Breathing and Ventilation

Chinedu Izuagba
Assessment
• Respiratory rate and SpO2
• Exposure and inspection essential: external signs of trauma, asymmetrical chest
movements
• Careful palpation over entire chest wall may reveal unsuspected injury such as
crepitus / surgical emphysema.
• Percussion – often difficult in a noisy trauma bay
• Auscultation – listening for air entry bilaterally, gauge adequacy and assess for
added sounds
• Trachea – palpate to see if deviated, although true tracheal deviation due to a
tension pneumothorax is pre-terminal and it is unlikely to be the only sign
• May be appropriate to log roll at this stage if concerned about a posterior chest
injury.
Hypoventilation
• Hypoventilation refers to a state of decreased or inadequate ventilation with an
increase in partial arterial CO2 pressure to a level above 45 mmHg.
• Retained PACO2  increase in PaCO2  respiratory acidosis.
• Decreased PAO2  decreased PaO2 (hypoxemia  hypoxia)  decreased SaO2.
• Causes (setting of trauma):
System Cause
Respiratory centre Trauma
Drugs: Narcotics

Chest Wall Flail Chest (multiple rib fractures, paradoxical breathing: fatal)
Muscles Damage to the phrenic nerve
Hyperventilation
• Hyperventilation refers to a state of increased ventilation with a decrease in
partial arterial CO2 pressure to a level below 35 mmHg.
• Rapid release of PACO2  decrease in PaCO2  respiratory Alkalosis.
• Increased PAO2
• Causes:
Systems Cause
Respiratory Centre Drugs: Aspirin, salicylates
High Altitudes
Septic shock
Chest wall Rib fracture  pain  hyperventilation
Lungs Pneumothorax (tension and spontaneous)
Management
• High flow oxygen 15L/min via non-rebreather mask on arrival
• Non-invasive ventilation is rarely indicated in trauma patients
• Patients requiring respiratory support are usually intubated and mechanically
ventilated
• Needle thoracotomy, finger thoracotomy or intercostal catheter insertion may be
required urgently
Tension Pneumothorax
• A life-threatening emergency
• Can lead to cardiac arrest within minutes!
• Occurs when gas progressively enters the pleural space, unable to leave ultimately
compressing the lung and shifting the mediastinum.
• Most caused by trauma but can be iatrogenic (placing central line)
• Diagnosis is entirely clinical. DO NOT waste time obtaining X-rays.
• Features:
• Dyspnoea, Tachypnoea, Acute respiratory distress
• Distended neck veins (unless hypovolemic), tachycardia, hypotension, and Ultimately loss of
consciousness
• Tracheal deviation and mediastinum shift away from affected side
• Hyper-resonance over the affected lung
• Absent breath sounds on the affected side
Tension Pneumothorax
• Treatment:
• Apply High flow O2 by face mask.
• Perform a thoracostomy which is a small incision of the chest wall, with maintenance of the
opening for drainage. Can be done via a needle/finger or tube.
• Needle thoracostomy is the currently accepted first-line intervention but it was never designed
to be a definitive treatment for pneumothorax.
• Usually done in adverse environment, where performing a complex and long procedure may
be impossible.
• Finger thoracostomy allows for maximum release of air from the pleural cavity and full lung re-
expansion.
• Indicated in any pneumothorax in a patient undergoing positive pressure ventilation. If the pt.
is in actual or near traumatic cardiac arrest or in a shocked state with no apparent cause.
• An advantage of it avoids risk of re-tension caused by blockage and kinking of drainage
systems but is an invasive procedure.
Performing a Thoracostomy
Needle thoracostomy
• The needle recommended for use is of 16-gauge diameter or higher
IV cannula.
• The NT should be placed at the 2nd intercostal space in the
midclavicular line, ipsilateral to the pneumothorax.
• Withdraw the needle and listen for a hiss of gas.
• Tap the cannula to the chest wall.
• Insert an axillary chest drain on the affected side immediately.
Tube thoracostomy
• The skin will be thoroughly cleaned. A local anesthetic (numbing)
medication will be used.
• An incision from ¾ inch to 1½ inches long, between the ribs
• The chest tube is inserted and will be stitched into place to prevent
it from slipping out.
• An airtight sterile dressing bandage is placed over the insertion site.
• The chest tube will be connected to a drainage collection device.
