flail chest

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chest

 [chest]
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 normal pressures 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 through surgery or trauma, when a defect in the alveoli allows air to enter the intrapleural space, and when there is an accumulation of fluid, as from pleural effusion. The effect of excessive amounts 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 has chest 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-seal drainage 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 pleural cavity to the outside and at the same time prevent the entry of atmospheric air into the pleural cavity.

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 the chest to prevent backflow.

2. The lumens of the tubes must be kept open to allow for drainage. If they are obstructed there will be no fluctuation of the fluid level in the glass tube that is connected to the chest tube at one end and kept under water in the bottle at the other end. In the Pleur-evac, the liquid in the chamber should rise on the right side and fall on the left side. If there is evidence that 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 tension pneumothorax.

3. The system must be a closed (airtight) system. There can be no leaks around connections, 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 once each hour for the first 24 hours after surgery. The chest tubes should be milked and stripped every one to two hours to assure patency and adequate drainage. The amount of air being removed is indicated by occasional bubbling in the water-seal chamber. Excessive bubbling may indicate air leaks in the tubing.

An important aspect of patient care is proper positioning to maintain adequate drainage. The positions allowed and the amount of mobility permitted will depend on the patient's surgical diagnosis, the placement of the tube(s), and preference of the attending physician. Frequent turning, coughing, and deep breathing are instituted on a regular basis to avoid serious pulmonary 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 usually are ordered for all patients with chest tubes. Some patients may require a ventilator during the immediate postoperative period.

The patient is observed for signs of respiratory distress and a buildup of air and fluid within the pleural cavity. Early correction of this condition can prevent mediastinal shift. Other signals that demand immediate attention are persistent bubbling in the underwater seal (fluid should fluctuate 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 and tubing 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, the wound is promptly sealed with a sterile petroleum jelly dressing to occlude the opening and prevent entry of air into the pleural space.
 One-, two-, and three-bottle methods for providing a closed drainage system. A, In the one-bottle system the drainage via the chest tube enters the bottle through the glass tube which has one end submerged under water to form a seal. This provides a one-way valve that prevents a backflow of air into the pleural cavity, which could collapse the lung. 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 second bottle 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 damage the pleural membrane. No drainage enters this bottle. Its only purpose is to control the force 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 tube that 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 their inception in 1967. (Courtesy of Deknatel, Inc., Fall River, MA.)

flail

 [flāl]
exhibiting abnormal or pathologic mobility, such as a flail chest or a flail joint.
flail chest a loss of stability of the chest wall due to three or more ribs that are broken in two or more places as a result of a crushing chest injury. The loose chest segment moves in a direction in the reverse of normal; that is, the segment moves inward during inhalation and outward during exhalation (paradoxical respiration). Other manifestations include shortness of breath, cyanosis, and extreme pain in the area of trauma.

Emergency treatment is aimed at stabilizing the loose chest segment to reduce ineffective and exhausting chest movement and provide for adequate ventilation of the lungs. The patient is transported lying on the affected side to further stabilize the chest wall and enable the use of the unaffected side for respiration.
Flail chest. A, Inspiration. As intrapleural pressure becomes increasingly negative, the flail segment and its underlying lung tissue are sucked inward, collapsing the lung on the affected side and shifting the mediastinum toward the unaffected side. B, Expiration. As intrapleural pressure becomes less negative, the flail segment and underlying tissue are pushed outward, and the mediastinum shifts to the affected side. Some air moves between the lungs instead of passing through the upper airways. Large arrows indicate structural movement; dashed arrows indicate abnormal air movement; small arrows indicate normal air movement; open arrows indicate flail segment movement. From Kitt et al., 1995.

flail chest

loss of stability of thoracic cage following fracture of sternum, ribs, or both; can cause respiratory failure.

flail chest

[flāl]
Etymology: ME, fleyl, whip; AS, cest, box
a thorax in which there are two fractures on at least two adjacent ribs causing instability in part of the chest wall and paradoxic breathing, with the lung underlying the injured area contracting on inspiration and bulging on expiration. If it is uncorrected, hypoxia will result.
observations Flail chest is characterized by sharp pain; uneven chest expansion; shallow, rapid respirations; and decreased breath sounds. Tachycardia and cyanosis may be present. Potential complications include atelectasis, pneumothorax, hemothorax, cardiac tamponade, shock, and respiratory arrest. Often other traumatic injuries are present in a patient with a flail chest.
interventions The treatment of choice is internal stabilization of the chest wall through the use of positive pressure. Bilevel positive pressure or mechanical ventilation may be used. If the patient breathes against the automatic ventilator, a sedative and muscle relaxant may be ordered to achieve ventilatory control. Chest tubes may be required to remove air or fluid that is preventing expansion of the affected lung, and a nasogastric tube may be ordered to provide food and fluids. The patient's vital signs and breath sounds are frequently evaluated, and arterial blood gases are monitored.
nursing considerations The patient with flail chest usually requires a long period of care involving frequent repositioning, scrupulous attention to the patency and cleanliness of the tracheostomy or endotracheal tube, skin care, oral hygiene, pain management, and emotional support. Members of the health care team perform passive range-of-motion exercises involving the extremities, explain the various procedures, and provide a pad and pencil or a magic slate with which the patient can communicate.
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Flail chest

flail chest

Traumatology Paradoxic movement of the anterior chest wall during inspiration, as the free-floating 'flailed' part of the wall moves inward as the chest expands, in response to the negative intrathoracic pressure; FC is caused by multiple anterior rib fractures, often due to MVAs or aggressive CPR

flail chest

(flāl chest)
Flapping chest wall; condition in which three or more consecutive ribs on the same side of the chest have been fractured in at least two places, with resulting instability of the chest wall, paradoxic respiratory movements of the injured segment, and loss of respiratory efficiency.

flail chest

A state of abnormal mobility of the chest wall due to rib fractures.

flail

exhibiting abnormal or pathological mobility, as flail chest or flail joint.

flail chest
a loss of stability of the chest wall due to multiple rib fractures or detachment of the sternum from the ribs as a result of a severe crushing chest injury. The loose chest segment moves in a direction which is the reverse of normal; that is, the segment moves inward during inspiration and outward during expiration (paradoxical respiration). Other manifestations of flail chest include shortness of breath, cyanosis, and extreme pain in the area of trauma.
flail joint
an unusually movable joint.
flail segment
the portion of skin, chest-wall or other structure lacking stability.
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