracically or costaly Rate Depth, Type and Rhythm of Breathing A. Eupnea, 16-20 BPMB. Tachypnea, respirations over 20 BPMC. Bradypnea, respirations under 10 BPMD. Apnea, absence of respirations E. Hyperpnea, increase in depth of respirations F. Cheyne-Stokes, altering hyperpnea and shallow respirations, followed by periods of apnea. G. Biot's, shallow breathing interrupted by apnea H. Kussmauls, increase in rate and depth Apneustic, long inspiration, short expiration Use of Accessory Muscles. A. Sternocleidomastoid muscle B. Scalenus Trapezius Symmetry of Chest Expansion Lips, Nailbeds, Nares Palpation: Identify Areas of Tenderness, Lesions, Masses, or Crepitation Respiratory Excursion. (Thoracic expansion) Can be assessed in anterior or posterior chest. Tactile Fremitus (vocal fremitus) - client says "99" while examiner palpates the thorax using palmar surface of fingers or ulnar aspect of hand. A. Normal fremitus B. Increased vocal fremitus C. Decreased or absent vocal fremitus Vibration (fremitus) During Quiet Inspiration and Expiration Palpate for Tracheal Deviation. Percussion: Percussion penetrates to a depth of approximately 5-7 cm. It is used to determine the relative amounts of air, liquid, or solid material in the underlying lung. Resonance - loud, low pitched hollow sound of a long duration. Abnormal percussion notes: Hyperresonance - occurs with increased amounts of air. Loud, low-pitched booming sound with a long duration. Dullness - occurs with fluid, pus, consolidation, or tumors. Medium soft intensity with a thud-like sound. Flatness- large amount of fluid over an area with little underlying air. (Pleural effusion). Soft, high-pitched sound with a very short duration. Diaphragmatic excursion Auscultation: Symmetrical Areas Should be Compared in Regard to Pitch Intensity Quality Duration Presence of Adventitious Breath Sounds. Instruct client to breathe slightly more deeply and slowly than normal respiration. Client should breathe through open mouth. Sound Duration of inspiration and expiration Diagram of sound Pitch Intensity Normal Location Abnormal Location Vesicular Inspiration > expiration 5 : 2 Low Soft Peripheral lung Over trachea and sternum Broncho-vesicular Inspiration = expiration 1 : 1 Moderate Moderate First and second intercostal spaces at the border over major bronchi Peripheral lung Bronchial (tubular) Inspiration < expiration 1 : 2 Pause between inspiration and expiration High Loud Over trachea Lung areas Changes in Normal Breath Sounds A. Deep breathing changes normal vesicular sounds to bronchovesicular sounds B. Breathing through the nose will alter normal breath sounds C. Fluid filling the alveoli will convert vesicular sounds to bronchovesicular sounds (early pneumonia). D. Large amounts of fluid collecting will change vesicular to bronchial sounds (lung consolidation). E. No breath soundsobstructed bronchuspneumothoraxfractured ribs with splintingobesitybarrel chestthickened pleuraair and fluid in pleural place Egophony - when listening over a normal peripheral lung you will hear the sound "eee" when the patient voices "eee." When the lung is compressed by fluid (pleural effusion), you will hear the sound "aye. "Adventitious Sounds A. Crackles (rales)Fine - high pitched Medium Coarse - low pitched B. Wheezes Sonorous (coarse) - low pitched Sibilant (wheezes) - high pitched (usually occurs during expiratory phase of respiration. Inspiratory wheezes indicate severe narrowing of the airway.)a. monophonic wheezes b. polyphonic wheezes C. Rhonchi (gurgles)D. Friction rub - loud dry creaking or grating sound heard best over lower anterolateral thorax E. Stridor - an inspiratory wheeze that is louder over the neck than the thorax. Home | Back7  Rib injuries On this page: Structure of the ribs Symptoms of rib injuries Blunt force is the common cause of injury Soft tissue injuries Rib fracture Flail chest is a serious injury Risk of serious injury Diagnosis of rib injuries Treatment of rib injuries Where to get help Things to remember The ribcage supports the upper body, protects internal organs, including the heart and lungs, and assists with breathing. Rib injuries include bruises, torn cartilage and bone fractures. Chest trauma may also cause life-threatening injuries such as a punctured lung or a ruptured aorta. Common causes of rib injury include motor vehicle accidents and falls. Treatment aims to relieve pain while the injury heals. Structure of the ribs The ribcage consists of 24 curved ribs arranged in 12 pairs. Each pair is attached to a vertebra in the spine. At the front of the body, the first seven pairs of ribs are attached directly to the sternum (breastbone) by cartilage known as costal cartilage. These ribs are often called ‘true ribs’. The next three pairs of ribs aren’t connected to the sternum. Instead, costal cartilage attaches these ‘false ribs’ to the last pair of true ribs. The remaining two pairs aren’t attached at the front of the body at all and are known as ‘floating ribs’. The ribcage is supported by ligaments and muscles, including the muscles between the ribs (intercostal muscles). These muscles allow the ribcage to expand when you breathe in and to drop when you breathe out. Back to top Symptoms of rib injuries The symptoms of rib injuries depend on the type and severity of the injury, but can include: Pain at the injury site Pain when the ribcage flexes – with movement, with a deep breath or when you cough, sneeze or laugh Crunching or grinding sounds (crepitus) when the injury site is touched or moved Muscle spasms of the ribcage Deformed appearance of the ribcage Breathing difficulties. Back to top Blunt force is the common cause of injury Rib injuries typically occur when the chest is directly hit. Situations that could cause blunt injuries to the ribcage include: Motor vehicle accidents – for example, slamming the chest against the steering wheel Crush injuries – for example, a heavy object landing directly on the chest Sports-related injuries – for example, a heavy tackle Falling from a reasonable height – for example, off a roof or ladder Assault – for example, getting hit by a baseball bat. Back to top Soft tissue injuries Soft tissue of the ribcage includes the intercostal muscles and the costal cartilage. Common injuries include: Bruising – the blood vessels rupture and leak blood into the surrounding tissues. Bruising of the chest wall is a common rib trauma. Intercostal strains – intercostal muscles allow the ribcage to move up and down. These muscles can be strained by any activity that involves extreme or forceful twisting of the body or swinging of the arms. Sports that commonly cause this type of injury include golf and tennis. Costochondral separation – the rib is torn loose from the costal cartilage and is detached from the sternum. Back to top Rib fracture The curved design of the ribs makes them resistant to fractures. Their ability to flex helps the bone to absorb the force of a blow. However, any bone will break if the force exerted against it is stronger than it can structurally withstand. A rib is most likely to fracture at its outer curve, which is its weakest point. Older people are more prone to rib fractures because bones thin with age. Children are less likely to break ribs because their bones are relatively flexible. Back to top Flail chest is a serious injury Flail chest is the most common serious injury to the ribs. It occurs when three or more ribs are broken in at least two places, front and back. This will only happen if there has been a great deal of blunt force. The key sign of flail chest is ‘paradoxical movement’, which means the natural movement of the ribcage during breathing is in reverse. For example, the injured area of ribcage sinks in when the person inhales, instead of lifting outwards. This reversal is caused by changes to air pressure in the ribcage as a result of injury. However, it is the accompanying injury to the lungs that usually causes complications, not the broken ribcage. Intubating the person (putting oxygen into the lungs via a tube placed down the trachea, or windpipe) will create a ‘normal’ pressure in the lungs. Back to top Risk of serious injury The ribs enclose vital organs such as the heart and lungs, so chest trauma can cause life-threatening injuries. These can include: Pneumothorax – collapsed lung due to changes in pressure within the chest. This could be caused by a broken rib tearing the lung or a puncture in the chest wall. Symptoms can include breathing difficulties, chest pain and coughing up blood. Cardiac and associated blood vessel injury – for example, trauma to the blood vessel servicing the heart (coronary artery) or a tear in the main artery of the body (aorta). Splenic rupture – the spleen is located on the left side of the abdomen. Its roles include filtering the blood to remove abnormal cells and the manufacture of some immune system cells including antibodies and lymphocytes. Splenic rupture means the outer capsule has split and the spleen bleeds into the abdominal cavity. Back to top Diagnosis of rib injuries Rib injuries are diagnosed using a number of tests including: History of the injury (where you explain to your doctor what has happened)Physical examination Chest x-ray. Back to top Treatment of rib injuries Unlike bones of the arms and legs, broken ribs can’t be set in a cast. Treatment aims to relieve pain while the injury heals, which can take up to six weeks (in the case of fracture), and 12 weeks or more if the rib has been torn from the cartilage. Treatment for bruised ribs is the same as for fractured ribs, but with a shorter recovery time. Options include: Rest Prescription strength pain-killing drugs Non-steroidal anti-inflammatory drugs (NSAIDs)Avoiding activities that aggravate the injury, such as sport Icepacks – may help to reduce inflammation in the early stages Mechanical ventilation (help with breathing) – may be needed in cases of severe flail chest. Back to top Where to get help Your doctor Doctor specialising in sports medicine Physiotherapist Sports Doctors Australia Tel. (02) 6241 9344Sports Medicine Australia – Victoria Tel. (03) 9674 8777Emergency department of your nearest hospital Always call an ambulance in an emergency Tel. 000Back to top Things to remember Common causes of rib injury include motor vehicle accidents and falls. Since the ribs enclose vital organs, including the heart and lungs, chest trauma can cause life-threatening injuries such as a punctured lung or a ruptured aorta. Broken ribs can’t be set in a cast, so treatment aims to relieve pain while the injury heals. Back to top  Tension Pneumothorax Tension Pneumothorax What EMS providers need to know about this rapidly lethal conditionby David Page MS, NREMT-PReviewed by James Dinsch, MS, NRP, CCEMT-P; Dennis C. Baier, BSN, RN, EMT-P; Christopher Touzeau, MS, NREMT-P, RN; Owen T. Traynor, MDContents Introduction Anatomy & Physiology Pathophysiology Epidemiology Assessment Treatment Conclusion References Share this article: EMS Reference editor's note: This article is co-authored by Samuel Chu, BSE, NREMT-P, L. Michael Bowen, NREMT-P, and Katie Lyman, Ph D, ATC, NREMT, CKTI. Introduction The thoracic cavity houses the heart, great vessels, diaphragm, lungs, and other vital organs. Because of this, any injury to the thoracic cavity can be rapidly lethal. Even small changes in the mechanics of oxygen exchange and circulation can have dire consequences for the patient. Tension pneumothorax is a rapidly lethal condition in which a damaged lung, bronchus, or bronchiole allows air to enter the chest cavity. As more air enters the pleural space, a buildup of pressure causes collapse of the affected lung, shifting of the mediastinum and compression of the structures in the chest, impairing ventilation and perfusion. 1 The structures affected are the lungs, the heart and great vessels, including the vena cava. The resulting increase in intrathoracic pressure reduces venous return to the heart, decreasing cardiac output, and poor ventilation rapidly creates a deadly combination. 2Anatomy & Physiology The volume of normal adult lungs is about 6 liters, with three lobes making up the right lung and two lobes making up the left. The apices of the lungs may reach 2–3 cm above the medial third of the clavicle, and the bases rest on the diaphragm, which is estimated to be at rib 6 midclavicular, rib 8 midaxillary, and rib 10 posteriorly. 3Visceral pleura covers the lungs while parietal pleura lines the chest cavity. The pleural space is potential space in between the two pleura. Normally, the pleural cavity contains a small amount of fluid to minimize friction. This is a potential space, meaning it has the potential to be filled with air, fluid, or blood—all of which can affect ventilation. 4The pleural membranes may adhere to one another causing pain. EMS providers should be aware of pleurisy or pleuritis, which causes pain during inhalation due to the friction. 5The alveoli are the termini of airflow in the human body. The average human adult has 300 million alveoli, comprising a total surface area of 150 m. 6 Gas exchange between inspired air and blood in surrounding capillaries occurs here. Oxygen concentration is higher in the alveolar space than in the surrounding capillaries, which causes oxygen to diffuse into the blood along a concentration gradient. Carbon dioxide concentration is higher in the capillaries that in the alveolar space. Capillary walls consist of a single layer of cells creating the perfect environment for diffusion of oxygen from the alveolar space to the capillary blood. Conversely, CO2readily diffuses from capillary blood into the alveolar space. Pulmonary circulation contains approximately 500 m L of blood, 100 m L of which is available for gas exchange in the capillary bed. Based on Fick’s law, which states that blood flow is proportional to the difference in concentration of a substance in the blood as it enters and leaves an organ, the large surface area of the alveoli and thin membranes of both the alveoli and capillaries allow for efficient gas exchange. 7The act of inspiration is an active process involving the diaphragm and external intercostal muscles. The ribs and sternum move superior as the diaphragm contracts flattening downward. Air rushes into the lungs because the intrapulmonary pressure is less than extra pulmonary pressure, a principle called Boyle’s Law, which states that pressure and volume are inversely proportional for a fixed amount of an ideal gas kept at a fixed temperature. During labored breathing, accessory muscles, such as the scalenes and sternocleidomastoids, assist with raising the ribs to increase space. This increase in volume due to muscle contraction creates a relative negative pressure space compared to the air pressure outside the body. Boyle’s law states pressure is inversely related to volume, so increasing the volume will decrease the pressure. Creating this concentration gradient between the lungs and the outside environment allows air to be drawn into the lungs; from diffusion, air will move from an area of higher concentration to lower concentration. Ventilation quickly becomes impaired when this gradient is disturbed, such as in tension pneumothorax. This patient appears anxious and hungry for air. Typically expiration is a passive process in which the muscles relax, reducing the space available in the lungs. This increases intrathoracic pressure above extra thoracic pressure, forcing air out of the lungs. Air is forced out of the lungs when the ribs, sternum, and diaphragm return to their original position. During labored breathing, internal and external muscles actively work to force air out of the lungs. Increases in intra-abdominal and intra-thoracic pressures assist with venous return to the heart. The increase in pressure squeeze blood in the pulmonary veins and inferior vena cavae to maintain venous return, otherwise known as the respiratory pump. 8Pathophysiology Several terminologies are associated with injuries to the lungs. Pneumothorax is defined as the presence of air in the pleural space. Hemothorax is defined as blood accumulation in the pleural space. 4 A tension pneumothorax involves pressure filling the pleural space, which causes ventilation to be impaired and pulmonary circulation to be shunted toward the unaffected lung. Tension pneumothorax is rapidly lethal because the increasing intrathoracic pressure eventually displaces mediastinal structures, which can interfere with venous return to the heart, causing cardiovascular collapse and shock. Early signs of tension pneumothorax may include agitation, air hunger, and an increase in respiratory rate. Mental status change and diminished breath sounds on the affected side may be found as the pneumothorax expands. Other signs and symptoms include: Chest pain,Respiratory distress,Tachycardia, and Ipsilateral decreased air breath sounds. Other less common signs and symptoms include: Low Sp O 2,Contralateral tracheal deviation, and Hypotension. 8The clinical signs are variable, and a high index of suspicion is needed. The patient will need close and frequent evaluation. As pressure continues to build in the pleural space, mediastinal shift occurs away from the building pressure. This results in compression of the vena cava and decreased venous return or cardiac preload. The late stage of tension pneumothorax includes such signs as jugular venous distension, tracheal deviation, cyanosis, apnea, and hyperresonance on percussion. Tachycardia and tachypnea are early compensatory changes as the body attempts to respond to hypoperfusion. Left untreated, tension pneumothorax can quickly cause irreversible shock and death. 1Epidemiology Pneumothorax is a rapidly deteriorating condition that requires early action. Pulmonary conditions commonly associated with tension pneumothorax in one 1978 included pneumonia, pulmonary emphysema, and pulmonary embolism, while procedures most frequently associated with pneumothorax were mechanical ventilation and CPR attempts. 9 In cases of penetrating trauma resulting in pneumothorax, 75% will also include hemothorax. 10Although a pneumothorax from any cause can develop into a tension pneumothorax, this condition is most often caused by traumatic injuries. Any injury to the chest can cause rib fractures, which may damage blood vessels and lung tissue. Liman, et al. found an association of hemothorax or pneumothorax development with the presence of rib fractures; 24.9% of patients with one rib fracture and 81.4% of patients with two or more rib fractures also had a hemothorax or pneumothorax. 6From the Vietnam Wound Data and Munitions Effectiveness Team study, researchers found that tension pneumothorax was the cause of death for 3–4% of fatally wounded combat casualties, (e.g., penetrating trauma). 11Although suspicion of tension pneumothorax should remain high for patients with rapidly developing shock, it is rare in primary spontaneous pneumothorax because it is normally associated with traumatic injuries. 12Assessment The primary survey for any patient with difficulty breathing begins with a general observation of the patient’s appearance, and their work of breathing. The patient with tension pneumothorax is no different. An accurate exam requires the chest to be exposed, observed and palpated. 13,14Hands on the bare chest accurately assesses mechanics of breathing in the field. Work of breathing will be heavy, the more severe the tension, the less lung tissue is able to expand. Look for such signs of “air hunger” as the use of accessory muscles, and rapid and shallow breaths due to decreased tidal volume. If visible, cyanosis or an ashen color will indicate poor perfusion. Palpation: EMTs and paramedics work in difficult environments. Palpation of the chest and feeling for un-equal chest rise is a much more reliable and sensitive method of discovering a pneumothorax than simple observation. Rapidly place your hands on both sides of the anterior chest. Each time, ask the patient to take a breath. This will reveal the quickest and some of the most reliable assessment of chest excursion on movement. Normally the more detailed exam of the chest is left for the secondary survey. In the case of a life threat, such as tension pneumothorax, the suspicion that breathing and circulation is being impaired should prompt you to interrupt a traditional approach, and immediately look for other signs confirming tension pneumothorax. With experience, providers palpating for equal rise should simultaneously be able to note any crepitation or rib instability, cool skin temperature, clammy skin, and the presence of subcutaneous air. All of these findings may suggest a tension pneumothorax and the presence of shock. Feeling for bilateral radial pulses, rapidly noting character and speed, should reveal tachycardia and weak pulses if tension pneumothorax is present. Change in pulse quality that occurs during inhalation may signal pulsus paradoxus. Pulsus paradoxus is a change in pulse quality, or even the dissapppearance of the pulse due to a fall in left ventricular stroke volume reflected as a fall in systolic blood pressure . Tension pneumothorax is a extracardiac pulmonary cause of pulsus paradoxus. 15A simple pneumothorax by definition will not disrupt circulation. However, because tension pneumothorax decreases cardiac output, the patient will be tachycardic. The heart speeds up to compensate for the decreases in stroke volume. 8Feeling for strength, rate and equality of pulses can help identify the initial stages of shock. Late and unreliable signs: Increasing tension may include tracheal deviation (or tracheal “tugging”) and jugular vein distension ( JVD ). 16 Simple visual inspection is unreliable in detecting tracheal deviation. Bates’ guide to physical examination recommends placing your fingers on either side of the trachea to determine if the distance between the trachea and the sternocleidomastoid muscle is equal bilaterally. 18 Prehospital Trauma Life Support (PHTLS) indicates the trachea is bound to the cervical spine and fascia, and deviation would be detected lower, at the sternal notch. In this case, providers would simply feel the deficiency of the trachea if it has shifted to one side. 17 These authors also point out that JVD might not be present either. If tension pneumothorax results in decreased cardiac output with hypotension, it is not likely to cause JVD. Note that although tracheal deviation is rare, it is primarily a sign of tension pneumothorax. In contrast, JVD can be present in multiple conditions, such as cardiac tamponade, so it is not necessarily an obvious tension pneumothorax finding. Diagnostic technologies: The use of ultrasonography in the out-of-hospital environment has been reported. 18-22 Paramedics in Texas and Washington have used the technique to better assess and confirm pneumothorax. Researchers have reported training 57 EMT and paramedic students in ultrasound for detection of pleural effusion and pneumothorax. The class was one hour in duration and accuracy of diagnosis was 55–95%. 23 The use of ultrasound in the field is still a novel concept, and technology is still developing. As this technology becomes more portable, rugged and affordable EMS systems may find it more realistic to adopt. The future widespread adoption of this technology is still in question. Treatment Definitive treatment for tension pneumothorax involves decreasing the intrapleural pressure to allow the affected lung to re-expand and blood to return un-impaired to the heart. When the field diagnosis is made, immediate needle decompression should be performed introducing a large-bore catheter (e.g., 14 gauge or larger) into the pleural space at the second intercostal space at the mid-clavicular line. Chest wall thickness may vary. Although an average adult chest should be 4.5 cm thick, researchers have predicted that as many as 35% of the U. S. patient population might has significantly thicker chest walls. 24,25 Researchers have also found that as many as 26% of chest decompressions failed because they were possibly too shallow. 26In a 2010 study comparing helicopter and ground EMS crews, researchers found a 65% failure rate when shorter needles were used. They recommend needles that are at least 2 inches (5cm) long. 27 Longer needles may be needed. If you don’t have a one-way valve, also called a Heimlich valve, try creating a flutter valve. Use the finger of a glove to create a flutter valve by placing the finger over the catheter hub, then cutting a small hole in the end of it. 28 There is some disagreement on the benefit of a Heimlich valve. According to the 8th edition of the Prehospital Trauma Life Support (PHTLS), the diameter of the decompression catheter is significantly smaller than the patient's airway, which means it is unlikely that any air movement through the catheter will significantly compromise ventilatory effort. Thus, creation of a Heimlich valve is probably unnecessary form a clinical standpoint. Immediate improvement should be noted after inserting the needle. Reassessment of vital signs is essential. Use of a one-way valve, such as a flutter valve, may be helpful in improving the mechanics of breathing. This valve will theoretically shut when the patient inhales (e.g., negative pressure in the chest), and allow air to escape the chest (e.g., flutter valve opens) when the patient exhales. No studies exist showing the effectiveness of this valve. Commercially available Heimlich valves are in use in some EMS systems. Create a flutter valve with the finger of a glove placed over the catheter hub. If needle decompression fails to produce improvement, or is not available, basic out-of-hospital care involves assisting ventilations and supplemental oxygen. Providers should note that assisting ventilations may cause the tension to worsen, and should only be performed as a last resort. Failure to get improvement after needle decompression may also indicate that the diagnosis was wrong. A reassessment of the overall diagnosis may also be appropriate. EMS providers should maintain good situational awareness and not fixate on one problem. If mechanism existed to create a tension pneumothorax, then other traumatic injuries may also be present. Thorough assessment and monitoring of the patient’s condition is also essential. Look for other causes, injuries and co-morbidities. It is important to reiterate that assessment and definitive field diagnosis can be complicated by noise, movement and varied temperature and light conditions. It is best to keep a high index of suspicion and identify early signs of growing tension (tachycardia, difficulty breathing, diminished lung sounds, pulse quality changes, or unequal chest expansion). 29 Hypotension is a late sign which would indicate a higher tension and longer progression of the tension pneumothorax. 