Often it is attached to suction to help draw out the air or fluid
Finger thoracostomy
• Abduct the arms to >90° and locate the triangle of safety.
• Lateral border of the pectoralis major (anteriorly),
Anterior border of the latissimus dorsi (posteriorly), The
axilla (apex) and at the level of the nipple in males or
mammary fold in females (base).
• The incision site is the 4th ICS anterior to the mid axillary
line and within the safety triangle.
• Using a scalpel make a 30-40mm incision into the
subcutaneous fat.
• With forceps gently push through the intercostal muscles
and pleura. A tract capable of having a finger inserted
should be achieved (insert finger to ensure).
• Perform a finger sweep to assess for the release of air or
blood and lung inflation or deflation.
Open Pneumothorax
• An open pneumothorax occurs when air accumulates between the chest wall and the lung as
the result of an open chest wound.
• Features
• An open chest wound may be visible, or a sucking sound may be audible when air enters the wound.
• Sudden chest pain, shortness of breath, rapid and shallow breathing, tachycardia and hypoxia.
• Hyper-resonant percussion note with decreased intensity of breath sounds or absent breath sounds
• Individuals may feel weak, dizzy, restless, or agitated.
• Diagnosis is through review of history, physical examination, and symptoms.
• Imaging can also assist in diagnosis
• The extended focused abdominal sonography for trauma (E-FAST) exam is one potential diagnostic tool.
• Computerized tomography (CT) and chest X-ray are also options, although an ultrasound is typically more useful than
a chest X-ray.
• If a patient is very unstable with a suspected open pneumothorax, treatment is typically initiated before imaging is
used to confirm the diagnosis.
Open Pneumothorax
Treatment
• Apply a sterile Occlusive Dressing to wound
• Tape dressing on 3 of the 4 sides (Valve effect)
• Offers only temporary stabilization until Chest Tube can be placed
• Chest Tube is the primary management for an open chest wound
• Do not completely occlude the wound until Chest Tube is in place (Tension Pneumothorax risk)
• Place Chest Tube remote from open wound
• Typical Chest Tube placement is over the 5th rib in the mid-axillary line
• Do not use the wound site for insertion of Chest Tube (contamination risk)
• Surgical Consultation
• Provides definitive chest wound closure
Haemothorax
• Blood may collect in the pleural cavity in association with pneumothorax
(Hemopneumothorax) or without (haemothorax).
• A large amount of bleeding (>1000ml) into the pleural space sufficient to produce
hypovolemic shock is termed Massive haemothorax.
• Diagnose the hemothorax with CXR vs. US definitively with CT.
• If the mechanism suggests hemothorax = rule out hemothorax despite CXR findings (CT if
patient hemodynamically stable)
• Features
• Respiratory distress reflects both pulmonary compromise and hemorrhagic shock.
• Tachypnea is common; shallow breaths may be noted.
• Diminished ipsilateral breath sounds with dullness to percussion over the affected lung.
• With massive haemothorax there is evidence of hypotension and tachycardia.
Haemothorax
Treatment
• Give O2 and insert 2 large venous cannula (send blood for Cross-matching)
• If hypovolaemic start IV fluids before inserting a large (>32G) chest drain.
• Autotransfusion can be done in patients with a massive haemothorax and can be considered with the
anticipated loss of at least 20% of the patient's estimated total body blood volume.
• It should also be considered if the Emergency Department cannot obtain or provide cross-matched
compatible blood.
• Thoracotomy is the procedure of choice for surgical exploration of the chest when massive hemothorax
or persistent bleeding is present.
• The Indications for thoracotomy after traumatic injury include:
• Mean greater than 1500 mL of initial chest tube output
• Continued hourly blood loss of 250 mL or more for 3 consecutive hours after tube thoracostomy.
• Surgical exploration of the chest may be required later in the course of the patient with hemothorax for
evacuation of retained clot, drainage of empyema, or decortication.
References
• Life in the Fastlane
https://litfl.com/trauma-initial-assessment-and-management/
https://litfl.com/finger-thoracostomy/
• Medscape
https://emedicine.medscape.com/article/2047916-treatment
• JAMA Network
https://jamanetwork.com/journals/jamasurgery/fullarticle/391389
• Access Medicine: Emergency medicine
https://accessemergencymedicine.mhmedical.com/content.aspx?
bookid=683&sectionid=45343842#57719854