Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 88: Tracheal Deviation, to the Left or to the Right?
Tracheal Deviation, to the Left, to the Right, which way does it go? This is probably one of the most common questions that I get from students studying for the NPTE. As it often does, the answer comes down to pressures.
Tune into this episode to learn ipsilateral vs. contralateral movement of the trachea.
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Welcome to Talking All Things Cardiopulm. I am your host, dr Rachele Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is brought to you by Jane, a clinic management software and EMR. Now, we all know choosing the right EMR can feel a bit overwhelming, especially when you're just starting out. You're trying to juggle both your practice needs and your budget, and that's not always the easiest combination. Well, that's why Jane came up with a new balance plan. It includes essential features for you to keep things running smoothly in your clinic without all the extra stuff. One-on-one telehealth, unlimited support, email reminders and much more are included, no matter which plan you choose. So if you're looking for an EMR that helps you focus on your clients, not your costs, jane is here for you. Plans start as low as $39 a month. Visit janeapp backslash pricing to learn more, and if you're ready to get started, use my code CARDIOPULM1MO at the time of signup for a one- month grace period applied to your new account. Thanks again, jane. All right, welcome back.
Rachele Burriesci:We are cruising in December I'm not going to say it because I think I have said it every single week this year but it's moving fast, real freaking fast. We're already getting ready to leave out of town for Christmas, I think, thanksgiving being the last weekend of the month wildly skewed time, which, by the way, I thought Thanksgiving always fell on the third Thursday of November. Apparently this is false information or I am misremembering, but that last weekend, or having that extra week in November and having it fall on that last weekend, wildly threw me off. So now I'm trying to figure out when we're making Christmas cookies. I don't know, it's a little bit crazy.
Rachele Burriesci:Anyway, I wanted to talk about tracheal deviation today. It is a question that I get from students quite a bit and it's just one of those things that sometimes it's just hard to pin down. So this might be a shorter episode overall, but I'm hoping to keep it quick and concise, to not muddy the waters any more than it needs to be. So tracheal deviation or tracheal shift is that the trachea shifts right or left, or we typically say ipsilateral versus contralateral, pending what is happening in the lung or the thorax right. This is really another conversation about pressure and volume, and if we can kind of think in terms of that, then we're usually golden From a how to perform perspective.
Rachele Burriesci:There is a number of different ways that can be taught how to assess tracheal shift. One is just observation. You might be able to visually see the trachea leaning one side versus the other. Typically you can see it on chest x-ray as well, and that's literally observation, seeing the trachea being pulled to one side or the other. But you can also palpate and, depending on which textbook you're in depends on how, they might tell you to do that. So sometimes they'll teach you to use your pointer finger, find the trachea at midline, kind of come down to that sternal notch and assess what it looks like. And then you're going to take your finger and basically slide to the left so that you're right over that SC joint and then slide to the right and see if there's any difference in position. Some people use a three finger technique, which sometimes can be a little bit easier to visually see. So you're going to use your middle finger as your middle point and then two fingers on either side of the SC joint, making sure that you're on the inside of the SCM and then you'd be able to see if there's any deviation one side or the other. So typically when I teach tracheal shift, I teach contralateral movement first, because I think it's the easiest to grasp. If you have increased pressure or increased volume within your hemithorax, that pressure is going to push the trachea away. It's going to move the trachea contralateral. So what are some examples of increased pressure, increased volume? Two that I think are easy to grasp are tumors and pleural effusion. So a tumor would be an increased something in this space, right? It's going to increase the pressure, increase the volume on that side, almost like you run out of space, and it's going to push that trachea over.
Rachele Burriesci:The one that gets students every year is a pneumothorax, and I think part of the reason why they get hung up is due to the layman's term of collapsed lung and how collapsed lung is used in other terminology. So I like to keep it as a pneumo, right. And it still kind of throws people because when they think of a pneumo they think of a collapsed lung. So then you want to think the opposite of what's actually happening, and I'm not going to say it incorrectly because I don't want to mess you up. So the way I teach this is really thinking about the anatomy.
Rachele Burriesci:We have a pleural space that hugs the lung right. That pleural space has negative pressure and that pleural space helps maintain an inflated lung. We have this transpulmonary pressure. One pulls towards the chest, one pulls toward the lung. But at the end of the day the main story here is that that pleural space has negative pressure and it's going to maintain that lungs position. It's going to maintain keeping that lung inflated. The other piece of this is understanding that the lungs are negative pressure. So if we have a pneumothorax, we have intrusion now of that pleural space. We have an opening and what happens in that is that we collect air. So now we have a change in pressure. We have increased air filling that pleural space, essentially making the lung itself smaller. When we make the lung smaller, smaller volume, in that case it's going to increase pressure. So we have increased air on that side, increased pressure on the lung. What is it going to do? It's going to push the trachea away. So when we think pneumo, you want to think air inside pleural space is going to increase pressure on that side of the thorax and that's going to push the trachea away.
Rachele Burriesci:When we have tracheal shift to the same side or ipsilateral side, we typically are discussing decreased volume on that side. So you can look at this two ways. If you have decreased volume, trachea is going to pull towards you. If you have decreased volume on this side, you probably have increased volume, increased pressure on the opposite side, pushing it away. But you always want to talk about the area. That is the problem that's being identified. So two examples of decreased volume are atelectasis and a pneumonectomy. This is where I think people might get tripped up.
Rachele Burriesci:Sometimes, in layman's terms, people will describe atelectasis as a collapsed lung. In my opinion, these are two very different diagnoses and two very different anatomical changes. Atelectasis is the collapse of the alveoli and yes, we have millions of alveoli through that lung. So what's happening with atelectasis is, when we have that collapse, we have decreased volume of the lung due to the collapse of the alveoli. Decreased volume shift to the same side. It's going to pull that trachea towards it. A pneumonectomy is the obvious of the decreased volume. If we literally remove any portion of the lung segment or lobe, then you're going to have decreased volume on that side and that's going to pull the trachea towards that side. So we have two options here. We have trachea shifts away and trachea moves toward the same side.
Rachele Burriesci:When you're reading a question in this area, or you have a patient that has one of these diagnoses, or you see it on chest x-ray that there's a trachea movement to one side or the other. It is all about volume and pressure. If you have increased pressure, increased volume on one side, it's going to push that trachea away, and if you have decreased volume, decreased pressure, it's going to pull the trachea towards kind of like a vacuum effect. That's really it. Students have a hard time with this one. It comes up a lot on PEAT exams and it is always a question that comes out.
Rachele Burriesci:I'm still finding a good way to do like an example, like a live example to visually give this, because I think sometimes that auditory hearing of it just isn't enough. Pictures can also help in this regard if you're teaching this material, but I'm still looking for a good homemade project to really demonstrate that movement to one side or the other. I haven't come up with a good one yet. I promised a student a while back that I was going to try to create something, but I haven't come up with a good one yet I promised a student a while back that I was going to try to create something, but I haven't come up with a good one, just because it's hard to replicate in real time without that closed unit. So we'll see if I can come up with something. I'm sure Google has a home project that can help demonstrate it. So if you know of a good visual project to show this, let me know. I would love to hear it.
Rachele Burriesci:But that's really it. If you have increased pressure, increased volume on one side, it's going to push that trachea away. If you have decreased volume, decreased pressure on one side, it's going to pull the trachea towards the same side ipsilaterally. All right, that's all I got for you today. This was a quick one. I hope that was helpful. If you have any questions, please reach out. Hope you all have a wonderful day and whatever you have to do, get after it.