8If an object is impaled it should be left in place if possible. Removal may cause greater injury as the object shears tissues and possibly releases pressure that results in additional bleeding. Conclusion Any injury between the umbilicus and the nipple line should be considered both a possible thoracic injury and a possible abdominal wound. EMS clinicians must maintain a high index of suspicion for tension pneumothorax. A common error in treating tension pneumothorax is to use a short needle for chest decompression. A large bore (14g or larger) needle with a catheter that is at least 2 inches (5 cm) long is needed to reach the pleural space with reliability in most patients. References Porth C. Essentials of pathophysiology. 3rd ed. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins. 2011. Light RW. Disorders of the pleura, mediastinum, and diaphragm. In: Kasper DL, Braunwald E, Hauser S, Longo D, Jameson LJ, Fauci AS. Harrison’s principles of internal medicine. 16th ed. New York: Mc Graw-Hill. 2005. p. 1565-69. Dartmouth Medical Center [Internet]. O’Rahilly; c2008. Swenson R, Caitlin B, Lyons, J. Chapter 22: The pleurae and lungs. Available from: http://www.dartmouth.edu/~humananatomy/part_4/chapter_22.html Tortora GJ, Derrickson BH. Principles of anatomy & physiology. Hoboken, NJ: Wiley & Sons. 2012. Anderson K. Mosby’s medical, nursing, & allied health dictionary. St. Louis: Mosby.1998. Ochs M, Nyengaard JR, Jung A, Knudsen L, Voigt M, Wahlers T, Richter J, Gundersen HJ. The number of alveoli in the human lung. Am J Respir Crit Care Med. 2004 Jan 1;169 (1):120-4. Epub 2003 Sep 25. Wilmore JH, Costill DL, Kenney WL. Physiology of sport and exercise, 4th ed. Champaign, Ill: Human Kinetics. 2008Leigh-Smith S, Harris T. Tension pneumothorax—time for a re-think? Emerg Med J. Jan 2005; 22 (1):8–16. doi: 10.1136/emj.2003.010421Ludwig J, Kienzle GD. Pneumothorax in a large autopsy population. A study of 77 cases. Am J Clin Pathol. 1978 Jul;70 (1):24-6. Liman ST, Kuzucu A, Tastepe AI, Ulasan GN, Topcu S. Chest injury due to blunt trauma. Eur J Cardiothorac Surg. 2003 Mar;23 (3):374-8. PMID 12614809. Mc Pherson JJ, Feigin DS, Bellamy RF. Prevalence of tension pneumothorax in fatally wounded combat casualties. J Trauma. 2006 Mar;60 (3):573-8. Noppen M. Spontaneous pneumothorax: Epidemiology, pathophysiology and cause. Eur Respir Rev. 2010 Sep;19 (117):217-9. doi: 10.1183/09059180.00005310. American College of Surgeons Committee on Trauma, National Association of EMTs. Prehospital Trauma Life Support (PHTLS). 7th ed. Burlington, Mass: Jones & Bartlett Learning. 2011. p. 114, 301. Bickley L. Bates' guide to physical examination and history-taking, 11th ed. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins. 2013. p. 305. Khasnis A, Lokhandwala Y. Clinical signs in medicine: Pulsus paradoxus. J Postgrad Med. 2002 Jan-Mar;48 (1):46-9. Tintinalli J, Stapczynksi. Ma OJ, Cline D, Cydulka R, Meckler G. Tintinalli's emergency medicine: A comprehensive study guide, seventh edition. 7th ed. New York: Mc Graw-Hill. 2011. p. 1745. Di Bartolomeo S, Sanson G, Nardi G, Scian F, Michelutto V, Lattuada L. A population-based study on pneumothorax in severely traumatized patients. J Trauma. 2001 Oct;51 (4):677-82. Bowman J. Visible improvement. JEMS. 2010 Sep;35 (9):36-8, 40, 42, passim. doi: 10.1016/S0197-2510 (10)70229-1. Razzaq QM. Use of the ‘sliding lung sign’ in emergency bedside ultrasound. Eur J Emerg Med. 2008 Aug;15 (4):238-41. doi: 10.1097/MEJ.0b013e3282f4d15b. Clinical Trials [Internet]. Bethesda, Md: National Libraries of Medicine. C2014. Bowman JP. Keller Prehospital ultrasound study. Keller Fire Rescue. University of Texas Health Science Center San Antonio. Available from: http://clinicaltrials.gov/show/NCT01074112Hoyer HX, Vogl S, Schiemann U, Haug A, Stolpe E, Michalski T. Prehospital ultrasound in emergency medicine: Incidence, feasibility, indications and diagnoses. Eur J Emerg Med. 2010 Oct;17 (5):254-9. doi: 10.1097/MEJ.0b013e328336ae9e. Journal of Emergency Medical Services [Internet]. San Diego: Pennwell Corp. c2012. Tinkoff G. Cipolle MD, Rhodes, M. How to recognize & treat the 12 types of thoracic injuries. Available from: http://www.jems.com/deadly-dozen. Pierog JE, Zaia BE, Bhat SR, Johnson DA, Gharahbaghian L, Gilbert GH, Williams SR. Out-of-hospital evaluation of effusion, pneumothorax and standstill: EMS and point-of-care ultrasonography. Ann Emerg Med. 2010;56;p-S115; Abstract 355:2010. doi: http://dx.doi.org/10.1016/j.annemergmed.2010.06.412Mc Lean AR., Richards ME, Crandall CS, Marinaro JL. Ultrasound determination of chest wall thickness: Implications for needle thoracotomy. Am J Emerg Med. 2011 Nov;29 (9):1173-7. doi: 10.1016/j.ajem.2010.06.030. Epub 2010 Oct 13. Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department evaluation and management. Emerg Med Clin. North Am. 2003 May;21 (2):291-313. Blaivas M. Inadequate needle thoracostomy rate in the prehospital setting for the presumed pneumothorax: An ultrasound study. J Ultrasound Med. 2010 Sep;29 (9):1285-9. Ball CG1, Wyrzykowski AD, Kirkpatrick AW, Dente CJ, Nicholas JM, Salomone JP, Rozycki GS, Kortbeek JB, Feliciano DV. Thoracic needle decompression for tension pneumothorax: Clinical correlation with catheter length. Can J Surg. 2010 Jun;53 (3):184-8. North Carolina College of Emergency Physicians. Standards Procedure (Skill) Chest Decompression. Available from: www.ncems.org/pdf2012/Proc30-Chest Decompression.pdf. American Academy of Orthopedic Surgeons, Caroline NL, Elling B, Smith M. Nancy Caroline’s emergency care in the streets 7th ed. Burlington, Ma: Jones & Bartlett Publishers; 2012. 730-864. The EMS Reference is a community project, and we encourage your suggestions. Give us your feedback. Published: January 8, 2015Revised: November 27, 2015  How Is a Flail Chest Treated? First Aid Broken Bones How Is a Flail Chest Treated? By Rod Brouhard, EMT-PUpdated February 16, 2018Share Pin Email Print There's a fine line between chest wall pain and cardiac pain. Jeannot Olivet / Getty Images Flail chest refers to a serious breach of the integrity of the rib cage from more than one adjacent broken ribs that are broken in more than one place each. Instead of rigidly holding the normal shape of the chest, flail chest results in a segment of the chest wall flailing back and forth in the opposite direction of the rest of the chest wall. The flailing is called paradoxical movement. When the patient inhales and the rest of the chest expands, a flail segment will sink inward. On the other hand, when the patient exhales and the rest of the chest contracts, the flail segment will bulge outward. This is a dangerous injury that requires emergency medical treatment. If not treated promptly, flail chest can lead to a collapsed lung ( pneumothorax) or blood around the heart (cardiac tamponade). Flail chest and rib fractures, in general, are more common in elderly patients than in younger patients. Be very aware when assessing older patients that have fallen or potentially injured their rib cages. Treating a Flail Chest Stay Safe. If you are not the patient, practice universal precautions and wear personal protective equipment if available. Be sure that whatever caused the injury to the patient is no longer a threat. Call 911. If the 911 operator gives instructions, follow those instructions and ignore the rest of this page. If 911 is not available, get the patient to emergency medical help as soon as possible. Stabilize the flail chest. Use a pillow to put pressure on the flail segment. Holding the flail segment in place keeps it from moving in an opposite direction as the surrounding muscle and bone. If it doesn't move, it won't cause more damage to the heart, lungs and surrounding tissues. If a pillow is not available, almost anything will do to stabilize the flail chest. Roll up a jacket or a blanket. If there is absolutely nothing available, at least have the patient lie on the affected side of the chest to discourage it from moving. Regardless how a flail chest is treated it is going to hurt, probably worse than anything the patient has ever encountered. Over the counter pain medications aren't going to do much for this level of pain and stronger painkillers aren't a good idea until emergency medical help is available to provide the full range of emergency treatment. Never take — or give to another patient — someone else's prescription medications. Always make sure that patients with flail chest get to emergency medical treatment. Failure to provide proper treatment for flail chest can lead to pneumonia and other life-threatening conditions. Sources: Balas MC, Casey CM, Happ MB. Comprehensive assessment and management of the critically ill. In: Boltz M, Capezuti E, Fulmer T, Zwicker D, editor (s). Evidence-based geriatric nursing protocols for best practice. 4th ed. New York (NY): Springer Publishing Company; 2012. p. 600-27. Henry, Mark C., and Edward R. Stapleton. EMT Prehospital Care. 3rd Ed. 2004. Mosby/Jems Pettiford, B. L., J. D. Luketich and R. J. Landreneau. "The management of flail chest." Thorac Surg Clin. 2007 Feb;17 (1):25-33  Symptoms of Pulled Chest Muscles Symptoms of Pulled Chest Muscles A pulled chest muscle is often the result of excessive stretching and tearing of muscle fibers, and leads to chest pain, as well as bruising and inflammation in severe cases. The current article provides signs and symptoms associated with different grades of muscle strains. Muscles in the chest are involved in various hand and shoulder movements, thus enabling us to perform a wide range of activities. Excess weight or pressure, and sudden jerks, may lead to the stretching of muscles beyond their normal capacity. This results in small tears in the muscle fibers and/or the associated tendons. Such injury may also occur due to physical trauma in the upper torso. This painful condition is called muscle strain or pulled muscle in chest. In most cases, it turns out to be a mild condition, but severe injury has been reported in a few instances. Pectoralis major and pectoralis minor are two important muscles present in the pectoral girdle. Pectoralis major is a thick, large muscle that forms a major portion of the chest wall, and is associated with flexion, medial rotation and adduction of the arm. Pectoralis minor is a smaller muscle present beneath pectoralis major, and is mainly involved in shoulder movements. Strain in these muscles, causes chest pain and difficulty while performing regular activities. Given below is brief account of the people at risk for such a condition, as well as the symptoms associated. Who is at Risk for Pulled Chest Muscles? Although anyone can experience a muscle strain in the chest, it is more common amongst athletes and those who indulge in weight training. Sportspersons such as tennis players, football and basketball players, boxers, and other professionals who indulge in quick movement of the chest muscles and recurrent usage of the upper body portion, are highly susceptible to a muscle strain in the chest. Signs and Symptoms Notable symptoms of a pulled muscle in chest are generally experienced within 24 hours after the injury. The most evident sign is pain and tightness in the chest, which worsens as a sharp burning pain during movement and/or rotation of the affected portion. Within a few days, muscle strain may become obvious even while lifting or moving the arms. Depending on severity of the condition, muscle strains are classified into three grades. The symptoms associated with each grade of muscle strain in chest, have been enlisted below. Grade I It involves mild injury to a few of the muscle fibers, and is generally experienced as mild chest pain. Other symptoms may include: Mild edema Chest discomfort Mild loss of strength Slight limitation in movements Grade II This grade involves moderate injury that affects a comparatively large number of muscle fibers, and inflicts significant tissue damage or partial muscle tear. Grade II strain in chest muscles may lead to: Chest pain Mild bruising Palpable muscle defect Evident loss of strength Pain during arm and shoulder movements Tenderness and inflammation in the affected area Grade III Severe injury that involves a complete muscle tear and loss of muscle function, is considered as a grade III strain. It causes extreme structural damage leading to: Severe chest pain Loss of strength Hematoma Inflammation of chest wall Limitation of arm and shoulder movements Post-treatment persistence of muscle pain Treatment and Recovery The most essential step, in case of a pulled muscle in chest, is to refrain from physical activities which may worsen the condition, namely lifting heavy objects, workouts and heavy exercise. Adequate muscle rest is the main approach for management and treatment of pulled muscles. It may be coupled with the use of analgesics as well as ice-packs and other home remedies. Grade III injuries may require surgical repair and physiotherapy. While a mild muscle pull usually heals within a few days, recovery from grade III injury requires several weeks, or even months. The symptoms of pulled muscle in chest range from mild discomfort to severe hematoma, depending on the degree of muscle injury. However, any severe muscle pain that affects daily activities, demands a professional consultation in order to understand its etiology, and the severity of damage. Disclaimer: This Buzzle article is for informative purposes only, and should not be used as a substitute for professional medical advice. Upper Right Chest Pain Left Side Chest Pain Chest Pain in Women Upper-left Chest Pain Chest Pain On the Right Side Burning Chest Pain Chest Pain After Eating Sharp Chest Pain: Causes of Chronic or Acute Chest Pain Dull Chest Pain Toys for Children with Cerebral Palsy  Pleurisy From Wikipedia, the free encyclopedia (Redirected from Pleuritic chest pain)navigation search This article is about the disease. For the plant known as "pleurisy root", see Butterfly weed. Pleurisy Synonyms Pleuritis, pleuritic chest pain [1]Figure A shows normal anatomy. Figure B shows lungs with pleurisy in the right lung and a pneumothorax of the left lung. Specialty Pulmonology Symptoms Sharp chest pain [1]Causes Viral infection, pneumonia, pulmonary embolism [2]Diagnostic method Chest X-ray, electrocardiogram (ECG), blood tests [3]Differential diagnosis Pericarditis, heart attack, cholecystitis [3]Treatment Based on the underlying cause [3]Medication Paracetamol (acetaminophen), ibuprofen [4]Frequency 1 million cases per year (United States) [5]Pleurisy, also known as pleuritis, is inflammation of the membranes ( pleurae) that surround the lungs and line the chest cavity. [1] This can result in a sharp chest pain with breathing. [1] Occasionally the pain may be a constant dull ache. [6] Other symptoms may include shortness of breath, cough, fever or weight loss, depending on the underlying cause. [6]The most common cause is a viral infection. [2] Other causes include pneumonia, pulmonary embolism, autoimmune disorders, lung cancer, following heart surgery, pancreatitis, chest trauma, and asbestosis. [2] Occasionally the cause remains unknown. [2] The underlying mechanism involves the rubbing together of the pleurae instead of smooth gliding. [1] Other conditions that can produce similar symptoms include pericarditis, heart attack, cholecystitis, and pneumothorax. [3] Diagnosis may include a chest X-ray, electrocardiogram (ECG), and blood tests. [3] [7]Treatment depends on the underlying cause. [3] Paracetamol (acetaminophen) and ibuprofen may be used to decrease pain. [4]Incentive spirometry may be recommended to encourage larger breaths. [5] About one million people are affected in the United States each year. [5] Descriptions of the condition date from at least as early as 400 BC by Hippocrates. [8]Contents [ hide ]1 Signs and symptoms2 Causes3 Diagnosis3.1 Physical examination3.2 Diagnostic tests4 Treatment4.1 Procedures4.2 Medications4.3 Lifestyle changes4.4 Treating the cause4.5 Alternative treatments5 Related problems5.1 Pleural effusion5.2 Pneumothorax5.3 Hemothorax6 Prognosis7 References8 External links Signs and symptoms [ edit]The defining symptom of pleurisy is a sudden sharp, stabbing, burning or dull pain in the right or left side of the chest during breathing, especially when one inhales and exhales. [9] It feels worse with deep breathing, coughing, sneezing, or laughing. The pain may stay in one place, or it may spread to the shoulder or back. [10] Sometimes, it becomes a fairly constant dull ache. [11]Depending on its cause, pleuritic chest pain may be accompanied by other symptoms: [12]Dry cough Fever and chills Rapid, shallow breathing Shortness of breath Fast heart rate Sore throat followed by pain and swelling in the joints Causes [ edit]Pleurisy Pleural linings and space (marked in blue)The pleural space can be invaded by fluid, air, and particles from other parts of the body, which fairly complicates diagnosis. [12] [13] Viral infection ( coxsackie B virus, HRSV, CMV, adenovirus, EBV, parainfluenza, influenza) is the most common cause of pleurisy. However, many other different conditions can cause pleuritic chest pain: [11]Aortic dissections Autoimmune disorders such as systemic lupus erythematosus (or drug-induced lupus erythematosus ), Autoimmune hepatitis (AIH), rheumatoid arthritis and Behçet's disease. Bacterial infections associated with pneumonia and tuberculosis Chest injuries (blunt or penetrating)Familial Mediterranean fever, an inherited condition that often causes fever and swelling in the abdomen or the lungs Fungal or parasitic infections Heart surgery, especially coronary-artery bypass grafting Cardiac problems ( ischemia, pericarditis)Inflammatory bowel disease Lung cancer and lymphoma Other lung diseases like cystic fibrosis, sarcoidosis, asbestosis, lymphangioleiomyomatosis, and mesothelioma Pneumothorax Pulmonary embolisms, which are blood clots that enter the lungs When the space between the pleurae starts to fill with fluid, as in pleural effusion, the chest pain can be eased but a shortness of breath can result, since the lungs need room to expand during breathing. Some cases of pleuritic chest pain are idiopathic, which means that the exact cause cannot be determined. Diagnosis [ edit]A diagnosis of pleurisy or another pleural condition is based on a medical history, physical examinations, and diagnostic tests. [12] The goals are to rule out other sources of the symptoms and to find the cause of the pleurisy so that the underlying disorder can be treated. Physical examination [ edit]A doctor uses a stethoscope to listen to the breathing. This method detects any unusual sounds in the lungs. A person with pleurisy may have inflamed layers of the pleurae that make a rough, scratchy sound as they rub against each other during breathing. This is called pleural friction rub. Diagnostic tests [ edit]Depending on the results of the physical examination, diagnostic tests are sometimes performed. Chest x-ray [ edit]A chest x-ray takes a picture of the heart and lungs. It may show air or fluid in the pleural space. It also may show the cause (e.g., pneumonia, a fractured rib, or a lung tumor) of the pleurisy. Sometimes an x-ray is taken while lying on the painful side. This may show fluid, as well as changes in fluid position, that did not appear in the vertical x-ray. Blood test [ edit]Blood tests can detect bacterial or viral infections, pneumonia, rheumatic fever, a pulmonary embolism, or lupus. ECG [ edit]Electrocardiography test can determine if a heart condition contributes to the symptoms. Ultrasound [ edit]Ultrasonography uses sound waves to create an image. It may show where fluid is located in the chest. It also can show some tumors. Although ultrasound may detect fluid around the lungs, also known as a pleural effusion, sound waves are scattered by air. Therefore, an actual picture of the lungs cannot be obtained with ultrasonography. Computed tomography (CT) scan [ edit]A CT scan provides a computer-generated picture of the lungs that can show pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor. Magnetic resonance imaging (MRI) [ edit]Magnetic resonance imaging (MRI), also called nuclear magnetic resonance (NMR) scanning, uses powerful magnets to show pleural effusions and tumors. Arterial blood gas [ edit]In arterial blood-gas sampling, a small amount of blood is taken from an artery, usually in the wrist. The blood is then checked for oxygen and carbon-dioxide levels. This test shows how well the lungs are taking in oxygen. Thoracentesis [ edit]The illustration shows a person undergoing thoracentesis. The person sits upright and leans on a table. Excess fluid from the pleural space is drained into a bag. Once the presence of an excess fluid in the pleural cavity, or pleural effusion, is suspected and location of fluid is confirmed, a sample of fluid can be removed for testing. [14] The procedure to remove fluid in the chest is called a diagnostic thoracentesis. [15] The doctor inserts a small needle or a thin, hollow, plastic tube in the chest wall and withdraws fluid. [16]Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is used to guide the needle to the fluid that is trapped in small pockets around the lungs. Thoracentesis usually does not cause serious complications. Generally, a chest x-ray is done after the procedure to evaluate the lungs. Possible complications of thoracentesis include the following: Bleeding and bruising where the needle went in. In rare cases, bleeding may occur in or around the lung. The doctor can use a chest tube to drain the blood. In some cases, surgery is needed. Infection where the needle went in Injury to the liver or spleen (in rare cases)Pain. Pneumothorax, or buildup of air in the pleural space, with a collapsed or partially collapsed lung. Sometimes air comes in through the needle or the needle makes a hole in the lung. Usually, a hole seals itself—but sometimes air builds up around the lung and makes it collapse. A chest tube removes the air and lets the lung expand again. The lung fluid is examined under a microscope and is evaluated for the presence of chemicals and for its color and texture. The degree of clarity is an indicator of infection, cancer, or other conditions that may be causing the buildup of fluid or blood in the pleural space. Biopsy [ edit]If tuberculosis or cancer is suspected, a small piece of the pleura may be examined under a microscope to make a definitive diagnosis. This is called a biopsy. Several approaches to taking tissue samples are available Insertion of a needle through the skin on the chest to remove a small sample of the outer layer of the pleura Insertion of a small tube with a light on the end ( endoscope) into tiny cuts in the chest wall to visualize the pleura, and biopsy of small pieces of tissue through the endoscope Removal of a sample of the pleura through a small cut in the chest wall (open pleural biopsy), usually done if the sample from the needle biopsy is too small for accurate diagnosis Treatment [ edit]Treatment has several goals: [12]Relief of symptoms Removal of the fluid, air, or blood from the pleural space Treatment of the underlying condition Procedures [ edit]If large amounts of fluid, air, or blood are not removed from the pleural space, they may cause the lung to collapse. The surgical procedures used to drain fluid, air, or blood from the pleural space are as follows: During thoracentesis, a needle or a thin, hollow, plastic tube is inserted through the ribs in the back of the chest into the chest wall. A syringe is attached to draw fluid out of the chest. This procedure can remove more than 6 cups (1.5 litres) of fluid at a time. When larger amounts of fluid must be removed, a chest tube may be inserted through the chest wall. The doctor injects a local painkiller into the area of the chest wall outside where the fluid is. A plastic tube is then inserted into the chest between two ribs. The tube is connected to a box that suctions the fluid out. A chest x-ray is taken to check the tube's position. A chest tube is also used to drain blood and air from the pleural space. This can take several days. The tube is left in place, and the patient usually stays in the hospital during this time. Sometimes the fluid contains thick pus or blood clots, or it may have formed a hard skin or peel. This makes it harder to drain the fluid. To help break up the pus or blood clots, the doctor may use the chest tube to put certain medicines into the pleural space. These medicines are called fibrinolytics. If the pus or blood clots still do not drain out, surgery may be necessary. Medications [ edit]A couple of medications are used to relieve pleurisy symptoms: Paracetamol (acetaminophen) or anti-inflammatory agents to control pain and decrease inflammation. Only indomethacin (brand name Indocin) has been studied with respect to relief of pleurisy. [17]Codeine -based cough syrups to control the cough There may be a role for the use of corticosteroids (for tuberculous pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of pleurisy. Further studies are needed. Lifestyle changes [ edit]The following may be helpful in the management of pleurisy: Lying on the painful side may be more comfortable Breathing deeply and coughing to clear mucus as the pain eases. Otherwise, pneumonia may develop. Getting rest Treating the cause [ edit]Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease. If the pleural fluid is infected, treatment involves antibiotics and draining the fluid. If the infection is tuberculosis or from a fungus, treatment involves long-term use of antibiotics or antifungal medicines. If the fluid is caused by tumors of the pleura, it may build up again quickly after it is drained. Sometimes anti-tumor medicines prevent further fluid buildup. If they don't, the doctor may seal the pleural space. This is called pleurodesis. Pleurodesis involves the drainage of all the fluid out of the chest through a chest tube. A substance is inserted through the chest tube into the pleural space. This substance irritates the surface of the pleura. This causes the two layers of the pleurae to squeeze shut so there is no room for more fluid to build up. Chemotherapy or radiation treatment also may be used to reduce the size of the tumors. If congestive heart failure is causing the fluid buildup, treatment usually includes diuretics and other medicines. The treatment for pleurisy depends on its origin and is prescribed by a physician on a base of an individual assessment. [18]Paracetamol (acetaminophen) and amoxicillin, or other antibiotics in case of bacterial infections, are common remedies dispensed by doctors to relieve the initial symptoms and pain in the chest, while viral infections are self-limited. Non-steroidal anti-inflammatory drugs (NSAIDs), preferably indometacin, are usually employed as pain control agents. [12]Alternative treatments [ edit]A number of alternative or complementary medicines are being investigated for their anti-inflammatory properties, and their use in pleurisy. At this time, clinical trials of these compounds have not been performed. Extracts from the Brazilian folk remedy Wilbrandia ebracteata ("Taiuia") have been shown to reduce inflammation in the pleural cavity of mice. [19] [20] The extract is thought to inhibit the same enzyme, cyclooxygenase-2 (COX-2), as the non-steroidal anti-inflammatory drugs. [20]Related problems [ edit]Pleurisy is often associated with complications that affect the pleural space. Pleural effusion [ edit]In some cases of pleurisy, excess fluid builds up in the pleural space. This is called a pleural effusion. The buildup of fluid usually forces the two layers of the pleura apart so they don't rub against each other when breathing. This can relieve the pain of pleurisy. A large amount of extra fluid can push the pleura against the lung until the lung, or a part of it, collapses. This can make it hard to breathe. In some cases of pleural effusion, the extra fluid gets infected and turns into an abscess. This is called an empyema. Pleural effusion involving fibrinous exudates in the fluid may be called fibrinous pleurisy. It sometimes occurs as a later stage of pleurisy. A person can develop a pleural effusion in the absence of pleurisy. For example, pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural effusion. Pneumothorax [ edit]Air or gas also can build up in the pleural space. This is called a pneumothorax. It can result from acute lung injury or a lung disease like emphysema. Lung procedures, like surgery, drainage of fluid with a needle, examination of the lung from the inside with a light and a camera, or mechanical ventilation, also can cause a pneumothorax. The most common symptom is sudden pain in one side of the lung and shortness of breath. A pneumothorax also can put pressure on the lung and cause it to collapse. If the pneumothorax is small, it may go away on its own. If large, a chest tube is placed through the skin and chest wall into the pleural space to remove the air. Hemothorax [ edit]Blood also can collect in the pleural space. This is called hemothorax. The most common cause is injury to the chest from blunt force or surgery on the heart or chest. Hemothorax also can occur in people with lung or pleural cancer. Hemothorax can put pressure on the lung and force it to collapse. It also can cause shock, a state of hypoperfusion in which an insufficient amount of blood is able to reach the organs. Prognosis [ edit]Pleurisy and other disorders of the pleurae can be serious, depending on what caused them. Generally, pleurisy treatment has an excellent prognosis, but if left untreated it can cause severe complications. For example, a resulting pulmonary heart disease cor pulmonale, which manifests itself with an inflammation of the arms and legs, can lead to heart failure. If the conditions that caused the pleurisy or other pleural disorders were adequately diagnosed and treated early, one can expect a full recovery. Help of a pulmonologist (respiratory physician in the U. K. and Australia) may be enlisted to address the underlying cause and chart post-illness rehabilitation. References [ edit]^ a b c d e "What Are Pleurisy and Other Pleural Disorders?". NHLBI. 