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.)

Action stat!

If you detect tracheal deviation, 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. catheter for fluid and drug administration. Palpate for subcutaneous crepitation in the neck and chest, a sign of tension pneumothorax. Obtain a chest X-ray. Chest tube insertion may be necessary to release trapped air or fluid and to restore normal intrapleural and intrathoracic pressure gradients.

History and physical examination

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.

Then perform a physical examination. Inspect the chest wall for symmetry during ventilation. Check pulse oximetry and vital signs. Auscultate the lungs for breath sounds. Note signs of respiratory distress. Place the patient on a cardiac monitor and assess heart sounds. Palpate the chest and abdomen for abnormalities.

Medical causes

Atelectasis.Extensive lung collapse can produce tracheal deviation toward the affected side. Respiratory findings 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.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 coughing, dyspnea, asymmetrical chest expansion and, possibly, asymmetrical breath sounds. Backache and fatigue are also common.

Mediastinal tumor.Typically producing 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.

Pulmonary tuberculosis (TB).With a large cavitation resulting from TB, 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 the disease progresses.

Retrosternal thyroid.Retrosternal thyroid can displace the trachea. The gland is felt as a movable neck mass above the suprasternal notch. Dysphagia, cough, hoarseness, and stridor are common. Signs of thyrotoxicosis may be present.

Tension pneumothorax.Tension pneumothorax is an acute, life-threatening condition that produces tracheal deviation toward the unaffected side. It's marked by a sudden onset of respiratory distress with 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.

Thoracic aortic aneurysm.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 jugular veins. The patient may also experience substernal, neck, shoulder, or lower back pain, possibly with paresthesia or neuralgia.

Nursing considerations

▪ Monitor the patient's respiratory and cardiac status.

▪ Administer oxygen if needed.

▪ Make sure that emergency equipment is readily available.

▪ Give analgesics for comfort, if needed.

▪ Prepare the patient for diagnostic tests, such as chest X-rays, bronchoscopy, an electrocardiogram, and arterial blood gas analysis.

▪ Assist with insertion of a large bore needle into the pleural space or a thoracostomy tube for tension pneumothorax.

Patient teaching

▪ Explain the underlying disorder and treatment plan.

▪ Teach the patient how to perform coughing and deep-breathing exercises.

▪ Explain signs and symptoms of respiratory difficulty to report immediately.

Pictures

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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