Mr. B has been transferred to your floor to wait and see whether the chest tube allows his lungs to completely re-expand. But when he arrives, he is in severe respiratory distress. He says "I felt better before I came into the ER! Is this tube doing anything?"You tell the Clinical Nurse Specialist (CNS). As the two of you move him into the bed, you notice that his chest tube bottle is lying on its side on the gurney, with air going into it. When you point this out to the CNS, she immediately grabs the bottle and sets it upright on the floor. You see air start bubbling through the fluid right away. "That was the problem!" she says. "They lost the water seal, and air was going into his chest from the bottle. You would not believe how many times that happens on transport." When you examine Mr. B, you have trouble detecting his lung sounds on the left. Even stranger, his apical heart sound is in the wrong place - it is over toward the right side of his chest. His respiration rate and heart rate are both increased, and he is struggling to breathe. "Let's give him a little oxygen. He'll be a lot better in a half-hour," says the CNS. "Check back on him."Why would accumulation of air in his pleural space cause his heart sounds to be in the wrong place?
Because the left side of Mr. B's chest is filling up with air, the organs in his chest are being pushed over to the right.
As Mr. B's left pleural cavity fills up with air, the organs in his chest will be pushed over to the right. If it gets bad enough, you will actually be able to see his trachea slanting toward the right as it runs down his neck. This condition is called a deviated mediastinum; the mediastinum is the big bundle of trachea, blood vessels, and heart that normally hangs in the center of the chest.