21 September 2011. Archived from the original on 8 November 2016. Retrieved 1 November 2016.^ a b c d "What Causes Pleurisy and Other Pleural Disorders?". NHLBI. 21 September 2011. Archived from the original on 8 October 2016. Retrieved 1 November 2016.^ a b c d e f Ferri, Fred F. (2016). Ferri's Clinical Advisor 2017: 5 Books in 1. Elsevier Health Sciences. p. 981. ISBN 9780323448383. Archived from the original on 3 November 2016.^ a b "How Are Pleurisy and Other Pleural Disorders Treated?". NHLBI. 21 September 2011. Archived from the original on 3 November 2016. Retrieved 1 November 2016.^ a b c Disease & Drug Consult: Respiratory Disorders. Lippincott Williams & Wilkins. 2012. p. Pleurisy. ISBN 9781451151947. Archived from the original on 3 November 2016.^ a b "What Are the Signs and Symptoms of Pleurisy and Other Pleural Disorders". NHLBI. 21 September 2011. Archived from the original on 8 October 2016. Retrieved 1 November 2016.^ Kass, SM; Williams, PM; Reamy, BV (1 May 2007). "Pleurisy". American Family Physician. 75 (9): 1357–64. PMID 17508531.^ Light, Richard W.; Lee, Y. C. Gary (2008). Textbook of Pleural Diseases Second Edition (2 ed.). CRC Press. p. 2. ISBN 9780340940174. Archived from the original on 3 November 2016.^ "The Lung Center: Understanding Pleurisy" (PDF). An online information portal for the community. The Lung Center, New Deli, India. Archived (PDF) from the original on 1 September 2012. Retrieved 22 June 2013.^ Beth Walsh, MA. Pleurisy (pleuritis). Archived 9 February 2013 at the Wayback Machine.^ a b Ferri, Fred F. Ferri's Clinical Advisor 2012. Philadelphia, PA: Elsevier Mosby, 2012, P. 790.^ a b c d e Sara M. Kass, CDR, MC, USN, Pamela M. Williams, MAJ, USAF, MC, and Brian V. Reamy, COL, USAF, MC, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Pleurisy. American Family Physician. 2007, 1 May; 75 (9):1357–1364. Archived 14 February 2015 at the Wayback Machine. PDF Archived 31 January 2016 at the Wayback Machine.^ Maskell, Nick, and Ann Millar. Oxford Desk Reference. Oxford: Oxford University Press, 2009. Chapter 14. Pleural Disease. PDF Archived 8 October 2013 at the Wayback Machine.^ Raed A. Dweik. Cleveland Clinic Center for Continuous Education: Pleural Disease. Archived 8 May 2013 at the Wayback Machine.^ Light, R. W. Diagnostic principles in pleural disease. European Respiratory Journal, 1997 Feb; 10 (2): 476–81. [1]^ Sahn, Steven A. Pleural Disease. Philadelphia: Saunders, 2006.^ Klein RC (October 1984). "Effects of indomethacin on pleural pain". South. Med. J. 77 (10): 1253–4. doi: 10.1097/00007611-198410000-00011. PMID 6207594.^ Fishman, Alfred P., and Jack A. Elias. Fishman's Pulmonary Diseases and Disorders. New York: Mc Graw-Hill, Health Professions Division, 1997.^ Peters RR, Saleh TF, Lora M, et al. (1999). "Anti-inflammatory effects of the products from Wilbrandia ebracteata on carrageenan-induced pleurisy in mice". Life Sci. 64 (26): 2429–37. doi: 10.1016/S0024-3205 (99)00200-3. PMID 10403502.^ a b Siqueira JM, Peters RR, Gazola AC, et al. (March 2007). "Anti-inflammatory effects of a triterpenoid isolated from Wilbrandia ebracteata Cogn". Life Sci. 80 (15): 1382–7. doi: 10.1016/j.lfs.2006.12.021. PMID 17286991. External links [ edit]Classification V · T · DICD - 10: J90, R09.1 ICD - 9-CM: 511 Me SH: D010998 Diseases DB: 29361External resources Medline Plus: 001371Tim Kenny; Colin Tidy (2002–2013). "Pleurisy and Pleuritic Pain". www.patient.info. Retrieved 2013-06-30. The Lung Association of Canada explanation of Pleurisy (also available in French)Pleurisy by the American Academy of Family Physicians [ show]v t e Symptoms and signs relating to the respiratory system ( R04–R07, 786) [ show]v t e Diseases of the respiratory system ( J, 460–519) [ show]v t e Inflammation Authority control NDL: 00569657Categories: Diseases of pleura Inflammations Symptoms and signs: Respiratory system  High Frequency Chest Wall Oscillation (HFCWO) High Frequency Chest Wall Oscillation (HFCWO)by joana lancastre Home » COPD Treatment » High Frequency Chest Wall Oscillation (HFCWO)Common symptoms of chronic obstructive pulmonary disease, or COPD , include shortness of breath, a frequent cough or cough that produces a lot of mucus, wheezing, and tightness in the chest. Excess mucus production and poor airway mucociliary clearance can obstruct air passages, making it difficult to breath, reducing the effectiveness of inhaled medications, and trapping bacteria that can lead to frequent infections. High frequency chest wall oscillation (HFCWO) is an airway clearance technique that loosens mucus by applying vibrations at different frequencies to the chest wall via a wearable vest. How does HFCWO work? HFCWO devices typically consist of an inflatable vest, connected by hoses to an external generator, that delivers percussion to the chest wall. Rapid and repeating pulses of positive air pressure gently oscillate (squeeze and release) the chest to facilitate mucus clearance. The therapy must be prescribed, and is typically used with a bronchodilator to enhance the opening of the airways. It is adapted for each person, starting with low pressures and frequencies that increase until a recommended pressure/frequency is reached. This treatment is usually given while the patient is seated an upright position, with sessions lasting about 30 minutes. Pauses are taken to cough out mucus that has loosened and moved into the large airways. Many of these devices use air bladder technology ( Smart Vest, The Vest ) with hoses connected to an external, programmable air pulse generator. HFCWO vests, however, feature built-in oscillating modules and is battery-powered, allowing for greater mobility during therapy. Treatment can also be given regardless of whether a person is sitting, standing, or laying down. Studies of HFCWO in COPD and other diseases A few studies have evaluated HFCWO in terms of life quality in people with COPD. One ( NCT00883616) was randomized and controlled crossover study that compared HFCWO treatment to self-administered breathing exercises in 22 COPD patients. Therapy was given in 20-minute sessions, twice daily, for four weeks, followed by a two-week washout period. Results showed that the treatment was well-tolerated and that mucus production declined during this treatment, easing symptoms and improving quality of life. Another, a Phase 2 study ( NCT00181285 ) — sponsored by Johns Hopkins University — evaluated HFCWO therapy in adults hospitalized due to asthma or COPD exacerbations. During four treatment periods, patients received either the HFCWO or a sham (fake device) treatment for 15 minutes, three times a day. Results of this study also showed that the treatment was well-tolerated in patients being treated for acute flares, and those given HFCWO demonstrated a clinically significant improvement in dyspnea (shortness of breath) after treatment compared to the control group. HFCWO is mainly used to treat cystic fibrosis, a condition characterized by accumulation of thick mucus in the airways. Besides COPD, it is also prescribed for people with bronchiectasis, cerebral palsy, and muscular dystrophy. COPD News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.  Pectus Excavatum Pectus Excavatum What is pectus excavatum? Click the video above to view an online presentation on diagnosis and treatment options for Pectus. Pectus excavatum, also called funnel chest, is the most common congenital deformity of the front wall of the chest. This abnormal formation of the rib cage develops during pregnancy and gives the chest a caved-in or sunken appearance. Researchers believe the cause is abnormal growth of the connective tissue that connects the ribs to the breastbone. A child with pectus excavatum usually has a depression in the center of the chest over the breastbone, which may appear quite deep. Severe cases of pectus excavatum may affect the function of the heart and lungs, in addition to creating psychological difficulty for the child. How is pectus excavatum diagnosed? Pectus excavatum is often diagnosed by the patient or their family members who notice an abnormal shape of the chest. This can occur as small children or develop later in life, especially during the prepubescent years, when kids go through their growth spurt. Pectus excavatum may occur with or without a family history. The majority of pectus excavatum cases are not associated with other conditions. However, tests may be done to rule out other suspected disorders, including Marfan syndrome, a connective tissue disorder that causes long limbs, curvature of the spine and chest abnormalities; Poland syndrome, a disorder marked by missing or abnormal muscle development on one side of the chest and abnormalities of the hand; scoliosis or curvature of the spine; or rickets, which results from a lack of vitamin D or calcium and not enough exposure to sunlight, which interferes with normal bone growth. These tests may include chromosome and metabolic studies, enzyme assays and x-rays. How is pectus excavatum treated? Your doctor may recommend physical therapy for your child to slow or reverse the effects of pectus excavatum. Surgery is generally advised for severe pectus excavatum that interferes with exercise and other activities of daily living. Some patients and parents make the decision to have surgery for cosmetic reasons. Severe pectus deformities can have a severe impact on the child’s social development and self-esteem. Surgery for pectus excavatum is typically performed when children are between 10 and 14 years of age. The primary goal of surgical repair is to correct the deformity, and improve posture and lung and heart function. The typical surgery involves removing a portion of the deformed cartilage and repositioning the breastbone. Most operations for pectus excavatum are performed by inserting a metal bar under the breastbone. This procedure is called a Nuss procedure and utilizes the Nuss bar. This minimally invasive approach is used in greater than 90% of pectus excavatum operations in the United States. In certain situations, the pectus deformity requires an open operation with removal of the abnormal cartilage that connects the ribs to the breastbone. The minimally invasive Nuss procedure for pectus excavatum is performed at Children’s Memorial Hermann Hospital. Patients undergo an extensive pre-surgery workup to assess the severity of the deformity and identify any additional problems. The operation is performed with small incisions along the chest utilizing a specialized camera in the chest. Most patients require a 5-7 day hospital stay. However, full recovery may require several weeks. Close follow-up is maintained until the Nuss bar is removed after approximately 2-3 years. Contact Us University of Texas Health Science Center Professional Building Department of Pediatric Surgery 6410 Fannin Street, Suite 950 Houston, TX 77030 Get Directions »Phone: (832) 325-7234Contact the Physician Office »This information, although based on a thorough knowledge and careful review of current medical literature, is the opinion of doctors at Mc Govern Medical School at UTHealth and is presented to inform you about chest wall conditions. It is not meant to contradict any information you may receive from your personal physician and should not be used to make decisions about treatment. If you have any questions about the information above or your child's care, please contact our doctors.  What Is a Chest Contusion? Health Conditions & Diseases Wounds & Bruises Q: What Is a Chest Contusion? A: Quick Answer Free MD explains that a chest contusion is a bruise to the chest wall and the bruise involves the skin, muscles or ribs of the chest wall. A serious chest contusion possibly causes bleeding in the underlying muscle and subcutaneous tissues, leading to a chest hematoma. Free MD lists the symptoms of a chest contusion as bruising, chest pain, swelling and chest wall tenderness. Continue Reading Keep Learning What Are the Color Stages of Bruises? What Symptoms Are Associated With Bruised Ribs? What Is a Bird Chest? Full Answer Healthwise Incorporated explains that chest contusions occur due to falls or direct blows to the chest. Injury from bicycle handlebars, getting punched and car crashes are some of the most common causes of chest contusions. If an extremely forceful blow is delivered to the chest, it is possible to have injury in the lungs, airway, liver, spleen, heart and blood vessels in the chest. An injury to muscles, ribs or cartilage typically causes chest pain. A chest contusion causes swelling, pain and a purplish discoloration, the University of Minnesota Medical Center states. It takes anywhere between a few days and several weeks to heal. For home care, rest is highly recommended. A person with a chest contusion must not lift anything heavy, do strenuous exertion or perform any activity that causes pain. The University of Minnesota Medical Center warns that prompt medical attention is necessary if a person experiences increasing chest pain with breathing, shortness of breath, dizziness or weakness, abdominal pain and fever above 100.4 degrees Fahrenheit. Learn more about Wounds & Bruises Sources: freemd.com uofmmedicalcenter.org myhealth.alberta.ca Related Questions Q: What Is a Knee Contusion? A: A knee contusion is a bruised knee, according to the American Society of Orthopaedic Surgeons. "Contusion" is medical jargon for a bruise. Contusions are o... Full Answer >Filed Under: Wounds & Bruises Q: What Are Common Causes of Soreness in the Chest? A: Common causes of soreness in the chest include swallowing disorders, acid influx, sore muscles, injured ribs and collapsed lungs, according to Healthlne. O... Full Answer >Filed Under: Pain & Symptoms Q: What Are Some Possible Causes for a Sharp Pain in the Heart? A: A sharp pain in the chest can indicate a heart attack, digestive issues or medical problems in the nerves, ribs, muscles, lungs or esophagus, explains Web M... Full Answer >Filed Under: Pain & Symptoms Q: What Must Be Done When You Get a Bruise With a Hard Lump? A: Treatment using factor concentrate following a doctor's instructions is necessary if a lump emerges in a bruise or if the lump grows, according to the Hemo... Full Answer >Filed Under: Wounds & Bruises You May Also Like Q: How Can You Treat a Knee Injury? Q: What Are Some Causes of Head Bumps? Q: What Kind of Injury Is an Avulsion? Q: What Do You Put on a Burn? Q: How Long Does It Take to Heal a Fractured Tibia? Q: What Is a Blood Blister on the Tongue?  Top 30 Doctor insights on: Treatments For Barrel Chest Top 30 Doctor insights on: Treatments For Barrel Chest Share Follow @Health Tap </> Embed Dr. Brian Mott2 doctors agreed:1 Is a pigeon chest and barrel chest the same thing? No: A pigeon chest is a deformity of the sternum in teenagers called pectus carinitum or excavatum. These are usually not responsible for any symptoms but are mostly cosmetic. A barrel chest is the ... Read more Dr. Herman Hammerstead2 Can a brace cure barrel chest disorder? NO: Noy correctable by brace Get help from a doctor now ›Dr. Robert Fietsam Surgery - Thoracic28 years in practice Get help from a real doctor now Continue Dr. Michael Sparacino1 doctor agreed:3 Treatment of right upper side chest pain? See below: These are symptoms that could be potentially serious. Yous should discuss these with your physician. He/she will thoroughly evaluate you and let you know what's going on. ... Read more Dr. Jeffrey Clemens2 doctors agreed:4 What is the treatment for a sucking chest wound? Hospital ASAP: Get to the hospital immediately. A sucking chest wound means that the chest cavity is open to air and the lung on that size is completely collapsed. First aid for this is classically placing an occlusive dressing that is taped down on three sides and left open on the fourth side. Definitive treatment is surg ... Read more Dr. Lyall Gorenstein5 Is there any treatment for barrel chest in a child? Yes: Bracing for 3-6 months will correct most pectus carinatum disorders. ... Read more Dr. John Feola6 Hi. I have slight pain and discomfort in front and back side chest with certain moves. Suggest me treatment n reason. Thanx? R/O COSTOCHONDRITIS: You need to be examined have blood work and ekg. If you had a recent viral infection, you may have a post infection COSTOCHONDRITIS which usually responds to a course of prednisone with taper over 8dys. Also PLEURITIS and pericarditis can mimic these symptoms ... Read more Dr. Robert Perlmuter Internal Medicineyears in practice Get help from a specialist now Continue Dr. Hesham Hassaballa1 doctor agreed:7 What does having a barrel chest mean? Shape of chest: A "barrel chest" is the change in shape of a chest due to emphysema. When the lungs get destroyed from smoking (most often), it is hard to blow the air out of the lungs, which causes the lungs to get bigger with the trapped air. Thus, the chest changes shape to look like a "barrel.". ... Read more Dr. Gerald Mandell2 doctors agreed:8 What causes someone to have a barrel chest? Chronic overaeration: Barrel chest deformities with increased anteroposterior chest diameters can be seen in obstructive forms of chronic pulmonary disease, such as cystic fibrosis and untreated or poorly controlled asthma. In older patients chronic obstructive pulmonary disease can be cause. Arthritis may limit ... Read more Dr. Harold Fields1 doctor agreed:9 How can barrel chest be corrected in adults? Barrel chest: This is a characteristic you were born with and I would try to learn to live with it. I suppose if you really looked you could find a surgeon willing to do major surgery to correct it but I would not adviceit. ... Read more Dr. Scott Mc Lean1 doctor agreed:10 Why do people have barrel chest? Heredity? Sometimes: Genetics can certainly influence the shape of the thorax through the the way that genes control the growth of the ribs, vertebrae, and lungs. Folks with either genetic or environmental reasons for big lungs, like alpha-1-antitrypsin deficience and emphysema from smoking, can have barrel shaped ... Read more Dr. Ahmad M Hadied5 doctors agreed:11 What is the treatment for chest wall pain? It is tricky ques: If you means non cardiac pain, mostly conservative by pain medications anti inflammatory medications and nerve blocks. ... Read more Dr. Mahesh Allam12 Best course of treatment for injured ribs/chest? Contusion: Pain control & incentive spirometry (deep breathing exercises). Make sure there is no internal bleeding ( hemothorax) & lung is not collapsed (pneumothorax) by a fractured ribs. Serial xray may be indicated. Consult a pulmonologist. ... Read more Dr. Brian Mott2 doctors agreed:13 Is a pigeon chest and barrel chest the same thing? No: A pigeon chest is a deformity of the sternum in teenagers called pectus carinitum or excavatum. These are usually not responsible for any symptoms but are mostly cosmetic. A barrel chest is the result of COPD or emphysema and is an over expansion of the lungs from smoking resulting in the entire rib cage billowing ... Read more Dr. Michael Borookhim1 doctor agreed:14 What is the treatment for leaking air inside chest? A penumothorax is: Usually treated with a chest tube as first line treatment. ... Read more Dr. Gutti Rao1 doctor agreed:15 Chest pain after the treatment of lymphoma. Why now? Chest pain: What treatment chemo or radiation? If it is radiation that you had for the chest you may have some scarring of lung may cause shortness of breath and chest pain. You may have to address this problem with your oncologist if related to therapy, if not you should see a cardiologist to rule out heart problems . ... Read more Dr. Calvin Weisberger4 doctors agreed:16 What is the treatment for chest pain caused by anxiety? Anxiety disorder: The treatment is that of the underlying anxiety disorder and a psychiatric professional should be consulted to help with this if a symptom like chest pain is being produced. ... Read more Dr. Mario Matos-Cruz2 doctors agreed:17 Any differences between barrel chest and pectus carinatum? Yes: The heart may be compressed to various degrees in excavatum, not so much in carinatum. ... Read more Dr. Aaron Milstone2 doctors agreed:18 What respiratory disease is "barrel chest" often indicative? COPD: Typically barrel chest is found in patients with COPD (chronic obstructive pulmonary disease); it is indicative of trapped air in the chest which affects the lateral (side) dimensions of the chest given the chest a rounded appearance. It is typically found in severe or very severe COPD although has occassionally being ... Read more Dr. Aaron Milstone1 doctor agreed:19 Are there any differences between a barrel chest and pectus carinatum? Yes: Barrel chest is an increase in the lateral (side) and front diameter of the chest. Pectus carinum is an outward bowing of the upper breastbone (also known as pigeon chest. Barrel chest is associated with COPD and pectus is usually from birth. ... Read more Dr. Thomas Rohde1 doctor agreed:20 So I have a barrel chest ribcage and I wanna know what my mom did wrong? Nothing! : Can't blame your mother for your appearance, and you shouldn't blame her for any of your shortcomings at your age! This could just be how god made you, or it could be an underlying lung problem like from toxin exposure or smoking. See a local doc to have this evaluated. ... Read more Dr. Lyall Gorenstein1 doctor agreed:21 Does anyone know differences between a barrel chest and pectus carinatum? The same: Also known as pigeon chest . Get help from a doctor now ›Dr. Calvin Weisberger2 doctors agreed:22 Inflamed ribs and bad chest pain. What would be the best treatment for this? Inflamed ribs: We often treat rib inflammation with anti-inflammatory drugs and/or injection with local anesthetic agents. ... Read more Dr. Dean Giannone23 Hi, I have keloids on my chest, i'd like to ask for best treatment. Thanks!Keloids. : Two options here. One would be steroid injections into the keloids, hoping they shrink over the long term. This is not always effective. Second, they can be cut out, but the problem would be that the healing from the resection of a keloid can, of course, produce another keloid. Discuss with Dermatologist ... Read more Dr. Bernard Seif24 My grandson has a misformed chest. Spine also affected. One rib missing and couple of ribs fused and not symmetric. Will he need treatment? Chest & spine: Issues need to be monitored by your grandson's baby doctor. He/she will keep an eye on what is happening and treat as needed. Catching things early on as they develop can make things easier. Peace and good health. ... Read more Dr. Zachary Veres1 doctor agreed:25 Whenever eating some oily or spicy food it's always feeling of burning or like acidity in chest. Is this a big problem or there is any treatment. Plz h? GERD: Sounds like acid reflux. avoid those food for awhile. Omeprazole or ranitidine may help ... Read more Dr. Tracy Berg4 doctors agreed:26 What sort of treatment is chest surgery? Remove or repair: Most surgical treatments are recommended to patients to either repair, remove or replace a broken body part. For chest body parts, the possiblities of chest surgery treatment are many and include remove a lung, or a lung mass, repair an artery or a heart valve. You can ask your surgeon or doctor for ... Read more Dr. Lyall Gorenstein1 doctor agreed:27 What does a barrel chest mean for your health? Nothing: It's purely a cosmetic issue, that can easily be fixed with bracing . ... Read more Dr. Bruce J. Stringer1 doctor agreed:28 I'd like to correct my barrel chest (not sure of cause) as it affects my appearance and posture. Is this possible? Smoker? Asthma? : Unlikely that your barrel chest can be corrected. It may be secondary to any chronic lung problem which causes over expansion of the lungs like asthma, COPD, Emphysema, alpha 1 antitrypsin deficiency. And others. Any history of smoking? Removing the inciting cause may slow progression. ... Read more Dr. David Rosenfeld4 doctors agreed:29 Is lortab an effective treatment for chest pain? See a doctor: Unless one is 100% percent sure that your chest pain is not coming from your heart taking anarcotic to treat it is foolish. ... Read more Dr. Alan Ali30 If I stop smoking will I shrink my barrel chest? Barrell chest: That depends on cause of barrell chest, plus, quitting smoking is overall heathy. ... Read more  Fremitus Fremitus Classification and external resources Diseases DB 13981 13982 [ edit on Wikidata]Fremitus is a vibration transmitted through the body. [1] In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall ( tactile fremitus) and/or heard by a stethoscope on the chest wall with certain spoken words ( vocal fremitus ), although there are several other types. Contents [ hide ]1 Types1.1 Vocal fremitus1.2 Hepatic fremitus1.3 Dental fremitus2 References Types [ edit]Vocal fremitus [ edit]When a person speaks, the vocal cords create vibrations ( vocal fremitus) in the tracheobronchial tree and through the lungs and chest wall, where they can be felt ( tactile fremitus ). [2] This is usually assessed with the healthcare provider placing the flat of their palms on the chest wall and then asking a patient to repeat a diphthong such as "blue balloons" or "toys for tots" (the original diphthong used was the German word Neunundneunzig but the translation to the English 'ninety nine' was not a diphthong and thus not as effective in eliciting fremitus). An increase in tactile fremitus indicates denser or inflamed lung tissue, which can be caused by diseases such as pneumonia. A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma. [2]Hepatic fremitus [ edit]Hepatic fremitus is a vibration felt over the person's liver. It is thought to be caused by a severely inflamed and necrotic liver rubbing up against the peritoneum. The name 'Monash sign' has been suggested for this clinical sign, after the Monash Medical Centre in Melbourne, Australia. [3] [ non-primary source needed]Dental fremitus [ edit]Fremitus appears when teeth move. This can be assessed by feeling and looking at teeth when the mouth is opened and closed. [4]References [ edit]^ " fremitus " at Dorland's Medical Dictionary^ a b Kacmarek, Robert M.; Stoller, James K.; Heuer, Al (2016-02-05). Egan's Fundamentals of Respiratory Care. Elsevier Health Sciences. p. 336. ISBN 9780323393850.