Tracheal deviation
Normally, the trachea is located at the midline of the neck — except at the bifurcation, where it shifts slightly toward the right. Visible deviation from its normal position signals an underlying condition that can compromise pulmonary function and possibly cause respiratory distress. A hallmark of life-threatening tension pneumothorax, tracheal deviation occurs with disorders that produce mediastinal shift due to asymmetrical thoracic volume or pressure. A nonlesion pneumothorax can produce tracheal deviation to the ipsilateral side. (See Detecting slight tracheal deviation.)
Emergency Actions
Be alert for signs and symptoms of respiratory distress (tachypnea, dyspnea, decreased or absent breath sounds, stridor, nasal flaring, accessory muscle use, asymmetrical chest expansion, restlessness, and anxiety). If possible, place the patient in semi-Fowler’s position to aid respiratory excursion and improve oxygenation. Give supplemental oxygen, and intubate the patient if necessary. Insert an I.V. line for fluid and drug administration. In addition, palpate for subcutaneous crepitation in the neck and chest, a sign of tension pneumothorax. Chest tube insertion may be necessary to release trapped air or fluid and to restore normal intrapleural and intrathoracic pressure gradients.
History
If the patient doesn’t display signs of distress, ask about a history of pulmonary or cardiac disorders, surgery, trauma, or infection. If he smokes, determine how much. Ask about associated signs and symptoms, especially breathing difficulty, pain, and cough.
Physical assessment
Take the patient’s vital signs and observe for respiratory distress. If the patient’s condition allows, perform a complete cardiopulmonary assessment.
Medical causes
Atelectasis
Extensive lung collapse can produce tracheal deviation toward the affected side. Respiratory findings of atelectasis include dyspnea, tachypnea, pleuritic chest pain, dry cough, dullness on percussion, decreased vocal fremitus and breath sounds, inspiratory lag, and substernal or intercostal retraction.
Hiatal hernia
With hiatal hernia, intrusion of abdominal viscera into the pleural space causes tracheal deviation toward the unaffected side. The degree of attendant respiratory distress depends on the extent of herniation. Other effects include pyrosis, regurgitation or vomiting, and chest or abdominal pain.
Kyphoscoliosis
Kyphoscoliosis can cause rib cage distortion and mediastinal shift, producing tracheal deviation toward the compressed lung. Respiratory effects include dry cough, dyspnea, asymmetrical chest expansion and, possibly, asymmetrical breath sounds. Backache and fatigue are also common.
Mediastinal tumor
Although it may produce no symptoms in its early stages, a mediastinal tumor, when large, can press against the trachea and nearby structures, causing tracheal deviation and dysphagia. Other late findings include stridor, dyspnea, brassy cough, hoarseness, and stertorous respirations with suprasternal retraction. The patient may experience shoulder, arm, or chest pain as well as edema of the neck, face, or arm. His neck and chest wall veins may be dilated.
Pleural effusion
A large pleural effusion can shift the mediastinum to the contralateral side, producing tracheal deviation. Related effects include dry cough, dyspnea, pleuritic pain, pleural friction rub, tachypnea, decreased chest motion, decreased or absent breath sounds, egophony, flatness on percussion, decreased tactile fremitus, fever, and weight loss.
Pulmonary fibrosis
Asymmetrical pulmonary fibrosis can cause tracheal deviation as the mediastinum shifts toward the affected side. Associated findings reflect the underlying condition and pattern of fibrosis. Dyspnea, cough, clubbing, malaise, and fever commonly occur.
Pulmonary tuberculosis
With a large cavitation, tracheal deviation toward the affected side accompanies asymmetrical chest excursion, dullness on percussion, increased tactile fremitus, amphoric breath sounds, and inspiratory crackles. Insidious early effects include fatigue, anorexia, weight loss, fever, chills, and night sweats. Productive cough, hemoptysis, pleuritic chest pain, and dyspnea develop as tuberculosis progresses.
Tension pneumothorax
Tension pneumothorax, an acute, life-threatening condition, produces tracheal deviation toward the unaffected side. It’s marked by a sudden onset of respiratory distress accompanied by sharp chest pain, dry cough, severe dyspnea, tachycardia, wheezing, cyanosis, accessory muscle use, nasal flaring, air hunger, and asymmetrical chest movement. Restless and anxious, the patient may also develop subcutaneous crepitation in the neck and upper chest, decreased vocal fremitus, decreased or absent breath sounds on the affected side, jugular vein distention, and hypotension. (See Associated disorder: Tension pneumothorax.)
Thoracic aortic aneurysm
A thoracic aortic aneurysm usually causes the trachea to deviate to the right. Highly variable associated findings may include stridor, dyspnea, wheezing, brassy cough, hoarseness, and dysphagia. Edema of the face, neck, or arm may occur with distended chest wall and neck veins. The patient may also experience substernal, neck, shoulder, or lower back pain, possibly with paresthesia or neuralgia.
Special considerations
Because tracheal deviation usually signals a severe underlying disorder that can cause respiratory distress at any time, monitor the patient’s respiratory and cardiac status constantly, and make sure that emergency equipment is readily available. Prepare the patient for diagnostic tests, such as chest X-rays, bronchoscopy, an electrocardiogram, and arterial blood gas analysis.
Pediatric pointers
Keep in mind that respiratory distress typically develops more rapidly in children than in adults.
Geriatric pointers
In elderly patients, tracheal deviation to the right commonly stems from an elongated, atherosclerotic aortic arch, but this deviation isn’t considered abnormal.
Patient counseling
Teach the patient to perform coughing and deep-breathing exercises properly. Discuss signs and symptoms of respiratory difficulty to report, such as shortness of breath and increased respiratory rate. Provide reassurance and emotional support because the patient may be frightened by his limited breathing capacity.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Throat symptoms
Read excerpts from these other book chapters related to Throat symptoms:
Medical Books Excerpts
- DYSPHAGIA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Dysphagia
- "In A Page: Pediatric Signs and Symptoms" (2007)
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- Dysphagia
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Dysphagia
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Mouth lesions
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Throat pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Dysphagia
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Dysphagia
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Tracheal deviation
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Dysphagia
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Throat pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Sore Throat
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
- Dysphagia
- "Nursing: Interpreting Signs and Symptoms" (2007)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Throat symptoms
» Next page: Sore Throat (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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