^ Nagappan R, Parkin G, Tsui A, Sievert W (2001). "Hepatic fremitus: 'Monash sign ' ". Intern Med J. 31 (9): 567–8. doi: 10.1046/j.1445-5994.2001.00145.x. PMID 11767877.^ Jr, Paul A. Levi; Rudy, Robert J.; Jeong, Y. Natalie; Coleman, Daniel K. (2015-12-29). Non-Surgical Control of Periodontal Diseases: A Comprehensive Handbook. Springer. pp. 213–214. ISBN 9783662466230. [ hide]v t e Symptoms and signs relating to the respiratory system ( R04–R07, 786)Medical examination and history taking Auscultation Stethoscope Respiratory sounds Stridor Wheeze Crackles Rhonchi Stertor Squawk Pleural friction rub Fremitus Bronchophony Terminal secretions Elicited findings Percussion Pectoriloquy Whispered pectoriloquy Egophony Breathing Rate Apnea Prematurity Dyspnea Hyperventilation Hypoventilation Hyperpnea Tachypnea Hypopnea Bradypnea Pattern Agonal respiration Biot's respiration Cheyne–Stokes respiration Kussmaul breathing Ataxic respiration Other Respiratory distress Respiratory arrest Orthopnea / Platypnea Trepopnea Aerophagia Asphyxia Breath holding Mouth breathing Snoring Other Chest pain In children Precordial catch syndrome Pleurisy Nail clubbing Cyanosis Cough Sputum Hemoptysis Epistaxis Silhouette sign Post-nasal drip Hiccup COPDHoover's signasthma Curschmann's spirals Charcot–Leyden crystalschronic bronchitis Reid indexsarcoidosis Kveim testpulmonary embolism Hampton hump Westermark signpulmonary edema Kerley lines Hamman's sign Golden S sign  Internal Fixation of Rib Fracture Number: 0822Policy Aetna considers internal fixation of rib fractures (e.g., Matrix RIB Fixation System, Rib Loc Rib Fracture Plating System) medically necessary in cases of severe flail chest failing to wean from a ventilator or when thoracotomy is required for other reasons. Aetna considers internal fixation of rib fractures experimental and investigational for all other indications. Aetna considers the following interventions experimental and investigational for internal fixation of rib fractures because the effectiveness of these approaches has not been established: Bioabsorbable plate Minimally invasive plate osteosynthesis See also CPB 0582 - Titanium Rib. Background Most injuries to the chest wall do not result in long-term respiratory dysfunction and operative indications for chest wall injuries are rare. Recent studies have explored the option of internal fixation of rib fracture for treatment of complex rib fractures, including flail chest, open fracture, symptomatic nonunion, and thoracotomy for other indications (Lafferty et al, 2011). Flail chest is diagnosed when multiple, consecutive ribs are fractured in two or more places, creating an incompetent region of the chest wall (Slater et al, 2001). A number of small scale studies have evaluated the use of internal fixation of rib fractures. Lardinois et al (2001) prospectively evaluated chest wall integrity and pulmonary function following operative stabilization of flail chest. They followed 66 patients with antero-lateral flail chest. Forty-seven percent of patients were able to be extubated immediately following the procedure and 85 % within 7 days post-operatively. Pulmonary function testing and clinical assessment were performed 6 months post-operatively. The results showed that the 30-day mortality was at 11 % and chest wall complains were noted in 6 of 57 patients, requiring removal of all plates and screws in 3 of those patients. Six month follow-up results also showed a significant difference between predicted and recorded vital capacity (p = 0.04) and forced expiratory volume (p = 0.001). The investigators concluded that antero-lateral flail chest injuries accompanied by respiratory insufficiency, particularly when stabilized early, may be cost effective in that they reduce days on mechanical ventilation and restriction-related working incapacity. Tanaka et al (2002) conducted a prospective randomized trial of 37 severe flail chest patients requiring mechanical ventilation, comparing the relative clinical efficacy of surgical stabilization (S group) and internal pneumatic stabilization (I group). The authors reported that “the S group showed a shorter ventilatory period (10.8 +/- 3.4 days) than the I group (18.3 +/- 7.4 days) (p < 0.05), shorter intensive care unit stay (S group, 16.5 +/- 7.4 days; I group, 26.8 +/- 13.2 days; p < 0.05), and lower incidence of pneumonia (S group, 24 %; I group, 77 %; p < 0.05). Percent forced vital capacity was higher in the S group at 1 month and thereafter (p < 0.05).” Although the findings of this study are encouraging, the relatively small sample size and the specificity of the inclusion criteria must be taken into account when attempting to generalize these findings. Granetzny et al (2005) randomly assigned 40 patients with flail chest to surgical fixation or an external adhesive plaster. The operative group demonstrated significantly fewer patients requiring mechanical ventilation, fewer days in the intensive care unit, shorter hospital stay, and a lower incidence of pneumonia compared with the conservatively managed group. Nirula et al (2006) conducted a matched case-control study to evaluate the impact of operative stabilization of rib fractures due to trauma. Thirty patients undergoing rib stabilization were matched with 30 controls and followed for length of intensive care unit stay (controls, 14.1 +/- 2.7 vs cases, 12.1 +/- 1.2, p = 0.51), total hospital stay (controls, 21.1 +/- 3.9 vs cases, 18.8 +/- 1.8, p = 0.59), total ventilator days (cases, 6.5 +/- 1.3 days versus controls, 11.2 +/- 2.6 days, p = 0.12), and ventilator days post-stabilization (cases, 2.9 +/- 0.6 days versus controls, 9.4 +/- 2.7 days, p = 0.02). The investigators concluded that rib fracture fixation may reduce ventilator requirements in trauma patients with severe thoracic injuries, but long-term functional outcomes need to be assessed to ascertain the impact of this procedure. Richardson et al (2007) performed open reduction and internal fixation on 7 patients using titanium plates and screws. The investigators reported that "there was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with no complications occurring in this group.". However, there are limitations to the degree to which findings can be extrapolated given the sample size of 7 patients. Campbell et al (2009) reported on open reduction and internal fixation using Inion OTPS wraps for treatment of rib fractures for 32 Parkinson’s disease patients with osteoporotic thoracolumbar compression fracture. Would infection occurred in 19 % of patients, chest wall stiffness in 60 %, dyspnea at rest in 20 %, and nonunion of fracture occurred in 1 patient. The authors reported patient satisfaction with the procedure was at 100 % and that the procedure allowed for excellent stabilization of the ribs in both ambulatory and ventilated patients. However, it should be noted that there was a small sample size and relatively high complication rate, although this patient population was one with significant co-morbidity. Mayberry et al (2009) conducted a survey of members of the Eastern Association for the Surgery of Trauma, the Orthopedic Trauma Association, and thoracic surgeons affiliated with teaching hospitals in the United States and received surveys from 238 trauma surgeons (TRS), 97 orthopedic trauma surgeons (OTS) and 70 thoracic surgeons (THS). Although 82 % of TRS, 66 % of OTS, and 71 % of THS thought that rib fracture repair was indicated in selected patients, only 26 % of surgeons reported that they had performed or assisted on a chest wall fracture repair, whereas 22 % of surgeons were familiar with published randomized trials of the surgical repair of flail chest. Mayberry et al (2009) concluded that “the published literature on surgical repair is sparse and unfamiliar to most surgeons. Barriers to surgical repair of rib and sternal fracture include a lack of expertise among TRS, lack of research of optimal techniques, and a dearth of randomized trials.”Marasco et al (2009) had conducted a pilot study of operative fixation of fractured ribs in 13 flail chest patients, requiring on average 4 ribs fixed. Positive results were achieved in all patients with the flail chest stabilized and paradoxical chest wall movement eliminated. Based on the findings of this pilot study, a prospective randomized trial is currently underway. Marasco et al (2010) explored the operative stabilization of rib fracture in 13 patients who had 58 ribs fixed with absorbable prostheses, of which 10 rib fixations failed. The investigators observed that stresses on the plate differed between inspiration and expiration, with greater stress on the screws on the posterior part of the broken rib, and separation of the plate from the rib seemed more likely to occur at this site. In September of 2008 the Food and Drug Administration granted 510K clearance to Synthes (West Chester, PA) for the Synthes Matrix RIB Fixation System for the fixation and stabilization of rib fractures, fusions and osteotomies of normal and osteoporotic bone (FDA, 2008). The Synthes Matrix RIB Fixation System is indicated for the fixation and stabilization of rib fractures, fusions and osteotomies of normal and osteoporotic bone. The system consists of bone plates, intra-medullary (IM) splints and screws. All plates, IM splints and screws are manufactured from titanium alloy. The current practice management guideline for pulmonary contusion - flail chest, issued by the Eastern Association for the Surgery of Trauma, states that surgical fixation may be considered in severe unilateral flail chest or in patients requiring mechanical ventilation when thoracotomy is otherwise required (Simon et al, 2012). However, this guideline is listed as a Level 3 recommendation, indicating that “the recommendation is supported by available data but adequate scientific evidence is lacking … This type of recommendation is useful for educational purposes and in guiding future clinical research”. The EAST Trauma practice guidelines recognize surgical fixation as a Level III recommendation for management of flail chest given the small numbers of patients randomized and a lack of generalizability due to strict exclusion criteria, and the absence of trials comparing operative repair with ‘‘modern’’ nonoperative treatments, such as epidural anesthesia and chest physiotherapy. The guidelines state (grade III recommendation): "Although improvement has not been definitively shown in any outcome parameter after surgical fixation of FC, this modality may be considered in cases of severe FC failing to wean from the ventilator or when thoracotomy is required for other reasons. The patient subgroup that would benefit from early 'prophylactic'’ fracture fixation has not been identified." The guidelines also state (grade III recommendation): "There is insufficient clinical evidence to recommend any type of proprietary implant for surgical fixation of rib fractures. However, in vitro studies indicate that rib plating or wrapping devices are likely superior to intramedullary wires and these should be used as the preferred fixation device." The guidelines noted that "significant quantitative and qualitative gaps exist in the body of knowledge regarding PC-FC." The guidelines identified indications and techniques of surgical fixation among areas in need of further investigation. Bottlang et al (2013) stated that surgical stabilization of flail chest injury with generic osteosynthesis implants remains challenging. A novel implant system comprising anatomic rib plates and intramedullary splints may improve surgical stabilization of flail chest injuries. In an observational study, these investigators evaluated the early clinical experience with this novel implant system to document if it can simplify the surgical procedure while providing reliable stabilization. A total of 20 consecutive patients who underwent stabilization of flail chest injury with anatomic plates and intramedullary splints were prospectively enrolled at 2 Level I trauma centers. Data collection included patient demographics, injury characterization, surgical procedure details and post-operative recovery. Follow-up was performed at 3 and 6 months to assess pulmonary function, durability of implants and fixation and patient health. Patients had an Injury Severity Score of 28 ± 10, a chest Abbreviated Injury Score of 4.2 ± 0.4 and 8.5 ± 2.9 fractured ribs. Surgical stabilization was achieved on average with 5 plates and 1 splint. Intra-operative contouring was required in 14 % of plates. Post-operative duration of ventilation was 6.4 ± 8.6 days. Total hospitalization was 15 ± 10 days. At 3 months, patients had regained 84 % of their expected forced vital capacity (% functional vital capacity [FVC]). At 6 months, 7 of 15 patients who completed follow-up had returned to work; there was no mortality. Among the 91 rib plates, 15 splints and 605 screws in this study there was no hard-ware failure and no loss of initial fixation. There was one incidence of wound infection; implants were removed in 1 patient after fractures had healed. The authors concluded that anatomic plates eliminated the need for extensive intra-operative plate contouring. Intramedullary rib splints provided a less-invasive fixation alternative for single, non-comminuted fractures. These early clinical results indicated that the novel implant system provided reliable fixation and accommodated the wide range of fractures encountered in flail chest injury. These early findings from a small observational study need to be validated by well-designed studies. The Rib Loc Rib Fracture Plating System (ACUTE Innovations, LLC; Hillsboro, OR) was cleared by the FDA through the 510 (k) process in January 2012; it is indicated to stabilize and provide fixation for fractures, fusions, and osteotomies of the ribs, and for reconstructions of the chest wall and sternum. The Rib Loc Rib Fracture Plating System consists of plates and screws for fractures, fusions, and osteotomies. The plates are pre-contoured to minimize bending that is done intra-operatively. Instrumentation is supplied with the implants to aid in the insertion of the plates and screws. All plates and screws are manufactured from titanium or titanium alloy. Large-scale, well-designed studies of this system need to be completed to evaluate the evidence-base for use of this system. Messing et al (2014) presented a review on the role of open reduction and internal fixation of flail chest injuries. A 37-year old woman involved in a motorcycle crash sustained comminuted rib fractures on her right 3rd through 12th ribs. On post-injury day 2, the patient's 5th through 9th ribs were surgically reduced and plated. Later that same day, the patient was successfully weaned from mechanical ventilation and experienced a rapid improvement in incentive spirometry volumes. The authors concluded that further studies are needed to definitively determine the benefits of rib plating versus conventional treatment. Fabricant et al (2014) performed a prospective clinical trial of resection with or without plate fixation for symptomatic rib fracture nonunion 3 or more months post-injury with 6-month post-operative follow-up. The Mc Gill Pain Questionnaire (MPQ) and RAND 36 Health Survey were administered and activity level (sedentary, ambulatory, moderately active, vigorous), functional status (disabled, non-physical labor, physical labor), and work status (employed, unemployed, retired, student) were queried pre- and post-operatively. A total of 24 patients 4 to 197 months (median of 16 months) post-injury underwent surgical intervention for 1 to 4 rib fracture nonunions (median of 2 nonunions). Evidence of intercostal nerve entrapment was present in 9 patients (38 %). MPQ Present Pain Intensity and Pain Rating Index and RAND 36 Physical Functioning, Role Physical, Social Functioning, Role Social, Bodily Pain, Vitality, Mental Health, and General Health were significantly improved at 6 months compared with study entry (p < 0.05). Activity levels significantly improved (p < 0.0001) but functional and work status did not change; 24-hour morphine equivalent dosage of opioids at study entry was 20.3 ± 30.8 (mean ± standard deviation) and at study completion was 9.4 ± 17.5 (p = 0.054). Complications included 1 wound infection, 2 partial screw back-outs, and 1 chest wall hernia at 1 year after resection of adjacent nonunions with significant gaps repaired with absorbable plates. The authors concluded that surgical intervention for rib fracture nonunion may improve chronic pain and disability but without change in functional or work status. Resection of adjacent nonunions with significant gaps may lead to chest wall hernia. Majercik et al (2014) noted that there has been increased interest in surgical stabilization of rib fractures (SSRF). It is difficult to define long-term benefits of the procedure. This is a descriptive study of patient outcomes after SSRF. Patients who had undergone SSRF between April 2010 and August 2012 at a Level I trauma center were identified. Data were collected from the medical records. A telephone survey asking about pain, satisfaction, and employment was administered to patients after hospital discharge. A total of 101 patients met inclusion criteria; 50 % patients completed the survey. Indications for SSRF included flail chest, displaced fractures, pain, and inability to wean from mechanical ventilation. Pain was gone at 5.4 ± 1.1 weeks post- discharge. Satisfaction with SSRF on a scale of 1 to 10 was 9.2 ± .2; and 90 % of employed patients returned to the same work at 8.5 ± 1.2 weeks. The authors concluded that SSRF patients were satisfied and were able to return to normal activity with few limitations. Moreover, they stated that a prospective study using modern rib fixation technology is needed to further define benefits. A drawback of this study was that only 50 % of patients completed the survey; thus the findings may have been skewed. An Up To Date review on “Inpatient management of traumatic rib fractures” (Bulger, 2014) states that “Rib fracture stabilization -- Rib fracture fixation has traditionally required an open thoracotomy for adequate exposure. Several plate types and plate fixation methods have been used, but the search for the optimal material and fixation method continues. Rib fracture fixation is complicated by the anatomy of the human rib. Rib thickness ranges from 8 to 12 mm with a very thin cortex. As a result, it does not hold cortical screws well. In addition, the rib tends to fracture in a spiral pattern or in many small fragments (i.e., comminuted), which complicate repair. Entrapment of the intercostal nerve either as a result of the injury or due to repair can lead to chronic postoperative rib pain. One approach to rib fracture fixation uses malleable plates attached to the anterior surface of the rib (image 1). However, fixation of these plates can be problematic. Another method of fixation uses wire cerclage (i.e., wrapped around the rib) but this can be complicated by wire breakage and plate dislodgement. In addition, circumferential fixation of the rib with a permanent material can potentially impinge the intercostal nerve, causing chronic pain which may require removal of the plates. For this reason, when cerclage is necessary (i.e., comminuted fracture), absorbable sutures should be used. As an alternative, screws can be used to hold the plates in place, but their use is often limited by cortical thickness. Novel techniques for rib fracture fixation include the use of contoured rib plates, absorbable plates, intramedullary rods, U-plates fixed with screws placed over the top of the rib minimizing the risk to the intercostal nerve, and application of osteogenic protein at the fracture site”. Wiese et al (2015) reported the experience with the Stratos system in 2 surgical centers for the management of 2 types of rib fractures:flail chest and multiple dislocated rib fractures with significant chest wall deformity. From January 2009 to May 2012, a total of 94 consecutive patients were included. Selected indications were extended antero-lateral flail chest (n = 68) and dislocated painful rib fractures (n = 26). The open reduction internal fixation (ORIF) system consists of flexible titanium rib clamps and connecting plates. The post-operative course was assessed. Clinical and functional outcomes were evaluated at 6 months. Functional assessment consisted of measurement of the FVC and magnetic resonance imaging (MRI) examination with determination of the radiological vital capacity (r VC) in patients with a flail chest. The median operation time and length of hospital stay were 122 mins and 19 days, respectively, in patients with a flail chest, and 67 mins and 11 days, respectively, in patients with dislocated painful rib fractures. The morbidity rate was 6.4 % and the overall 30-day mortality rate was 1.1 %. Clinical evaluation and pulmonary function testing at 6 months revealed no deformity of the chest wall, symmetrical shoulder girdle mobility in 88 % and a feeling of stiffness on the operated side in 19 % of the patients operated for a flail chest. Median ratio of FVC was 88 %, not suggesting any restriction after stabilization. Magnetic resonance imaging was performed in 53 % (36 of 68) of the patients with a flail chest. The analysis of the r VC showed, on average, no clinically relevant restriction related to the operation, with a mean r VC of the operated relative to the non-operated side of 92 % (95 % confidence interval [CI]: 83 to 100). Stabilization of more than 4 ribs was associated with a lower median r VC than stabilization of 4 or less ribs. The authors concluded that these findings suggested that stabilization of the chest wall with this screwless rib fixation device can be performed with a low morbidity and lead to early restoration of chest wall integrity and respiratory pump function, without clinically relevant functional restriction. Owing to the simplicity of the fixation technique, indications for stabilization can be safely enlarged to selected patients with dislocated and painful rib fractures. The findings of this small study (only 26 patients with rib fractures) need to be validated by well-designed studies. Girsowicz et al (2012) examined if surgical stabilization is effective in improving the outcomes of patients with isolated multiple distracted and painful non-flail rib fractures. Of the 356 papers found using a report search, 9 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers were given. These researchers concluded that, on the whole, the 9 retrieved studies clearly support the use of surgical stabilization in the management of isolated multiple non-flail and painful rib fractures for improving patient outcomes. The interest and benefit was shown not only in terms of pain (Mc Gill pain questionnaire) and respiratory function (forced vital capacity, forced expiratory volume in 1 second and carbon monoxide diffusing capacity), but also in improved quality of life (RAND 36-Item Health Survey) and reduced socio-professional disability. Indeed, most of the authors justified surgical management based on the fact that the results of surgical stabilization showed improvement in short- and long-term patient outcomes, with fast reduction in pain and disability, as well as lower average wait before recommencing normal activities. Hence, the current evidence showed surgical stabilization to be safe and effective in alleviating post-operative pain and in improving patient recovery, thus enhancing the outcome after isolated multiple rib fractures. However, the authors concluded that given the little published evidence, prospective trials are needed to confirm these encouraging results. Leinicke et al (2013) performed a systematic review and meta-analysis of studies comparing operative to non-operative therapy in adult patients with flail chest. Outcomes were duration of mechanical ventilation (DMV), intensive care unit length of stay (ICULOS), hospital length of stay (HLOS), mortality, incidence of pneumonia, and tracheostomy. A comprehensive search of 5 electronic databases was performed to identify randomized controlled trials (RCTs) and observational studies (cohort or case-control). Pooled effect size (ES) or relative risk (RR) was calculated using a fixed or random effects model, as appropriate. A total of 9 studies (538 patients) met inclusion criteria. Compared with control treatment, operative management of flail chest was associated with shorter DMV [pooled ES: -4.52 days; 95 % CI: -5.54 to -3.50], ICULOS (-3.40 days; 95 % CI: -6.01 to -0.79), HLOS (-3.82 days; 95 % CI: -7.12 to -0.54), and decreased mortality (pooled RR: 0.44; 95 % CI: 0.28 to 0.69), pneumonia (0.45; 95 % CI: 0.30 to 0.69), and tracheostomy (0.25; 95 % CI: 0.13 to 0.47). The authors concluded that as compared with non-operative therapy, operative fixation of flail chest was associated with reductions in DMV, LOS, mortality, and complications associated with prolonged MV. They stated that these findings supported the need for an adequately powered clinical study to further define the role of this intervention. Slobogean et al (2013) compared the results of surgical fixation and non-operative management for flail chest injuries. These investigators performed a systematic review of previously published comparative studies using operative and non-operative management of flail chest. Medline, Embase, and the Cochrane databases were searched for relevant studies with no language or date restrictions. Quantitative pooling was performed using a random effects model for relevant critical care outcomes. Sensitivity analysis was performed for all outcomes. A total of 11 manuscripts with 753 patients met inclusion criteria. Only 2 studies were randomized controlled designs. Surgical fixation resulted in better outcomes for all pooled analyses including substantial decreases in ventilator days (mean 8 days, 95 % CI: 5 to 10 days) and the odds of developing pneumonia (odds ratio [OR] 0.2, 95 % CI 0.11 to 0.32). Additional benefits included decreased ICU days (mean of 5 days, 95 % CI: 2 to 8 days), mortality (OR 0.31, 95 % CI: 0.20 to 0.48), septicemia (OR 0.36, 95 % CI: 0.19 to 0.71), tracheostomy (OR 0.06, 95 % CI: 0.02 to 0.20), and chest deformity (OR 0.11, 95 % CI: 0.02 to 0.60). All results were stable to basic sensitivity analysis. The authors concluded that the findings of this meta-analysis suggested surgical fixation of flail chest injuries may have substantial critical care benefits; however, the analyses were based on the pooling of primarily small retrospective studies. They stated that additional prospective RCTs are still needed. Doben et al (2014) examined the impact of surgical rib fixation (SRF) in a treatment protocol for severe blunt chest trauma. Patients with flail chest admitted between September 2009 and June 2010 to the authors’ level I trauma center who failed traditional management and underwent SRF were matched with an historical group. Outcome variables evaluated include age, injury severity score, intensive care unit length of stay (LOS), hospital LOS, ventilator days, total number of rib fractures, and total number of segmental rib fractures. The 2 groups were similar in age, injury severity score, intensive care unit LOS, hospital LOS, total number of rib fractures, and total segmental rib fractures. The operative group demonstrated a significant reduction in total ventilator days as compared with the non-surgical group (4.5 [0 to 30] versus 16.0 [4 to 40]; p = 0.040). Patients with SRF were permanently liberated from the ventilator within a median of 1.5 days (0 to 8 days). The authors concluded that surgical rib fixation resulted in a significant decrease in ventilator days and may represent a novel approach to decreasing morbidity in flail chest patients when used as a rescue therapy in patients with declining pulmonary status. They stated that larger studies are needed to further identify these benefits. Zhang et al (2015) compared the clinical efficacy of surgical fixation and nonsurgical management of flail chest and pulmonary contusion (FC-PC). Data on 39 patients diagnosed with FC-PC from July 2010 to December 2013 from the intensive care unit of Shanghai First People's Hospital and analyzed retrospectively. The patients required ventilator support and were divided into a surgical group and a nonsurgical group, according to the treatment method. Clinical data on mortality, the duration of mechanical ventilation (DMV), intensive care unit length of stay, hospital length of stay, days of antibiotic use, transfusion volume, medical expense and incidence of tracheotomy, pleural effusion, and incidence of ventilator associated pneumonia, were collected for all subjects. The surgical group was further divided into 2 groups according to the surgery timing. Surgery within 7 days of admission was defined as early surgery, and all other times were defined as late surgery. The clinical data and incidence of incision infection were collected and compared. The patients in the surgical group had a slightly shorter hospital length of stay. No differences were noted in mortality and the other clinical data between the groups. The early surgical group had a shorter duration of mechanical ventilation and less incidence of tracheotomy. The other parameters had no differences. The investigators concluded that surgery for FC-PC could reduce the HLOS, and early surgery could decrease the DMV and the need for tracheotomy. Xu et al (2015) reported on a retrospective study comparing surgical and conservative treatments for flail chest. In this study, 32 patients with severe flail chest were treated in the Fujian Provincial Hospital (China) between July 2007 and July 2012 with surgical internal rib fixation (n = 17) or conservative treatments (n = 15). Mechanical ventilation time, intensive care unit (ICU) stay time, pulmonary infection, antibiotic treatment duration, acute physiology and chronic health evaluation II (APACHE II) scores 7 and 14 days after trauma, rate of tracheostomy, and rate of endotracheal re-intubation were compared. One patient died in the conservative treatment group. Better short-term outcomes were observed in the surgery group, such as total mechanical ventilation time (10.5 ± 3.7 versus 13.7 ± 4.4 days, p = 0.03), ICU stay (15.9 ± 5.0 versus 19.6 ± 5.0 days, p = 0.05), pulmonary infection rate (58.8 % versus 93.3 %, p = 0.02), and APACHE II scores on the 14th day (6.5 ± 3.8 versus 10.1 ± 4.7, p = 0.02). No difference was observed in the therapeutic time of antibiotics, rate of tracheostomy, and the rate of endotracheal re-intubation between the 2 groups. The authors concluded that internal fixation surgery resulted in better outcomes in the management of severe flail chest compared with conservative treatments. Vana et al (2014) stated that thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of 3 or more ribs in 2 or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. These investigators reviewed the history of management for flail chest alone and when combined with pulmonary contusion; they proposed an algorithm for non-operative and surgical management. De Jong et al (2014) noted that rib fractures can cause significant problems in trauma patients, often resulting in pain and difficulty with respiration. To prevent pulmonary complications and decrease the morbidity and mortality rates of patients with rib fractures, currently there is a trend to provide surgical management of patients with flail chest. However, the indications for rib fracture fixation require further specification. Past and current strategies were described according to a review of the medical literature. These researchers performed a systematic review including current indications for rib fracture fixation. Medline (2000 to 2013) was searched, as well as Embase (2000 to 2013) and Cochrane Databases, using the keywords rib, fracture, fixation, plate, repair, and surgery. A total of 3 retrospective studies were found that described different techniques for rib fracture fixation. The results demonstrated a reduced number of ventilation days, decreased long-term morbidity and pain, and satisfactory rehabilitation after surgical treatment. In addition to flail chest, age, Injury Severity Score, and the number of rib fractures were important predictive factors for morbidity and mortality. The authors concluded that surgical rib fracture fixation might be indicated in a broader range of cases than is currently performed. Moreover, they stated that prospective RCTs are needed for further confirmation. Cataneo et al (2015) conducted a Cochrane review to evaluate the effectiveness and safety of surgical stabilization compared with clinical management for people with flail chest (FC). The authors searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE (Ovid SP), EMBASE Classic and EMBASE (Ovid SP), CINAHL Plus (EBSCO), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and clinical trials registers. The authors also screened reference lists and contacted experts. The review included randomized controlled trials of surgical versus non-surgical treatment for people diagnosed with FC. Two review authors selected relevant trials, assessed their risk of bias, and extracted data. The authors included three studies that involved 123 people. The methods used for blinding the participants and researchers to the treatment group were not reported, but as the comparison is surgical treatment with medical treatment this bias is hard to avoid. There was no description of concealment of the randomization sequence in two studies. All 3 studies reported on mortality, and deaths occurred in 2 studies. There was no clear evidence of a difference in mortality between treatment groups (risk ratio (RR) 0.56, 95 % confidence interval (CI): 0.13 to 2.42); however, the analysis was underpowered to detect a difference between groups. Out of the 123 people randomized and treated, 6 people died; the causes of death were pneumonia, pulmonary embolism, mediastinitis, and septic shock. Among people randomized to surgery, there were reductions in pneumonia (RR 0.36, 95 % CI: 0.15 to 0.85; 3 studies, 123 participants), chest deformity (RR 0.13, 95 % CI: 0.03 to 0.67; 2 studies, 86 participants), and tracheostomy (RR 0.38, 95 % CI: 0.14 to 1.02;2 studies, 83 participants). Duration of mechanical ventilation, length of ICU, and length of hospital stay were measured in the 3 studies. Due to differences in reporting, the authors could not combine the results and have listed them separately. Chest pain, chest tightness, bodily pain, and adverse effects were each measured in 1 study. The Cochrane review concluded that there was some evidence from 3 small studies that showed surgical treatment was preferable to non-surgical management in reducing pneumonia, chest deformity, tracheostomy, duration of mechanical ventilation, and length of ICU stay. The review concluded that further well-designed studies with a sufficient sample size are required to confirm these results and to detect possible surgical effects on mortality. Given the limitations of the literature, rib fracture fixation is rarely performed in North America (Slobogean and Stockton, 2015). In a review of outcomes and treatment practices from the American College of Surgeon's National Trauma Data Bank (NTDB), out of 3,467 patients with a flail chest injury, 0.7 percent were treated with surgical fixation (Dehghan et al, 2014). Results of a pilot study conducted in Canada enrolled 14 participants, and did not specify a primary outcome; the results of this study have not been published. Multicenter randomized controlled clinical trials of surgical stabilization of acute, unstable chest wall injuries is currently ongoing (Mc Kee et al, 2015; Granhed, 2014). Slobogean and Stockton (2015) commented; "Several issues remain to be resolved before operative fixation of unstable chest wall injuries is accepted as standard practice with appropriate guidelines for its implementation. Very little evidence exists regarding the long-term outcomes of operatively fixing rib fractures. A minority of studies discussed complications encountered with operative intervention. As with any surgical procedure, rib fixation is associated with the risk of complications like wound infection, hardware failure, malunion or nonunion, and symptomatic hardware requiring subsequent operations. Considering the thin layer of soft tissue covering any proposed implant, these complications must be further elucidated prior to widespread implementation. As with much trauma literature, evidence so far has been hampered by small sample sizes and uncontrolled study designs . . . The current state of the modern literature suggests potential benefits for operative treatment compared with non-operative treatment of flail chest injuries. Recommendations regarding fixation of rib fractures for other indications such as intractuable acute pain are primarily anecdotal at this time. Though intial results are encouranging, several important questions remain to be addressed. Cooperative efforts between centers and across the surgical specialties will be instrumental in addressing the limitations of the literature and improving the care of these critically injured trauma patients". Bioabsorbable Plate: Oyamatsu and colleagues (2016) noted that a new technique for fixing rib fracture (bioabsorbable plate made of poly-L-lactide and hydroxyapatite) has received attention. These researchers adopted this new technique for a rib fracture by bending the plate into a U-shape and fixing it with suture through the holes in the mesh of the plate and holes that were drilled in the edge of the fractured rib. The suture was also wound around the plate. The clinical value of bioabsorbable plate for fixation of rib fracture needs to be ascertained in well-designed studies. An Up To Date review on “Initial evaluation and management of rib fractures” (Karlson, 2016) does not mention bioabsorbable plate as a management tool. An Up To Date review on “Inpatient management of traumatic rib fractures” (Bulger, 2016) states that “Rib fracture fixation has traditionally required an open thoracotomy for adequate exposure; however, minimally invasive approaches are now being developed. Several plate types and plate fixation methods have been used, but the search for the optimal material and fixation method continues”. Minimally Invasive Plate Osteosynthesis: Bemelman and associates (2016) stated that since the introduction of plate fixation for fractures, several plates and screws have been developed, all with their own characteristics. To accomplice more fracture stability, it was thought the bigger the plate, the better. The counter side was a compromised blood supply of the bone, often resulting in bone necrosis and ultimately delayed or non-union. With the search and development of new materials and techniques for fracture fixation, less invasive procedures have become increasingly popular. This resulted in the minimally invasive plate osteosynthesis (MIPO) technique for fracture fixation. With the MIPO technique, procedures could be performed with smaller incisions and thus with less soft tissue damage and a better preserved blood supply. In the previous 5 years, rib fixation has become increasingly popular, rising evidence has become available suggesting that surgical rib fixation improves outcome of patients with a flail chest or isolated rib fractures. Many surgical approaches for rib fixation have been described in the old literature, however, most of these techniques are obscure nowadays. Currently mostly large incisions with considerable surgical insult are used to stabilize rib fractures. The authors think that MIPO deserves a place in the surgical treatment of rib fractures. They presented the aspects of diagnosis, pre-operative planning and operative techniques in regard to MIPO rib fixation. The authors stated that no scientific reports have so far described the use of MIPO for rib fixation. This reflects the fact that MIPO for rib fixation is a new and developing technique. The clinical value of MIPO for fixation of rib fracture needs to be ascertained in well-designed studies. An Up To Date review on “Inpatient management of traumatic rib fractures” (Bulger, 2016) states that “Rib fracture fixation has traditionally required an open thoracotomy for adequate exposure; however, minimally invasive approaches are now being developed. Several plate types and plate fixation methods have been used, but the search for the optimal material and fixation method continues”. CPT Codes / HCPCS Codes / ICD-10 Codes Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+": Code Code Description CPT codes covered is selection criteria are met:21811 - 21813 Open treatment of rib fracture (s) with internal fixation, includes thoracoscopic visualization when performed, unilateral HCPCS codes not covered for indications listed in the CPB: Internal fixation systems [e.g. Rib Loc Rib Fracture Plating System, bioabsorbable plate, minimally invasive plate osteosynthesis] - no specific code: ICD- 10 codes covered if selection criteria are met: S22.5xx+ Flail chest ICD- 10 codes not covered for indications listed in the CPB (not all- inclusive): S22.31x+ - S22.49x+ Fracture of rib (s)The above policy is based on the following references: Slater MS, Mayberry JC, Trunkey DD. Operative stabilization of a flail chest six years after injury. Ann Thorac Surg. 2001;72:600-601. Lardinois D, Krueger T, Dusmet M, et al. Pulmonary function testing after operative stabilisation of the chest wall for flail chest. Eur J Cardiothorac Surg. 2001;20 (3):496-501. Tanaka H, Yukioka T, Yamaguti Y, et al. Surgical stabilization of internal pneumatic stabilization? A prospective randomized study of management of severe flail chest patients. J Trauma. 2002;52 (4):727-732. Granetzny A, Abd El-Aal M, Emam E, et al. Surgical versus conservative treatment of flail chest. Evaluation of the pulmonary status. Interact Cardiovasc Thorac Surg. 2005;4 (6):583-587. Nirula R, Allen B, Layman R, Somberg LB. Rib fracture stabilization in patients sustaining blunt chest injury. Am Surg. 2006;72 (4):307-309. Simon B, Ebert J, Bokhari F, et al. Practice management guideline for 'pulmonary contusion - flail chest.' Chicago, IL: Eastern Association for the Surgery of Trauma (EAST); 2006. Richardson JD, Franklin GA, Heffley S, Seligson D. Operative fixation of chest wall fractures: An underused procedure? Am Surg. 2007;73 (6):591-596. U. S. Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH). Synthes Matrix RIB Fixation System. 510K no. K081623. Rockville, MD: FDA; September 8, 2008. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf8/K081623.pdf. Accessed: September 28, 2011. Mayberry JC, Ham LB, Schipper PH, et al. Surveyed opinion of American trauma, orthopedic, and thoracic surgeons on rib and sternal fracture repair. J Trauma. 2009;66 (3):875-879. Campbell N, Conaglen P, Martin K, Antippa P. Surgical stabilization of rib fractures using Inion OTPS wraps -- techniques and quality of life follow-up. J Trauma. 2009;67 (3):596-601. Marasco S, Cooper J, Pick A, Kossmann T. Pilot study of operative fixation of fractured ribs in patients with flail chest. ANZ J Surg. 2009;79 (11):804-808. Marasco SF, Sutalo ID, Bui AV. Mode of failure of rib fixation with absorbable plates: A clinical and numerical modeling study. J Trauma. 2010;68 (5):1225-1233. Lafferty PM, Anavian J, Will RE, Cole PA. Operative treatment of chest wall injuries: Indications, technique, and outcomes. J Bone Joint Surg Am. 2011;93 (1):97-110. Bottlang M, Long WB, Phelan D, et al. Surgical stabilization of flail chest injuries with Matrix RIB implants: A prospective observational study. Injury. 2013;44 (2):232-238. U. S. Food and Drug Administration (FDA), Center for Devices and Radiologic Health (CDRH). ACUTE Innovations Modular Rib Loc Fixation Systems. 510 (k) no. K113318. Rockville, MD: FDA; November 9, 2011. Messing JA, Gall V, Sarani B. Successful management of severe flail chest via early operative intervention. J Trauma Nurs. 2014;21 (2):83-85. Fabricant L, Ham B, Mullins R, Mayberry J. Prospective clinical trial of surgical intervention for painful rib fracture nonunion. Am Surg. 2014;80 (6):580-586. Majercik S, Cannon Q, Granger SR, et al. Long-term patient outcomes after surgical stabilization of rib fractures. Am J Surg. 2014;208 (1):88-92. Bulger EM. Inpatient management of traumatic rib fractures. Up To Date [serial online]. Waltham, MA: Up To Date; reviewed August 2014. Zhang Y, Tang X, Xie H, Wang RL. Comparison of surgical fixation and nonsurgical management of flail chest and pulmonary contusion. Am J Emerg Med. 2015;33 (7):937-940. Xu JQ, Qiu PL, Yu RG, et al. Better short-term efficacy of treating severe flail chest with internal fixation surgery compared with conservative treatments. Eur J Med Res. 2015;20:55. Wiese MN, Kawel-Boehm N, de la Santa PM, et al. Functional results after chest wall stabilization with a new screwless fixation device. Eur J Cardiothorac Surg. 2015;47 (5):868-875. National Institute for Health and Clinical Excellence (NICE). Insertion of metal rib reinforcements to stabilize a flail chest wall. NICE Interventional Procedura Guidance 361. London, UK: NICE; October 2010. Available at: www.nice.org.uk/guidance/IPG361. Accessed August 27, 2015Althausen PL, Shannon S, Watts C, et al. Early surgical stabilization of flail chest with locked plate fixation. J Orthop Trauma. 2011;25 (11):641-647.de Moya M, Bramos T, Agarwal S, et al. Pain as an indication for rib fixation: A bi-institutional pilot study. J Trauma. 2011;71:1750-1754. Simon B, Ebert J, Bokhari F, et al; Eastern Association for the Surgery of Trauma. Management of pulmonary contusion and flail chest: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73 (5 Suppl 4): S351-S361. Girsowicz E, Falcoz PE, Santelmo N, Massard G. Does surgical stabilization improve outcomes in patients with isolated multiple distracted and painful non-flail rib fractures? Interact Cardiovasc Thorac Surg. 2012;14:312-315. Leinicke JA, Elmore L, Freeman BD, Colditz GA. Operative management of rib fractures in the setting of flail chest: A systematic review and meta-analysis. Ann Surg. 2013;258 (6):914-921. Slobogean GP, Mac Pherson CA, Sun T, et al. Surgical fixation vs non-operative management of flail chest: A meta-analysis. J Am Coll Surg. 2013;216 (2):302-311. Marasco SF, Davies AR, Cooper J, et al. Prospective randomized controlled trial of operative rib fixation in traumatic flail chest. J Am Coll Surg. 2013;216 (5):924-932. Doben AR, Eriksson EA, Denlinger CE, et al. Surgical rib fixation for flail chest deformity improves liberation from mechanical ventilation. J Crit Care. 2014;29 (1):139-143. Vana PG, Neubauer DC, Luchette FA. Contemporary management of flail chest. Am Surg. 2014;80 (6):527-535.de Jong MB, Kokke MC, Hietbrink F, Leenen LP. Surgical management of rib fractures: Strategies and literature review. Scand J Surg. 2014;103 (2):120-125. Dehghan N, de Mestral C, Mc Kee MD, et al. Flail chest injuries: A review of outcomes and treatment practices from the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76 (2):462-468. Slobogean GB, Stockton DJ. A review of the modern literature. In: MD Mc Kee, EH Schemitsch, eds. Injuries to the Chest Wall: Diagnosis and Management. Cham, Switzerland: Springer International Publishing AG; September 14, 2015. Cataneo AJ, Cataneo DC, de Oliveira FH, et al. Surgical versus nonsurgical interventions for flail chest. Cochrane Database Syst Rev. 2015;7: CD009919. Mc Kee M, Schemitsch E. Treatment of acute, unstable chest wall injuries. Clinical Trials.gov Identifier: NCT01367951. Bethesda, MD: National Library of Medicine; updated May 18, 2015. O'Brien PJ. Flail chest: A randomized controlled study. Clinical Trials.gov Identifier: NCT01308697. Bethesda, MD: National Library of Medicine; updated May 27, 2015. Granhed H. Operative treatment of unstable thoracic cage injuries and chest wall deformity in trauma. Clinical Trials.gov Identifier: NCT02132416. Bethesda, MD: National Library of Medicne; updated November 21, 2014. Schulte K, Whitaker D, Attia R. In patients with acute flail chest does surgical rib fixation improve outcomes in terms of morbidity and mortality? Interact Cardiovasc Thorac Surg. 2016;23 (2):314-319. Coughlin TA, Ng JW, Rollins KE, et al. Management of rib fractures in traumatic flail chest: A meta-analysis of randomised controlled trials. Bone Joint J. 2016;98-B (8):1119-1125. Bemelman M, van Baal M, Yuan JZ, Leenen L. The role of minimally invasive plate osteosynthesis in rib fixation: A review. Korean J Thorac Cardiovasc Surg. 2016;49 (1):1-8. Karlson KA. Initial evaluation and management of rib fractures. Up To Date Inc., Waltham, MA. Last reviewed July 2016. Bulger EM. Inpatient management of traumatic rib fractures. Up To Date Inc., Waltham, MA. Last reviewed July 2016. Oyamatsu H, Ohata N, Narita K. New technique for fixing rib fracture with bioabsorbable plate. Asian Cardiovasc Thorac Ann. 2016 May 18 [Epub ahead of print].  Trauma to the Chest in Dogs Trauma to the Chest in Dogs29 Jun, 2015 Pet Place.com Veterinarians 15,456 Views Share Canine Chest Trauma A major cause of serious and potentially life threatening chest damage in dogs can result from blunt force trauma. Automobile injuries, falls and kicks are the primary causes of blunt force trauma to the chest cavity. The heart, lungs and airways are located within the chest cavity and are protected by ribs and chest wall muscles. The diaphragm is a thin muscle that separates the chest cavity from the abdominal cavity. Trauma to the chest can result in bruising of the lungs and heart, lacerations of the lungs, bleeding or rupture of lungs or airways. Broken ribs, torn muscles and even tears of the diaphragm can occur. All injuries to the chest should be considered serious and immediate veterinary care is essential. Diagnosis of Chest Trauma in Dogs The diagnosis of chest trauma is based on a recent history of blunt force trauma such as being hit by an automobile, falling or receiving a kick to the chest area. Tests include: Physical exam that reveals difficulty breathing, pain, bruising of the skin overlying the chest and possible broken ribs. Auscultation of the chest (listening with a stethoscope) may reveal harsh lung sound with crackles and wheezes, or, in lung collapse, may reveal little to none of the normal lung sounds. Heart rate may be increased or erratic. X-rays of the chest are necessary to determine the extent of the lung, airway and diaphragm damage. Unfortunately, X-rays cannot reveal injuries to the heart walls. Electrocardiograms and possibly ultrasound may be required to detect heart wall damage. Treatment of Chest Trauma in Dogs Treating chest trauma can be difficult and complex. Determining the extent of the damage may not be easy. Assisting in breathing as well as maintaining a normal heart rhythm is crucial. Additional treatment may include: Oxygen supplementation Steroids, pain medications and possible a chest tube Intravenous fluids to help treat shock as well as maintain blood pressure Antibiotics Additional medications if the heart rhythm becomes erratic and life threatening Emergency surgery as well as blood transfusions in severe cases Home Care There is no home care for chest trauma. After treatment by a veterinarian, home care is primarily aimed at reducing activity and allowing the dog to heal. Watching for difficulty breathing, weakness, lack of appetite or pain should prompt you to consult your veterinarian immediately. Preventative Care The best way to prevent chest trauma is to reduce the potential for trauma to occur. Keep your dog confined on a leash or in a fenced in yard. Do not allow your dog to wander or roam. Careful observation around large animals such as cattle and horses will help prevent kicks. Have all windows screened and make sure the screens are securely attached to the window frame. Is Pet Insurance Right for you? The best pet insurance offers coverage that’s broad enough for whatever care your pet needs and with enough options to get the perfect coverage for you and your pet. As one of the first pet insurance providers in the U. S., Pet Partners has been offering affordable, comprehensive pet health insurance to dogs and cats in all 50 states since 2002. Trusted as the exclusive pet insurance provider for the American Kennel Club and the Cat Fanciers’ Association, Pet Partners highly customizable options allow pet owners to create a plan that fits their individual needs and budget — so you’re not paying for added coverage you don’t necessarily need or want. Visit www. Pet Partners.com today to see if pet insurance is right for you and your family.”)Are you pet crazy? Sign up for our email newsletter and get the latest health and wellness info, useful tips, product recalls, fun stuff, and so much more!Share  Review ArticleChemical pleurodesis for spontaneous pneumothorax Journal of the Formosan Medical Association Volume 112, Issue 12, December 2013, Pages 749-755open access Review Article Chemical pleurodesis for spontaneous pneumothorax Cheng-Hung How Hsao-Hsun Hsu Jin-Shing Chen Show morehttps://doi.org/10.1016/j.jfma.2013.10.016 Get rights and content Under an Elsevier user license Pneumothorax is defined as the presence of air in the pleural cavity. Spontaneous pneumothorax, occurring without antecedent traumatic or iatrogenic cause, is sub-divided into primary and secondary. The severity of pneumothorax could be varied from asymptomatic to hemodynamically compromised. Optimal management of this benign disease has been a matter of debate. In addition to evacuating air from the pleural space by simple aspiration or chest tube drainage, the management of spontaneous pneumothorax also focused on ceasing air leakage and preventing recurrences by surgical intervention or chemical pleurodesis. Chemical pleurodesis is a procedure to achieve symphysis between the two layers of pleura by sclerosing agents. In the current practice guidelines, chemical pleurodesis is reserved for patients unable or unwilling to receive surgery. Recent researches have found that chemical pleurodesis is also safe and effective in preventing pneumothorax recurrence in patients with the first episode of spontaneous pneumothorax or after thoracoscopic surgery and treating persistent air leakage after thoracoscopic surgery. In this article we aimed at exploring the role of chemical pleurodesis for spontaneous pneumothorax, including ceasing air leakage and preventing recurrence. The indications, choice of sclerosants, safety, effects, and possible side effects or complications of chemical pleurodesis are also reviewed here. Previous article Next article Keywordsair leakage pleurodesis pneumothorax recurrencethoracoscopy Definition and classification of spontaneous pneumothorax Pneumothorax, a common pleural disease worldwide, is defined as the presence of air in the pleural cavity, resulting in parenchymal collapse. 1 Pneumothorax can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause a shift of the mediastinum and compromise hemodynamic stability. Clinically, pneumothorax is divided into spontaneous and traumatic. Spontaneous pneumothorax is sub-divided into primary and secondary, according to with or without precipitating underlying lung disease. 2−4Primary spontaneous pneumothorax (PSP), which is defined as a pneumothorax without obvious underlying lung disease, most commonly occurs in young, tall, lean males. 2,4 PSP occurs at a frequency of 7.4–18 cases per 100,000 population per year in men and in 1.2–6 cases per 100,000 population per year in women. 5,6 With regard to the etiology of PSP, anatomical abnormalities are commonly demonstrated at the apex of the lung. Emphysema-like changes, including subpleural blebs and bullae were found in 50–90% of PSP patients on high-resolution computed tomography (CT) scanning and in 76–100% of PSP patients during video-assisted thoracoscopic surgery (VATS) or thoracotomy. 7−12Secondary spontaneous pneumothorax (SSP) usually occurs in older people with underlying lung disease, such as emphysema, chronic obstructive lung disease, catamenial pneumothorax, cystic fibrosis, pulmonary infection, or lymphangioleiomyomatosis. 3,13–16Clinical presentation and diagnosis of spontaneous pneumothorax Sudden onset of dyspnea and pleuritic chest pain were most complained. 17,18 The severity of the symptoms is primarily related to the volume of air in the pleural space. Symptoms are greater in SSP, even if the pneumothorax is relatively small in size. 4 Owing to the additional presence of the patient's underlying lung disease, SSP is considered a potentially life-threatening event, whereas PSP is virtually always a nuisance rather than a life-threatening condition. 19Diagnosis of pneumothorax is confirmed by imaging studies, primarily a plain chest film obtained during forced inspiration with the patient in a standing position. 20,21 The presence of a pneumothorax is established by demonstrating a white visceral pleural line on the chest radiograph. Inspiratory and expiratory films have equal sensitivity in detecting pneumothoraces; thus, a standard inspiratory chest radiograph is sufficient in most cases. The percentage of collapsed lung can be estimated using a plain chest film by the measurement of the average diameter of the collapsed lung and the involved hemithorax (Light's formula). 22Although chest CT scans can reveal the underlying pathophysiologic lesions that cause spontaneous pneumothorax and can be regarded as the “gold standard” in the detection of small pneumothoraces and in size estimation, 23,24 the American Collage of Chest Physicians (ACCP) does not recommend the routine use of this imaging technique for patients with first-time primary or secondary pneumothoraces. 21 CT may, however, be useful for evaluating patients with recurrent secondary pneumothorax, to determine the best treatment for persistent air leakage, or to plan a surgical intervention. 25 The British Thoracic Society (BTS) recommends using CT when required to differentiate between pneumothorax and bullous lung disease, when aberrant tube placement is suspected and when the plain chest radiograph is difficult to read owing to the presence of subcutaneous emphysema. 4Treatment options for spontaneous pneumothorax The management of pneumothorax focused on evacuating air from the pleural space, ceasing air leakage, and preventing recurrences. 4,19,21 Available therapeutic options include observation, simple aspiration, intercostal drainage with a pigtail catheter or chest tube, intercostal drainage with chemical pleurodesis, medical thoracoscopy with chemical pleurodesis, or surgical intervention (VATS or thoracotomy) with/without chemical pleurodesis. The selection of an approach depends on the size of the pneumothorax, the severity of symptoms, whether there is a persistent air leakage, and whether the pneumothorax is primary or secondary. 4,19,21 Generally, surgical intervention is reserved for patients with recurrent or complicated spontaneous pneumothorax, and chemical pleurodesis can be used as an adjunct after drainage or surgery. Chemical pleurodesis Pleurodesis is a procedure to achieve symphysis between the two layers of pleura to prevent recurrent pleural effusion or recurrent pneumothorax. 4,26,27 Either instilling a chemical irritant (chemical pleurodesis) or performing mechanical abrasion (mechanical pleurodesis) that induced inflammation and fibrosis caused the symphysis between the two layers of pleura. 8 Clinically, chemical pleurodesis was widely applied for stopping air-leak or for preventing pneumothorax recurrence. Chemical pleurodesis can be applied through the intercostal drainage tube, medical thoracoscopy, or during the operation. In clinical practice, a variety of sclerosants have been used, including tetracycline and derivatives (doxycycline or minocycline), talc, bleomycin, autologous blood patch, iodopovidone, picibanil, silver nitrate, and quinacrine. 27−31 In a survey from five English-speaking countries (United States, United Kingdom, Canada, Australia, and New Zealand), the most commonly used agent was talc followed by tetracycline derivatives and bleomycin. 32Chemical pleurodesis for persistent air leakage after chest drainage Persistent air leakage is defined as air leakage more than 5–7 days after intercostal drainage, which are more common with secondary pneumothorax than with primary pneumothorax. 33−35 For patients with persistent air leakage, physicians must consider surgical intervention to prevent prolonged hospitalization and the possibility of a recurrent pneumothorax. 4,19,21 VATS has been advocated in the management of patients with PSP and the selection of patients with SSP who suffer from persistent air leakage. 33,36−39 For patient has objective evidence of inoperable condition, chemical pleurodesis is a reasonable option. In 1994, Alfageme et al 40 reported that the intrapleural instillation of tetracycline has 60% of success rate among spontaneous pneumothorax patients with persistent air leakage. Cagirici et al 41 in 1998 conducted a prospective randomized study to examine the efficacy of autologous blood patch pleurodesis when compared with tube thoracostomy alone. Air leakage resolution occurred in 84% of patients within 72 hours and was significantly reduced when compared with tube thoracostomy alone. Chemical pleurodesis for preventing pneumothorax recurrence One of the most important issues of managing spontaneous pneumothorax is to prevent pneumothorax recurrence. The 1-year recurrence rate in PSP patients with the first episode using chest tube drainage is around 30% (16–52%) and progressively increases after the second or third episode. 19,42 Although chemical pleurodesis effectively reduces the recurrence of spontaneous pneumothorax in surgical and nonsurgical patients, 22,43−45 published guidelines do not recommend it as the initial treatment for primary spontaneous pneumothorax. 4,19−21In a recent published clinical trial, Chen et al 46 randomized patients with the first episode of PSP to simple aspiration/drainage only (control, n = 108) or simple aspiration/drainage and minocycline pleurodesis ( n = 106). After a follow-up for at least 12 months, pneumothorax recurrence was lower in the minocycline group (29.2%) compared with controls (49.1%), which led to fewer subsequent surgical interventions. 46 Autologous blood patch pleurodesis maybe also effective to prevent pneumothorax recurrence. The pneumothorax recurrence rate following autologous blood patch pleurodesis ranged from 0% to 29%, in comparison with tube thoracostomy alone 35–41%. 47−49Although surgical treatment is the most effective way in treating spontaneous pneumothorax, 5–15% of patients developed pneumothorax recurrence after thoracoscopic surgery, which is significantly higher compared with thoracotomy (0–1%). 4,44,50,51 The possible explanations have included inadequate exposure of chest cavity and decreased severity of pleural inflammation caused by thoracoscopy than by thoracotomy. 36,44 Loubani et al 52 reported significant reduced rates of pneumothorax recurrence in patients who underwent thoracoscopic staple bullectomy alone (20%) against those who received bullectomy and tetracycline pleurodesis (4%). Similar result was also reported by Chen et al 43,44 that additional minocycline pleurodesis after thoracoscopic surgery had lower pneumothorax recurrence compared with thoracoscopic surgery alone. Chemical pleurodesis for postoperative air leakage after surgery for pneumothorax Prolonged air leakage is the most common complication, range from 7% to 14%, following thoracoscopic treatment for PSP, and the optimal management is rarely mentioned. 35,53−55 Recently, How et al 55 reported that chemical pleurodesis using OK-432 or minocycline were effective to cease air leakage for patients of PSP with prolonged air leakage after thoracoscopic surgery. Furthermore, patients undergoing OK-432 pleurodesis seems to be more effective by having shorter durations of post pleurodesis chest drainage and postoperative hospital stay than those undergoing minocycline pleurodesis. 55Sclerosing agents for chemical pleurodesis Talc At the present time, talc is one of the agents most commonly used for chemical pleurodesis in patients with either a spontaneous pneumothorax or a recurrent pleural effusion, even though the occasional reports of severe side effects. 32,56 There are at least 32 cases of adult respiratory failure syndrome (ARDS) following intrapleural talc administration in the literature, 17 following the use of talc slurry, and the remaining 15 following talc insufflation. 56–58The development of ARDS after talc pleurodesis was later found to be related to the size of the particles as well as the employed doses. In a multicentre prospective study conducted by Bridevaux et al, 59 including 418 patients diagnosed with spontaneous pneumothorax, neither ARDS nor pneumonitis cases were reported using low doses of talc (2 g) and medium-sized particles (31.5 μm). Empyema is also reported after talc pleurodesis, which may be related to techniques used for the sterilization of talc. 60,61 The other concern regarding the potential effect of long-term pulmonary function by talc pleurodesis on young pneumothorax patients has been addressed. Although Lange et al 28 showed only a mild restrictive respiratory impairment at a follow-up of 22–35 years, Dubois et al 53 showed that thoracoscopic apical bullectomy and talc poudrage would cause changes in pulmonary function at 1 year. Another important concern in patients undergoing talc pleurodesis is the possibility of false positives in the interpretation of fluorine 18 (18 F) flurorodeoxyglucose (FDG) due to a high capitation of FDG in the acute and chronic phases of pleural inflammation, leading to pleural symphysis or the appearance of pleural pseudotumoral granulomatous (talcoma) or pseudosarcomatous reactions, similar to primary malignant tumoral or metastatic lesions with increased metabolic activity as reported by the positron emission tomography-computed tomography (PET-CT). 62Tetracycline and minocycline Tetracycline, which was the most commonly used irritant, 22 is no longer available. Minocycline, a derivative of tetracycline, is as effective as tetracycline in inducing pleural fibrosis in rabbits. 63 No major complication or mortality was associated with chemical pleurodesis using minocycline. The main disadvantage of minocycline is immediate chest pain after instillation, which is relieved spontaneously within several hours and does not impair pulmonary function or increase the risk of residual chest pain 6 months after the operation. 43,44Bleomycin Bleomycin was widely used for the treatment of malignant pleural effusions because of its antineoplastic actions and because it appeared comparable in effectiveness to tetracycline in the treatment of malignant pleural effusions. 64,65 In an animal study, Vargas et al 64 revealed that the intrapleural injection of bleomycin was ineffective in creating pleural fibrosis, either grossly or microscopically. As bleomycin is expensive and relatively ineffective compared with other sclerosing agents, 31 it is not recommended be used as a pleural sclerosant in patients with non-neoplastic pleural disease, such as pneumothorax, congestive heart failure, or liver cirrhosis. 64Autologous blood patch In contrast to other chemical irritants for pleurodesis such as talc or tetracycline, autologous blood patch does not cause systemic inflammatory reactions or severe pain. The procedure of pleurodesis with autologous blood was as following: 50 m L of autologous blood without anticoagulant was obtained from each patient. As soon as the blood was drawn, it was immediately injected into the pleural space through a chest tube. 66 Although transient fever may develop following autologous blood patch pleurodesis, 48,67 most authors emphasized that no major complication was observed. 49 Other possible complications of autologous blood patch pleurodesis have included empyema and pleural effusions. 41 However, a reported case of tension pneumothorax highlights the potential risk for an obstructing clot in the chest tube. 68OK-432 (Picibanil)OK-432 ( Picibanil ), a lyophilized mixture of a low virulence strain (Su) of Streptococcus pyogenes incubated with benzylpenicillin, has been used in sclerotherapy for neck lymphangioma, malignant pleural effusion, and intractable pneumothorax with satisfactory results. 69−71 No major complication of pleurodesis using picibanil was reported. The main side effects of the pleurodesis with picibanil were fever and chest pain, which were well controlled by nonsteroidal anti-inflammatory drugs. 55,69Iodopovidone Iodopovidone is a topical antiseptic and has been shown to be safe and effective in several studies. 30,31,72 A solution containing a mixture of 20-m L 10% iodopovidone and 80-m L normal saline was used to create pleurodesis. Iodopovidone pleurodesis is generally safe. The most common side effect is chest pain. Fever and empyema were also mentioned in some studies with low incidence. 72,73Conclusions and future perspectives Although there are many options in the management of spontaneous pneumothorax, chemical pleurodesis should play a more important role in this benign disease. The most updated clinical trial showed that minocycline pleurodesis effectively reduces pneumothorax recurrence and subsequent thoracoscopic surgery in the first episode of PSP. For pneumothorax patients suffered from persistent air leakage, pleurodesis using autologous blood patch, talc, and picibanil are safe and effective. Additional chemical pleurodesis following VATS bullectomy was also effective to reduce the pneumothorax recurrence rate in PSP patients. More and more clinical evidence showed that chemical pleurodesis through a drainage tube/catheter is easy, safe, and cost-effective for the treatment of spontaneous pneumothorax. The optimal timing and choice of chemical pleurodesis for spontaneous pneumothorax, however, depends on the patient's condition, physician's experience, and availability of sclerosants. The indications, effects, and complications of common sclerosing agents are summarized in Table 1. 11,22,27–30,34,40,41,43–49,53,55,58–61,66–69,72–77 Future studies should focus on the comparison of safety and efficacy of different sclerosing agents in specific clinical settings of spontaneous pneumothorax. Table 1. Indications, effects, and complications of chemical pleurodesis for spontaneous pneumothorax. Sclerosing agent Indications Effect Side effects and complications Talc 28,30,45,53,58–61,74,75 Initial treatment for PSP and SSP Decreased pneumothorax recurrence to 0–9% Chest pain (7–15.6%), fever (1.6–63.2%), dyspnea (57.9%), pleural effusion (1.2%), pneumonia (0.5–0.9%), hemothorax (0.9%), and ARDS (0–9%)Autologous blood patch 29,34,41,47–49,66–68Initial treatment for PSP and SSP Ceasing air leakage in 75–93% Decreased pneumothorax recurrence to 0–29% after VATS Empyema (5–9.4%), pleural effusion (5–15.6%), and fever (10–12.5%)Tetracycline 22,27,40,76Initial treatment for PSP and SSP Decreased pneumothorax recurrence to 9–25% Chest pain (33–90%), fever (9–81%), dyspnea (36%), and elevated liver enzyme (45%)Minocycline 55Prolonged air leakage for PSP after VATS Ceasing air leakage in 63% Chest pain, fever (1%), and loculated effusion (1.7%)Minocycline 11,46Initial treatment for PSP Decreased pneumothorax recurrence to 13–29% Chest pain (67%)Minocycline 43,44,77Adjuvant treatment for PSP after VATS Decreased pneumothorax recurrence to 2–4% Chest pain (44.6–83.5%), fever (4.1%), and hemothorax (0.6%)Povidone-iodine 30,72,73Initial treatment for PSP and SSP Decreased pneumothorax recurrence to 0–6% Chest pain (13%), fever (6.1–33%), empyema, and wound infection (2.4%)Picibanil 55,69 Adjuvant treatment for PSP after VATS and initial treatment for SSP Ceasing air leakage in 95% and decreased pneumothorax recurrence to 5% after VATS Chest pain and fever (21%)ARDS = acute respiratory distress syndrome; PSP = primary spontaneous pneumothorax; SSP = secondary spontaneous pneumothorax; VATS = video-assisted thoracoscopic surgery. 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Thoracoscopic pleurodesis for primary spontaneous pneumothorax with high recurrence risk: a prospective randomized trial Ann Surg, 255 ( 2012), pp. 440 - 445Copyright © 2013 Published by Elsevier (Singapore) Pte Ltd.  Chapter 23 66 terms Tejeda637Chapter 23Learn Flashcards Write Spell Test Match Gravity Advertisement Upgrade to remove ads Like this study set? Create a free account to save it. Create a free account Maybe later Sort Which of the following statements regarding the thorax is MOST correct? The diaphragm inserts into the anterior thoracic cage below the fifthe rib Bony structures of the thorax include all of the following, EXCEPT the: acromion The eighth,ninth,and tenth ribs are indirectly attached to the sternum by the: costal cartilage The eleventh and twelfth ribs are known as the floating ribs becuase they: are not attached anteriorly to the sternum The space between the second and third ribs is called the: second intercostal spacewhich of the follwoing is NOT a mediastinal structure? LUNGThe visceral pericardial layer adheres to the heart and forms the epicardium The anterior-most portion of the heart is the: right ventricle The pressure within the right ventricle is one fourth of the pressure within the left ventricle Most of the heart is protected anteriorly by the sternum What is the cardiac output for an 80-kg man who has a heart rate of 80 beats/min and stroke volume of 60 ml? 4,800 m LAs soon as the aorta exits the left ventricle,it: ascends toward the right shoulder Which of the following is NOT a sight of potential injury when the aorta is subjected to shearing forces during rapid deceleration Coronary sinus If the pleural space becomes filled with air or blood: surface tension is lost and the lung collapses The diaphragm forms a barrier between the thoracic and abdominal cavities A flail chest is characterized by: a free- floating segment of fractured ribs Isolatedrib fractures may result in inadequate ventilation becuase: the patient often purposely limits chest wall movement Ribs 4 through 9 are the most commonly fractured because: they are less procted by the other bony and muscular structures The self-spliniting effect observed in patients with chest wall trauma: may cause atelectasis,hypoxemia or pneumonia Barotrauma causes a pneumothorax when: pressure is applied to the chest during a period of inhalation and glottic closure An open pneumothorax causes ventilatory inadequancy when: negative pressure created by inspiration draws air into the pleural space. Pneumpthoraces create a ventilation-perfusion mismatch when: perfusion of the involved lung continues while the pneumothorax prevents adequate ventilation What type of chest injury is characterized by air accummulation in the pleural space when a perforation in the lung parenchyma acts as a one way valve? Tension pneumothorax As air accumulates in the pleural space, the FIRST thing to occur is: decreased pulmonary function Most hemothoraces occur when a fractured rib injures the lung parenchyma By definition, a massive hemothorax is characterized by: more than 1,500 m L of blood within the pleural space. A pulmonary contusion following blunt chest trauma results in: alveolar and capillary damage with intraparenchymal lung hemmorage Which of the following statements regarding a pericardial tamponade is MOST correct? In a pericardial tamponade,blood collects between the visceral and parietal pericardium Dysrhythmias following a myocardial contusion are usually secondary to: damage to myocardial tissue at the cellular level Commotio cordis is a phenomenon in which: ventricular fibrillation is induced follwoing blunt trauma to the chest during the hearts repolarization period Traumatic injuries to the aorta are MOST commonly the result of: shearing forces With the exception of the aorta, great vessel injury is MOST likely to occur following: penetrating traumawhich of the follwoing statements regarding diaphragmatic injury is MOST correct? Because the diaphragm is protected by the liver on the right side,most diaphragmatic injuried caused by blunt force trauma occur on the left side Tracheobronchial injuries have a high mortality due to: associated airway obstruction Common clinicla findings associated with a traumatic asphyxia include all of the following EXCEPT: hyphema Which of the folowing clinical findings is MOST suggestive of inadequate oxygenation? Altered mental status Increased intravenous pressure commonly manifests as: jugular venous distention Any patient with a presumptive diagnosis of a pneumothorax should: be considered unstable and reassessed every 5 minuets Which of the follwoing thoracic injuries would you LEAST likely discover in the initial assessment? Myocardial contusion Patients suspected of having a partial tracheal tear should be managed with: the least invasive airway techniques possible Which of the follwoing thoracic generally does NOT require immediate treatment? Myocardial contusion You would NOT expect a patient with a flail chest to present with: hyperpnea Any normotensive patient with a sternal fracture should receive: ECG monitoring A patient with a small simple pneumothorax would MOST likely present with diminished breath sounds: in the apices of the affected lung if he or she is sitting upright Immediate treatment for an open pneumothorax involves: converting the pneumothorax to a closed injury Jugular venous distention during a tension pneumothorax is caused by blood accumulation in the vena cava A blood pressure of 100/70 mm Hg in the presence of clinical signs of a tention pneumothorax: suggestes adequate cardiac compensation for the diminished venous return. Which of the following clinical signs may not be present in a patient with a tension pneumothorax and associated internal bleeding? : Jugular vein distention The preferred site for performing a needle thoracentesis is: superior to the third rib into the intercostal space at the midclavicular line. When performing a needle decompression of the chest, you should insert the needle: at a 90-degree angle and listen for the release of air Unlike a tension pneumothorax,a massive hemothorax would MOST likely present with: collapsed jugular veins Due to intrapulmonary hemorrhage, patients with a pulmonary contusion may present with: hemoptysis You should be MOST suspicious that your patient has a pericardial tamponade if he or she presents with hypotension,jugular vein distention and: normal lung sounds Crackles or rales in the lungs follow a myocardial contusion would MOST likely result from: left ventriculardysfunction Most patients with an aortic injury will complain of pain: behind the sternum or in the scapula Management of a diaphragmatic injury focuses on: maintaining adequate oxygen and ventilation and rapid transport A 16-year old man collapsed after being struck on the center of the chest by a line drive during a high school baseball game. Your assessment reveals that he is pulseless and apneic. As your partner initiates one rescuer CPR, your MOST important action should be to: attach the ECG leads and be prepared to defibrillate You are assessing a 39 yr old man who experienced blunt chest trauma. He is semiconscious and has poor respiratory effort with stridor. You should: insert a nasal airway and assist ventilations with a bag-mask device A 50 yr old man was working on his car when the jacks collapsed and the car landed on his chest. Your assessment reveals profound cyanosis and swelling to his chest and face,agonal respirations, and a weak carotid pulse. This patient will benefit MOST from: aggressive airway management and rapid transport A 26 yr old unrestrained woman struck her chest on the steering wheel when her car collided with another vehicle. After performing your initial assessment and administering high-flow oxygen, you assess her chest and note a segment of obviously fractured ribs that bulges outward during exhalation. You should: apply a bulky dressings to the segment of fractured ribs A 30 year old man felt a snap in his chest when he abruptly twisted his torso. He is conscious and alert, and complains of severe pain during inhalation. Your assessment reveals palpable tenderness over the fifth and sixth ribs on the left side. His vital signs are stables and he denies other injuries. In addition to administering supplemental oxygen, the MOST appropriate treatment for this patient involves: instructing the patient to hold a pillow against his chest, considering IV analgesics and transporting to the hospital You are transporting a conscious and alert young male who experienced an isolated blunt injury to the right anterolateral chest. His vital signs are stable,but he is dyspneic and his breath sounds are diminished ovre the apex of his right lung. In addition to administering high flow oxygen, the MOST critical intervention for this patient involves: frequently reassessing him for signs of clinical deterioration A convenience store clerk was stabbed during a robbery attempt. He is semi conscious with a shallow breathing and weak radial pulses. During the rapid trauma assessment, you find a single stab wound to his left anterior chest. His jugular veins are distended and his breath sounds are bilaterally diminished but equal. The MOST appropriate treatment for this patient involves: covering the stab wound with an occlusive dressing, assisting ventilations, transporting at once and establishing large bore-IV lines en route You are dispatched to a residence for an injured person, Law enforcement arrives before you and advises that the scene is safe. Your patient , a young female, tells you that her boyfriend kicked her in the chest yesterday during an argument. Your assessment reveals that the patient is in significant pain, is dyspneic, has a heart rate of 98 beats/min and strong, and an area of ecchymosis over her left lower ribcage. Auscultation to the left side if her chest reveals coarse crackles. Which of the follwoing treatment interventions is likely NOT indicated for this patient? Intravenous fluid boluses A robbery suspect was shot once in the anterior chest by law enforcement personnel when he pulled a gun on them. The patient is ehibiting obvious signs of shock, is in significant respiratory distress, and is coughing up blood. Further assessment reveals collapsed jugular veins and absent sounds over the left hemithorax. After covering the gunshot wound with appropriate dressing you should: provide oxygen and ventilation support, transport at once and maintain adequate perfusion with IV fluids while in route to a trauma center. FOllowing a blunt trauma to the anterior chest a 44 yr old man presents with restlessness, respiratory distress, perioral cyanosis, and tachycardia. Further assessment reveals a midline trachea,engorged jugular veins, and absent breath sounds on the right side of his chest. You should: perform an immediate needle thoracentesis to the right side of the chest.  Trauma nursing: Penetrating chest wounds Trauma nursing: Penetrating chest wounds May 01, 2004 By Rita M. Barry, RN, BSN, CENRN/DREXEL Home Study Program CE CENTERCE credit is no longer available for this article. Expired July 2005Originally posted May 2004Trauma nursing: Penetrating chest wounds RITA M. BARRY, RN, BSN, CENRITA BARRY is a nurse manager at Pennsylvania State University Milton S. Hershey Medical Center in Hershey, Pa. KEY WORDS: penetrating chest injuries, hemothorax, pericardial tamponade, open pneumothorax (sucking chest wound), tension pneumothorax, Kussmaul's sign, pericardiocentesis When someone has been shot or stabbed in the chest, time is of the essence. Here's what you need to know about the life-threatening complications to look for and the immediate treatment you'll need to initiate. Jump to: The police and an EMS crew respond to a call from a local bar. A 24-year-old man has been shot after getting into a fight with another patron. They arrive to find the victim, Ricky Bennett, conscious and yelling, "I'm dying!" His heart rate is 120, respiratory rate is 40, and blood pressure is 90/60. While transporting Ricky to a Level 1 trauma center, the paramedics give oxygen via a nonrebreather oxygen mask, apply a dressing to his chest wound, and start a 16-gauge IV catheter in each antecubital fossa. Unlike blunt chest injuries, which we covered in March, penetrating chest injuries puncture the muscular chest wall and often directly damage the intrathoracic organs. Gunshot wounds and stabbings are the most frequent causes, but any object capable of piercing the chest wall, such as a nail from a nail gun, can result in a penetrating injury. 1 According to the National Center for Injury Prevention and Control, there were more than 29,000 deaths and 60,000 injuries from firearms alone in the United States in 2001. 2Although penetrating chest injuries are frequently lethal, there is much that can be done to bolster a patient's chance of survival. These include being highly suspicious of pneumothorax, hemothorax, pericardial tamponade, and other life-threatening complications during your assessment, providing rapid resuscitation, and ensuring that surgery is performed without delay. These actions are all associated with a higher rate of recovery. 3Start by checking for airway obstruction Because patients with penetrating chest injuries can deteriorate rapidly, simultaneous assessment and treatment are key. Learning about the circumstances that led to the injury, particularly details about the weapon or object involved, can give you additional clues about the types of injuries to suspect and how extensive they may be. (See the " Looking for clues during assessment " box. )Follow Advanced Trauma Life Support (ATLS) protocols, beginning with a primary survey of the patient's ABCs—airway, breathing, and circulation. Look, listen, and feel for the signs and symptoms of airway obstruction, which include tachypnea, stridor, anxiety, and the use of accessory muscles for respiration. 4 Feel for trachea deviation, but keep in mind that you may not be able to detect this in patients who received an endotracheal tube from paramedics. Assess the patient's mental status. Agitation can suggest hypoxia, and confusion might indicate hypercapnia. Cyanosis is a late sign of hypoxia. 4If the patient's airway is blocked, rapidly secure a patent airway to prevent hypoxia of the brain and myocardium. This can be done with a chin lift/jaw thrust, but before hyperextending the patient's head for airway positioning, be certain that cervical spine damage has been ruled out. 5 A patent airway can also be established by orotracheal intubation—as was done with Ricky—nasotracheal intubation, or by surgically creating an airway with a cricothyrotomy or tracheostomy. Does the patient have a sucking chest wound? Once your patient has a patent airway, assess his breathing, which requires the lungs, diaphragm, and chest wall to be functioning adequately. In patients with penetrating chest injuries, breathing can be impaired by an open pneumothorax or a tension pneumothorax. Open pneumothorax, which is commonly referred to as an open or sucking chest wound, is the most likely result of penetrating chest trauma. 5 It occurs when there's a large defect in the chest wall that allows air to move freely between the pleural space and the atmosphere. 4 Some small sucking chest wounds may seal by themselves, but larger ones require immediate intervention. Open pneumothorax is generally easy to identify by the sucking sound typically heard on inspiration as air moves from the atmosphere and into the chest through the chest wall. Other signs and symptoms include dyspnea, chest pain, and significantly decreased breath sounds on the injured side. 4If not managed quickly and appropriately, an open pneumothorax can lead to hypoxia and hypercarbia. Treat this injury by placing a sterile occlusive dressing over the wound, but tape only three sides. As the patient breathes in, the dressing is sucked over the wound and prevents air from entering; as he exhales, air will push the dressing off the chest and be able to escape. Securing the dressing on all four sides could lead to a buildup of air in the pleural space. Chest tube insertion is the typical treatment for an open pneumothorax, so if your patient has a sucking chest wound, prepare him for this procedure and continue to closely monitor his vital signs. He'll probably need surgery to close the chest wall defect. Breathing can also be impaired by a tension pneumothorax, which is a progressive build-up of air in the pleural space that's usually caused by a lung laceration. 6 With each breath, air is drawn into the thoracic cavity without any means of escape. Eventually the pressure from the trapped air is greater than the pressure in the lung. This collapses the lung on the wounded side of the chest and pushes the mediastinum to the opposite side, decreasing venous return and compressing the opposite lung. Signs and symptoms of tension pneumothorax include dyspnea, low blood pressure, tachycardia, and cool, clammy skin. A physical exam may reveal a trachea deviated toward the unaffected side and neck vein distention. Breath sounds may be diminished on the injured side and heart sounds may be distant. A chest X-ray is required for a definitive diagnosis. In the meantime, a patient who is rapidly deteriorating and whose breath sounds are significantly diminished on the injured side requires immediate needle decompression. The physician will need to insert a large-bore needle into the second intercostal space at the midclavicular line of the affected side to convert the tension pneumothorax into a simple open pneumothorax. This will let air escape the pleural space, and it won't build up under pressure. Then perform a repeat assessment to confirm that your patient is improving. Needle decompression should be followed by chest tube insertion. 7Watch for hemothorax, pericardial tamponade Assess your patient's circulation by palpating pulses and looking for obvious hemorrhaging. It's important to rapidly identify any probable causes of shock and quickly begin treatment. Hypovolemia from hemorrhage is the most common cause of shock in a patient with penetrating chest trauma. Symptoms include tachycardia, cutaneous vasoconstriction, and a narrow pulse pressure. Massive hemothorax and pericardial tamponade are two life-threatening conditions to look for when assessing a patient with a penetrating chest injury. Massive hemothorax is the rapid accumulation of more than 1,500 ml of blood in the pleural space. 5 It's most commonly caused by penetrating chest injuries to the aortic arch, hilum of the lung, or intercostal or internal mammary arteries. When a patient with a penetrating wound develops a hemothorax, it's usually associated with arterial (not venous) injury and requires immediate surgery. A patient with a large, clinically significant hemothorax will show signs of respiratory distress and profound hemorrhagic shock, and breath sounds will be significantly diminished on the injured side. Decreased chest expansion and dullness to percussion are other classic signs. 8 However, most small or moderate hemothoraces are diagnosed only after chest X-ray. 8Chest tube placement to drain the hemothorax is the first step of treatment. 8 Prepare to assist with the immediate placement of a 36 – 40 F chest tube. If you haven't already established two large-bore antecubital IV lines for aggressive fluid resuscitation, blood transfusion, and autotransfusion, you'll need to do so now. Patients with penetrating anterior chest wounds medial to the nipple line and posterior wounds medial to the scapula may require thoracotomy because of possible damage to the great vessels and the heart—and the potential for pericardial tamponade. 9This life-threatening complication, also called cardiac tamponade, occurs when the pericardium fills with blood from the heart or great vessels, as was the case with Ricky. Because the pericardial sac is a fibrous structure that doesn't stretch, even a relatively small leak can fill the pericardial sac, externally compress the heart, and interfere with cardiac filling and output. One challenge to successfully managing pericardial tamponade lies in making the diagnosis in the first place. While the signs and symptoms include Beck's triad—muffled heart tones, distended neck veins, and hypotension—they may be hidden or absent. 10Muffled heart tones can be difficult to hear in a noisy trauma bay, for instance, or distended neck veins may be hidden underneath a cervical collar. Kussmaul's sign—a paradoxical rise in venous pressure during inspiration—is sometimes seen in patients with pericardial tamponade. 10 Pulseless electrical activity in the absence of hypovolemia and tension pneumothorax may be indicators as well. Focused Abdominal Sonography for Trauma (FAST) is a rapid ultrasound performed in the ED to look for blood in the pericardium, peritoneum, and pleural space. 11 FAST was used to diagnose Ricky's pericardial tamponade, but this technology may not be available at your facility. If your patient's blood pressure has not responded to fluid resuscitation and pericardial tamponade is strongly suspected, he'll need pericardiocentesis stat. (See the " Pericardiocentesis: A lifesaving procedure " box.) Since untreated pericardial tamponade is always fatal, it's best to prepare your patient for pericardiocentesis as soon as the condition is suspected. Patients who undergo this procedure will usually require exploratory thoracotomy or median sternotomy to evaluate the heart and great vessels. 3Danger remains even after stabilization Even when the patient appears stable, it's important to be vigilant. Perform a secondary survey, reassessing his ABCs and looking for other life-threatening injuries. This is the time to collect any information about the patient or the incident that wasn't obtained earlier. In addition to circumstances directly related to the injury, find out as much as possible about the patient's medical history, medications, when he last ate, and if he consumed any alcohol or recreational drugs. Remove all of the patient's clothing, if that hasn't already been done, and keep the patient warm with blankets. But proceed with caution: Because penetrating chest injuries usually involve violence, it's important to collect evidence according to your hospital's policy. Place each piece of clothing in a separate paper bag. If a piece of clothing has holes from a bullet or knife, remove it by cutting along the seams to keep evidence intact; never poke anything through any hole. 7 Retain any weapons or bullets, and notify the police promptly. Thoroughly examine the patient's chest, focusing on detecting any injuries that may have progressed since your initial evaluation and anything you may have missed. 12 If you're dealing with a patient who's been shot, always look for both entrance and exit wounds to help determine the wound track. If an object is impaled in the patient's body, leave it in place until it can be surgically removed—it may be pressing on a slashed artery and pulling it out could cause significant hemorrhaging or could tear an artery or organ. 7 While you're focusing on your patient's chest trauma, be aware that the bullet, knife, or other object may have punctured the diaphragm and injured other organs. Diagnostic testing, including chest X-ray, arterial blood gas, pulse oximetry monitoring, EKG, CT scan, and transthoracic ultrasound, can help identify other injuries. All patients with stab wounds between the neck and umbilicus and those with gunshot wounds between the neck and pelvis/buttock area should receive chest X-rays to detect injuries in the thoracic cavity or mediastinum that may not be clinically evident. 12 If possible, have the patient sit upright while the X-ray is taken to increase the likelihood that a small hemothorax or pneumothorax can be detected. 12In Ricky's case, he went to the OR following pericardiocentesis. The surgeons found bleeding wounds on the anterior and posterior wall of the left pulmonary artery. The projectile—a 9 mm bullet—was found inside the wall of the bronchus. The bleeding wounds were surgically repaired, and 10 days later, he went home. Not all penetrating chest injury victims fare as well as Ricky. His good fortune of being close to a Level 1 trauma center staffed with highly skilled clinicians with experience in caring for gunshot victims meant he would live to tell his children about his experience. REFERENCES1. Revere, C. J. (1998). Mechanisms of injury. In L. Newbury (Ed. ), Sheehy's emergency nursing principles and practice (4th ed. ), (pp. 291 – 306). St. Louis: Mosby-Year Book.2. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. "Web-based Injury Statistics Query and Reporting System (WISQARS)." 2004. www.cdc.gov/ncipc/wisqars (13 Feb. 2004).3. Mittal, V., Mc Aleese, P., et al. (1999). Penetrating cardiac injuries. Am Surg, 65 (5), 444.4. University Air Care, The University Hospital Health Alliance. "Thoracic trauma." 2002. www.universityaircare.org/ce/chest/chesttrauma.htm (9 Feb. 2004).5. Lanros, N. E., & Barber, J. M. (1997). Emergency nursing (4th ed.). Stamford, CT: Appleton & Lange.6. Trauma.org. "Pneumothorax—tension." 2004. www.trauma.org/thoracic/CHESTtension.html (19 Feb. 2004).7. Carroll, P. (1999). Chest injuries. RN, 62 (1), 36.8. Trauma.org. "Haemothorax." 2004. www.trauma.org/thoracic/CHESThaemo.html (19 Feb. 2004).9. American College of Surgeons. (1997). Thoracic trauma. In ATLS: Advanced trauma life support (6th ed. ), (pp.125 – 141). Chicago: American College of Surgeons.10. Yarlagadda, C., & Hout, W. M. "Cardiac tamponade." 2002. www.emedicine.com/med/topic283.htm (13 Feb. 2004).11. Trauma.org. "The FAST examination: Pericardial scanning." 2001. www.trauma.org/radi ology/FASTpericardium.html (19 Feb. 2004).12. Trauma.org. "Chest trauma: Initial evaluation." 2004. www.trauma.org/thoracic/CHESTintro.html (19 Feb. 2004). Looking for clues during assessment While assessing a patient who has sustained a penetrating chest injury, finding out as much as possible about the incident that caused the wound can do much to guide treatment. For instance, with gunshot victims, it's crucial to know something about the type of firearm and the bullets involved. Some bullets, such as those with a hollow point, are designed to mushroom upon impact. The "mushroom" creates a larger frontal surface and more damage to tissue than a typical narrow bullet point. Other bullets are designed to break apart into many pieces and scatter when the bullet hits tissue, causing large, cavernous wounds that may be contaminated with fragments. In addition, there are the bullets from an M-16 assault rifle that are designed to slow down and tumble once they enter tissue. The tumbling widens the wound track and causes massive tissue injury. These bullets, as well as those used in an M-14 and AK 47, are classified as high-energy. In addition to creating a wound track, high-energy bullets also produce a shock wave that causes tissue around the bullet's path to expand and contract several times after the bullet has passed through. This movement of tissue creates a cavity that may be 30 – 40 times larger than the bullet itself. The shock wave causes damage to tissue and structures far from the wound track. Unlike the bullets from rifles, those from handguns are considered medium-energy. By compressing and stretching tissue, they create a cavity that can be two to three times larger than the bullet itself. If a patient has been stabbed, the injury pattern depends upon the length, shape, and size of the object used and the location of the wound. As a result, it's very helpful to have the dimensions of the object used. Stab wounds generally produce straight-line tissue damage along the path of the weapon or object. However, if the blade of a knife or similar object is "rocked" in the wound, either by the assailant moving or twisting the knife, or the patient moving in relation to the knife, internal damage will be more extensive. If a patient was stabbed with a knife, the depth of a wound may be deeper than the length of the knife due to indentation caused by a forceful thrust. To see if this may be the case, look for a bruise surrounding the wound in the shape of the hilt of the knife or a fist. Sources: 1. Armstrong, J. (1999). Bullets: Damage by design. RN, 62 (1), 38. 2. Lanros, N. E., & Barber, J. M. (1997). Major trauma. In Emergency nursing (4th ed. ), (p. 153). Stamford, CT: Appleton & Lange. Pericardiocentesis: A lifesaving procedure Pericardial tamponade occurs in only an estimated 2% of patients who sustain penetrating chest injuries. However, when it does occur, it is fatal unless treatment is initiated immediately. Pericardiocentesis—inserting a needle attached to a syringe into the pericardial cavity to remove blood—can provide palliative treatment to buy time to get the patient to the OR for definitive repair of the injury. But it is not without risk; potential complications include dysrhythmias, pneumothorax, and air embolism. When caring for a patient who's about to undergo a pericardiocentesis, start by placing him in a semi-Fowler's position to lower the diaphragm and abdominal organs and allow blood to pool at the apex of the heart. Provide oxygen via a nonrebreather mask if the patient is breathing on his own, and apply regular EKG leads and a Fast-Patch for defibrillation. Your patient will need fluids, which will help increase blood volume and, in turn, ventricular filling. Have vasopressors, such as dopamine HCl (Intropin), ready in case they're needed. Other supplies needed for the procedure are a 16- or 18-gauge, 4 – 6 inch, over-the-catheter needle; a three-way stopcock; a 50 cc syringe; gauze; tape; local anesthetic; an antiseptic to cleanse the insertion site; and sterile gloves, gown, and masks. Because your patient's preload is already reduced, there's no need to administer vasodilators such as nitroglycerin (Tridil) or nitroprusside sodium (Nipride). The physician will cleanse the area from the xiphoid process to the left costal margin with an antiseptic solution and inject a local anesthetic. He'll palpate the junction of the xiphoid and left costal arch and insert the needle below the xiphoid at a 30 – 45 degree angle, then advance it slowly toward the left shoulder while he gently aspirates the syringe. The doctor will meet resistance on the surface of the pericardium and may feel a pop as the needle penetrates; there should be a flashback of blood into the needle hub. During the procedure, monitor the patient's EKG for ST segment changes, T wave inversion, and premature ventricular contractions, which could signal that the needle injured the myocardium. These changes may not be evident if the patient has scar tissue from an old infarct. If there are no EKG changes, the physician will drain off as much blood as possible. Removing as little as 15 – 20 ml can save a patient's life. After the fluid is drained, the physician will remove the needle, apply pressure over the site, and affix a dressing. Prepare the patient for an exploratory thoracotomy. Be sure to document all assessments and interventions. Sources: 1. Metules, T. (1999). Preparing for pericardiocentesis. RN, 62 (12), 30. 2. Yarlagadda, C., & Hout, W. M. "Cardiac tamponade." 2002. www.emedicine.com/med/topic283.htm (12 Feb. 2004). 3. Lanros, N. E., & Barber, J. M. (1997). Chest trauma: Damage to the heart, pericardium, and aortic arch. In Emergency nursing (4th ed. ), (p. 206). Stamford, CT: Appleton & Lange. Kathleen Moore, ed. Rita Barry. Trauma nursing: Penetrating chest wounds. RN May 1, 2004;67:36. Published in RN Magazine.  pneumothorax pneumothorax (redirected from Collapsed lung) Also found in: Dictionary, Thesaurus, Encyclopedia . Pneumothorax Definition Pneumothorax is a collection of air or gas in the chest or pleural space that causes part or all of a lung to collapse. Description Normally, the pressure in the lungs is greater than the pressure in the pleural space surroundingthe lungs. However, if air enters the pleural space, the pressure in the pleura then becomesgreater than the pressure in the lungs, causing the lung to collapse partially or completely. Pneumothorax can be either spontaneous or due to trauma. If a pneumothorax occurs suddenly or for no known reason, it is called a spontaneouspneumothorax. This condition most often strikes tall, thin men between the ages of 20 to 40. In addition, people with lung disorders, such as emphysema, cystic fibrosis, and tuberculosis, are at higher risk for spontaneous pneumothorax. Traumatic pneumothorax is the result of accident or injury due to medical procedures performed to the chest cavity, such as thoracentesis or mechanical ventilation. Tension pneumothorax is a serious and potentially life-threateningcondition that may be caused by traumatic injury, chronic lung disease, or as a complication of a medical procedure. In this type of pneumothorax, air enters the chest cavity, but cannot escape. This greatly increased pressure in the pleural space causes the lung to collapse completely,compresses the heart, and pushes the heart and associated blood vessels toward the unaffectedside. Causes and symptoms The symptoms of pneumothrax depend on how much air enters the chest, how much the lungcollapses, and the extent of lung disease. Symptoms include the following, according to thecause of the pneumothorax: Spontaneous pneumothorax. Simple spontaneous pneumothorax is caused by a rupture of a small air sac or fluid-filled sac in the lung. It may be related to activity in otherwise healthypeople or may occur during scuba diving or flying at high altitudes. Complicated spontaneouspneumothorax, also generally caused by rupture of a small sac in the lung, occurs in peoplewith lung diseases. The symptoms of complicated spontaneous pneumothorax tend to be worse than those of simple pneumothorax, due to the underlying lung disease. Spontaneouspneumothorax is characterized by dull, sharp, or stabbing chest pain that begins suddenlyand becomes worse with deep breathing or coughing. Other symptoms are shortness of breath, rapid breathing, abnormal breathing movement (that is, little chest wall movementwhen breathing), and cough. Tension pneumothorax. Following trauma, air may enter the chest cavity. A penetrating chestwound allows outside air to enter the chest, causing the lung to collapse. Certain medicalprocedures performed in the chest cavity, such as thoracentesis, also may cause a lung to collapse. Tension pneumothorax may be the immediate result of an injury; the delayedcomplication of a hidden injury, such as a fractured rib, that punctures the lung; or the result of lung damage from asthma, chronic bronchitis, or emphysema. Symptoms of tensionpneumothorax tend to be severe with sudden onset. There is marked anxiety, distendedneck veins, weak pulse, decreased breath sounds on the affected side, and a shift of themediastinum to the opposite side. Diagnosis To diagnose pneumothorax, it is necessary for the health care provider to listen to the chest (auscultation) during a physical examination. By using a stethoscope, the physician may notethat one part of the chest does not transmit the normal sounds of breathing. A chest x ray willshow the air pocket and the collapsed lung. An electrocardiogram (ECG) will be performed to record the electrical impulses that control the heart's activity. Blood samples may be taken to check for the level of arterial blood gases. Treatment A small pneumothorax may resolve on its own, but most require medical treatment. The object of treatment is to remove air from the chest and allow the lung to re-expand. This is done by inserting a needle and syringe (if the pneumothorax is small) or chest tube through the chestwall. This allows the air to escape without allowing any air back in. The lung will then re-expanditself within a few days. Surgery may be needed for repeat occurrences. Prognosis Most people recover fully from spontaneous pneumothorax. Up to half of patients withspontaneous pneumothorax experience recurrence. Recovery from a collapsed lung generallytakes one to two weeks. Tension pneumothorax can cause death rapidly due to inadequateheart output or insufficient blood oxygen (hypoxemia), and must be treated as a medicalemergency. Prevention Preventive measures for a non-injury related pneumothorax include stopping smoking andseeking medical attention for respiratory problems. If the pneumothorax occurs in both lungs or more than once in the same lung, surgery may be needed to prevent it from occurring again. Key terms Electrocardiagram — A test that provides a typical record of normal heart action. Mediastinum — The space between the right and left lung. Pleural — Pleural refers to the pleura or membrane that enfolds the lungs. Thoracentesis — Also called a pleural fluid tap, this procedure involves aspiration of fluid fromthe pleural space using a long, thin needle inserted between the ribs. Resources Organizations American Association for Respiratory Care. 11030 Ables Lane, Dallas, Texas 75229. (972) 243-2272. http://www.aarc.org. American Lung Association. 1740 Broadway, New York, NY 10019. (800) 586-4872.http://www.lungusa.org. Other"Spontaneous Pneumothorax." Health Answers.com. http://www.healthanswers.com. Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.pneumothorax [ noo″mo-thor´aks] accumulation of air or gas in the pleural cavity, resulting in collapse of the lung on the affected side. The condition may occur spontaneously (spontaneous pneumothorax), as in the course of a pulmonary disease, or it may follow perforating trauma to the chest wall or lung parenchyma (traumatic or open pneumothorax). Spontaneous Pneumothorax. This condition occurs when there is an opening on the surface of thelung allowing leakage of air from the airways or lung parenchyma into the pleural cavity. Mostoften it occurs when an emphysematous bulla or other weakened area on the lung ruptures. Normally the pleural cavity is an airtight compartment with a negative pressure. When air entersthe pleural cavity the lung collapses, producing shortness of breath and mediastinal shift towardthe unaffected side (see also mediastinal shift ). Other signs and symptoms are a sudden sharpchest pain, fall in blood pressure, weak and rapid pulse, and cessation of normal respiratorymovements on the affected side of the chest. A small spontaneous pneumothorax may require no specific treatment beyond rest andadministration of oxygen for relief of dyspnea. Chest x-rays should be obtained. The patientusually is more comfortable if allowed to sit up. A larger spontaneous pneumothorax may require a more aggressive approach such as aspiration to allow for reexpansion of the lung. If aircontinues to leak from the defect in the lung surface a continuous closed-drainage apparatus is set up (see chest tube ). As soon as the lung lesion heals and the lung is reexpanded, the patient is allowed to resume usual daily activities. Guidelines for the treatment of spontaneouspneumothorax have been published by the American College of Chest Physicians and areavailable on their web site at http://www.chestnet.org. Tension pneumothorax. This is a particularly dangerous form that occurs when air escapes intothe pleural cavity from a bronchus but cannot regain entry into the bronchus. As a result,continuously increasing air pressure in the pleural cavity causes progressive collapse of the lungtissue. Emergency aspiration of air from the pleural cavity is necessary in this disorder. If untreated, increased pressure within the pleural cavity will cause lung collapse and mediastinal shift. Pneumothorax. Air within the pleural cavity has entered some of the spacenormally occupied by the lung, thus preventing its expansion and causing partialcollapse. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.pneu·mo·thor·ax ( nū'mō-thōr'aks ), The presence of free air or gas in the pleural cavity. [G. pneuma, air, + thorax]Farlex Partner Medical Dictionary © Farlex 2012pneumothorax/pneu·mo·tho·rax/ ( -thor´aks) air or gas in the pleural space, usually as a result of trauma (traumatic or open p.) or some pathological process.tension p. pneumothorax in which the pressure within the pleural space is greater thanatmospheric pressure; as a result, the mediastinum is displaced to one side, which interfereswith breathing. Tension pneumothorax. Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.pneumothorax (no͞o′mō-thôr′ăks′, nyo͞o′-)n. Accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury, or sometimes induced to collapse the lung in the treatment of tuberculosis and other lungdiseases. The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin Company. All rights reserved.pneumothorax [no̅o̅′mōthôr′aks]Etymology: Gk, pneuma, air, thorax, chestthe presence of air or gas in the pleural space, causing a lung to collapse. Pneumothorax may be the result of an open chest wound that permits the entrance of air, the rupture of an emphysematous vesicle on the surface of the lung, or a severe bout of coughing. It may alsooccur spontaneously without apparent cause.observations The onset of pneumothorax is accompanied by a sudden sharp chest pain,followed by difficult, rapid breathing; decreased breath sounds and cessation of normal chestmovements on the affected side; tachycardia; a weak pulse; hypotension; diaphoresis; an elevated temperature; pallor; dizziness; and anxiety.interventions The patient is assured that the condition can be treated, is urged to remainstill, and is placed in bed in Fowler's position. Oxygen is administered through a nasalcannula, unless contraindicated, and the air in the pleural space is immediately aspirated. A chest tube is inserted and attached to an underwater seal; a waterless, disposable system; or a mobile chest drain; the tube is not removed until air is no longer expelled through the sealand a radiographic examination shows that the lung is completely expanded. Pain may be controlled by administering appropriate analgesics, but the use of respiratory depressants is avoided. Intermittent positive-pressure breathing may be administered.nursing considerations The patient is taught how to turn, cough, breathe deeply, andperform passive exercises and is told to avoid stretching, reaching, or making suddenmovements. The patient is advised not to smoke but to drink fluids copiously, to exercise, to avoid fatigue and strenuous activity, and to report any symptoms of recurrence, such as chestpain, difficult breathing, fever, or respiratory infection. Pneumothorax Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.pneumothorax Lung collapse Pulmology The presence of air in the pleural space, whichmay be 1º–seen in tall, thin, young ♂, characterized by subpleural apical blebs, 2º–asthma, COPD,PCP, trauma, TB, iatrogenic–due to thoracentesis, subclavian line placement, PEEP, bronchoscopy Clinical Pleural pain, dyspnea, ↓ breath sounds, percussion hyperresonance, ↓ tactile fremitus Management Small blebs may heal spontaneously, larger pneumothoraces require chest tubedrainage, pleurodesis. See Spontaneous pneumothorax. Mc Graw-Hill Concise Dictionary of Modern Medicine. © 2002 by The Mc Graw-Hill Companies, Inc.pneu·mo·thor·ax ( nū'mō-thōr'aks) The presence of air or gas in the pleural cavity. [G. pneuma, air, + thorax]Medical Dictionary for the Health Professions and Nursing © Farlex 2012pneumothorax (noo?mo-thor'aks?, nu?) (-thor'a-sez?)plural. pneumothoraces plural. pneumothoraxes [ pneum- + thorax] PNEUMOTHORAXPNEUMOTHORAXPNEUMOTHORAXA collection of air or gas in the pleural cavity. The gas enters following a perforation throughthe chest wall, e.g., due to traumatic or iatrogenic injury, or the pleura, e.g., from therupture of an emphysematous bleb or superficiallung abscess. Some tall, slender young menand women suffer repeated episodes of spontaneous pneumothorax. illustration;Symptoms The onset is sudden, usually with a severesharp pain in the side of the chest, anddyspnea. The physical signs are those of a distended unilateral chest, increased resonance,decrease in or absence of breath sounds, and, if fluid is present, a splashing sound on succussion (shaking) of the patient. Patientsoften report chest pain is worsened by coughing,deep breathing, or movement. Diagnosis Chest x-rays confirm the diagnosis, revealing air in the pleural space, often identified as a lineseen outlining a partially collapsed lung. A shift of the mediastinum toward one side of the chest or the other may be seen in tensionpneumothorax. See: tension pneumothorax Treatment Treatment varies according to type and amount of lung collapse. Traumatic or iatrogenicpneumothorax requires chest tube insertion to closed (water-sealed) chest drainage for lung re-expansion. Surgical repair also may be required. Spontaneous pneumothorax may be treatedconservatively with bedrest if there is no sign of increased pleural pressure, less than 15% lungcollapse, no dyspnea or other indication of physiological compromise. If the patient'scondition worsens or if more than 15% of thelung is collapsed, a thoracostomy tube may be placed anteriorly in the second intercostal spaceand attached to a Heimlich flutter valve or chest-drainage unit. If fluid is present in the pleuralspace, a thoracostomy tube is placed in thefourth, fifth, or sixth intercostal space moreposteriorly to drain it. Patient care The patient's vital signs, chest expansion,oximetry and/or blood gases are monitored andoxygen administered to prevent hypoxia. Thepurpose and process for placing a chest tubeare explained to the patient to allay anxiety andfoster cooperation with the procedure. After thesurgeon prepares and drapes the patient in sterile fashion, and administers localanesthesia, a small incision is made. A thoracostomy tube is attached to a water-sealeddrainage device. The patient is placed in thesemi-Fowler position to promote drainage,comfort, and ease of breathing. Vital signs andventilatory status are monitored. Once the tube is placed, deep breathing (incentive spirometry)and coughing are encouraged (at least hourly) to promote lung expansion, with prescribedanalgesics provided to control pain anddiscomfort (due in part to the tube itself). Ambulation is encouraged to facilitate fullinspiration and enhance lung expansion. Thethoracostomy tube site is kept sealed, generally by using a purse-string suture and occlusivedressing. Care is taken to avoid tension on thetubing, and all connections also are sealed to avoid air leaks. If the tube is accidentallydislodged, an occlusive (petroleum gauze)dressing is placed over the opening immediately to prevent lung collapse. When chest x-raydemonstrates adequate lung re-expansion thatremains stable without suction, thethoracostomy tube is carefully removed, and theincision is covered with an occlusive dressing. The importance of follow-up examination, x-ray,and any needed care is explained prior to discharge. Patients who smoke are urged to stop smoking and exercise is increasedgradually as determined by follow-up evaluation.artificial pneumothorax An intentionally and artificially induced pneumothorax, used to facilitate transcutaneous mediastinalbiopsy and, infrequently, to treat pulmonary tuberculosis and pneumonia. Pneumothorax allows thediseased lung to rest temporarily. The lung collapses when the air enters the pleural space. Scattered adhesions may afford only a partial collapse. Effusion may occur in about one third of thecases. Hazards include pain, infection, and respiratory distress.catamenial pneumothorax Pneumothorax that occurs during menses and resulting from endometrial implants in the chest, e.g.along the diaphragm or in the pleural space.extrapleural pneumothorax The formation of a pneumothorax by introducing air into the space between the pleura and the inside of the rib cage.occult pneumothorax A pneumothorax that is not detected by physical examination of the patient or by plain x-rays but is identified instead by other means, usually a CT scan of the chest and abdomen. The condition may be life-threatening.open pneumothorax A pneumothorax in which the pleural cavity is exposed to the atmosphere through an open wound in the chest wall.spontaneous pneumothorax The spontaneous entrance of air into the pleural cavity. The pressure may collapse the lung anddisplace the mediastinum away from the side of the lesion. Symptoms Although some patients with pneumothorax have few symptoms, most people who come to clinicalattention report the sudden onset of left- or right-sided chest pain, often accompanied by shortness of breath. Breath sounds may be absent on the affected side, or the lung percussion note on thatside may reveal increased resonance.tension pneumothorax A type of pneumothorax in which air can enter the pleural space but cannot escape via the route of entry. This leads to increased pressure in the pleural space, resulting in lung collapse. The increase in pressure also compresses the heart and vena cavae, which impairs circulation. Patient care The patient is assessed for evidence of respiratory failure or the need for immediate intervention. Thedevelopment of tension pneumothorax is a medical emergency; if it is not promptly relieved, thepatient will experience inadequate cardiac output and hypoxemia (and may die). To prevent rapiddecompensation, a large-bore needle is inserted emergently into the pleural space at the secondintercostal space, mid-clavicular line (needle decompression, needle thoracotomy). This temporizingprocedure must be followed by thoracostomy tube placement and water-sealed chest drainage unit. Medical Dictionary, © 2009 Farlex and Partnerspneumothorax The presence of air in the normally potential space between the twolayers of the PLEURA (the pleural cavity). This may occur spontaneously from the rupture of a CONGENITAL bleb on the inner layer, or may result from air access from the outside through a wound. Pneumothorax causes the collapse of the lung on the same side. In minor cases there is recovery without treatment, but the air may have to be withdrawn through a tube. Collins Dictionary of Medicine © Robert M. Youngson 2004, 2005pneumothoraxair in the pleural cavity, between the chest wall and the lungs, either by escape from damaged lungs or by entry from outside with a penetrating injury. Causes compression of lung tissue and potentially respiratory distress. Can occur spontaneously, especially in theyoung, as a complication of lung disease or in sport, most commonly as a result of direct trauma. May also occur by barotrauma in scuba diving and flying at altitude. Symptoms include sharpchest pain and shortness of breath. Diagnosis is clinical, confirmed by chest X-ray. If small, usuallyheals spontaneously but if larger and symptomatic may require the use of a chest drain to re-expand the lung. If recurrent, may require surgery. Dictionary of Sport and Exercise Science and Medicine by Churchill Livingstone © 2008 Elsevier Limited. All rights reserved.pneumothorax (nōōˈ·mō·thōˑ·raks),n an abnormal condition characterized by the buildup of air within the space between thelungs and the chest wall; as a result, the lung is unable to expand properly during respirationand eventually collapses because of the increased pressure. Symptoms include chest painand shortness of breath; although rare, it is a potential complication of acupuncturetreatments. Jonas: Mosby's Dictionary of Complementary and Alternative Medicine. (c) 2005, Elsevier.pneu·mo·thor·ax ( nū'mō-thōr'aks) Presence of free air or gas in pleural cavity. [G. pneuma, air, + thorax]Medical Dictionary for the Dental Professions © Farlex 2012pneumothorax (noo´mōthôr´aks),n an accumulation of air or gas in the pleural cavity. The air enters by way of an externalwound, a lung perforation, a burrowing abscess, or rupture of a superficial lung cavity. It is accompanied by sudden, severe pain and rapidly increasing dyspnea. Mosby's Dental Dictionary, 2nd edition. © 2008 Elsevier, Inc. All rights reserved.pneumothoraxentry of air into the pleural cavity in sufficient quantity to cause collapse of the lung andconsequent respiratory embarrassment. If it is unilateral there is a mediastinal shift withdisplacement of the heart to the other side of the chest. Breath sounds are absent from theaffected side. Pneumothorax. By permission from Ettinger SJ,Feldman E, Textbook of Veterinary Internal Medicine, Saunders, 2004closed pneumothoraxair leaks from a discontinuity in the lung into the pleural cavity.false pneumothoraxartifactual increased radiolucency of the thorax resembling free air in the pleural cavity.iatrogenic pneumothoraxmay occur following intrathoracic surgery or in association with procedures which involveentry into the pleural cavity, such as thoracentesis or placement of a chest drain.open pneumothoraxcaused by an open wound in the chest wall.spontaneous pneumothoraxdue to an unknown cause.tension pneumothoraxa particularly dangerous form of pneumothorax that occurs when air escapes into thepleural cavity from a bronchus but cannot regain entry into the bronchus. As a result,continuously increasing air pressure in the pleural cavity causes progressive collapse of the lung tissue. If not relieved, it can lead to lung collapse and mediastinal shift. Saunders Comprehensive Veterinary Dictionary, 3 ed. © 2007 Elsevier, Inc. All rights reserved Want to thank TFD for its existence? Tell a friend about us, add a link to this page, or visit the webmaster's page for free fun content . Link to this page:<a href="https://medical-dictionary.thefreedictionary.com/Collapsed+lung">pneumothorax</a>Facebook Twitter  Overview Overview Pectus excavatum Pectus excavatum is a condition in which a person's breastbone is sunken into his or her chest. In severe cases, pectus excavatum can look as if the center of the chest has been scooped out, leaving a deep dent. While the sunken breastbone is often noticeable shortly after birth, the severity of pectus excavatum typically worsens during the adolescent growth spurt. Also called funnel chest, pectus excavatum is more common in boys than in girls. Severe cases of pectus excavatum can eventually interfere with the function of the heart and lungs. But even mild cases of pectus excavatum can make children feel self-conscious about their appearance. Surgery can correct the deformity. Pectus excavatum care at Mayo Clinic Symptoms For many people with pectus excavatum, their only sign or symptom is a slight indentation in their chests. In some people, the depth of the indentation worsens in early adolescence and can continue to worsen into adulthood. In severe cases of pectus excavatum, the breastbone may compress the lungs and heart. Signs and symptoms may include: Decreased exercise tolerance Rapid heartbeat or heart palpitations Recurrent respiratory infections Wheezing or coughing Chest pain Heart murmur Fatigue Request an Appointment at Mayo Clinic Causes While the exact cause of pectus excavatum is unknown, it may be an inherited condition because it sometimes runs in families. Risk factors Pectus excavatum is more common in boys than in girls. It also occurs more often in people who also have: Marfan syndrome Ehlers-Danlos syndrome Osteogenesis imperfecta Noonan syndrome Turner syndrome Complications Severe cases of pectus excavatum can compress the heart and lungs or push the heart over to one side. Even mild cases of pectus excavatum can result in self-image problems. Heart and lung problems If the depth of the breastbone indentation is severe, it may reduce the amount of room the lungs have to expand. This compression can also squeeze the heart, pushing it into the left side of the chest and reducing its ability to pump efficiently. Self-image problems Children who have pectus excavatum also tend to have a hunched-forward posture, with flared ribs and shoulder blades. Many are so self-conscious about their appearance that they avoid activities, such as swimming, where the indentation in their chests is more difficult to camouflage with clothing. By Mayo Clinic Staff Pectus excavatum care at Mayo Clinic Request an Appointment at Mayo Clinic Diagnosis & treatment March 09, 2018Share on: Facebook Twitter References Related Pectus Excavatum Wheezing Cough Fatigue Pectus excavatum Symptoms & causes Diagnosis & treatment Doctors & departments Care at Mayo Clinic Advertisement Mayo Clinic does not endorse companies or products. Advertising revenue supports our not-for-profit mission. Advertising & Sponsorship Policy Opportunities Ad Choices Mayo Clinic Marketplace Check out these best-sellers and special offers on books and newsletters from Mayo Clinic. FREE TRIAL – Mayo Clinic Health Letter Stop Osteoporosis in Its Tracks Improve Your Hearing and Balance Best Treatment Strategies for Arthritis The Mayo Clinic Diet Online CON-20248760Patient Care & Health Information Diseases & Conditions Pectus excavatum  Background Background Pectus excavatum, also known as sunken or funnel chest, is a congenital chest wall deformity in which several ribs and the sternum grow abnormally, producing a concave, or caved-in, appearance in the anterior chest wall. The image below illustrates the typical appearance of this deformity in a 16-year-old boy. A 16-year-old boy with severe pectus excavatum. Note the appearance of the caved-in sternum and lower ribs. View Media Gallery Pectus excavatum is the most common type of congenital chest wall abnormality (90%), followed by pectus carinatum (5-7%), cleft sternum, pentalogy of Cantrell, asphyxiating thoracic dystrophy, and spondylothoracic dysplasia. Pectus excavatum occurs in an estimated 1 in 300-400 births, with male predominance (male-to-female ratio of 3:1). The condition is typically noticed at birth, and more than 90% of cases are diagnosed within the first year of life. Worsening of the chest’s appearance and the onset of symptoms are usually reported during rapid bone growth in the early teenage years. Many patients are not brought to the attention of a pediatric surgeon until the patient and the family notice such changes. The appearance of the chest can be very disturbing to young teenagers. Problems with self-esteem and body image perception are frequently reported in teenaged patients. Psychologic disturbances are not unusual in older patients. Examples of pectus excavatum in young girls are shown in the images below. A 10-year-old girl with severe pectus excavatum. In girls, the deformity is of particular concern because of the medial displacement of the breast, resulting in significant asymmetry of the breasts and nipples (cross-eyed appearance of the nipples). View Media Gallery A 10-year-old girl with severe pectus excavatum. Note the significant asymmetry of the breasts and nipples (cross-eyed appearance of the nipples). View Media Gallery A 12-year-old girl with severe pectus excavatum. Note the significant asymmetry of the breasts. Preoperative photograph. View Media Gallery Next: Pathophysiology 