From the Guidelines
The next step in management for this 55-year-old intubated patient with respiratory failure and high PEEP who has developed high ventilatory pressures after chest tube placement is to immediately assess for tension pneumothorax or tube malposition and check the chest tube drainage system to ensure it is placed below the chest tube and functioning properly. This assessment is crucial as it directly addresses potential life-threatening complications such as tension pneumothorax, which requires immediate decompression, and ensures that the chest tube is not the cause of the high ventilatory pressures due to malposition or obstruction 1. The chest X-ray should be urgently reviewed to evaluate the position of the chest tube, lung expansion, and to rule out pneumothorax, hemothorax, or tube kinking. If tension pneumothorax is identified, immediate decompression is required. The chest tube should be assessed for patency by checking for air leak, drainage, and ensuring it's not clamped or kinked. Ventilator settings should be temporarily adjusted by reducing tidal volume to 4-6 mL/kg ideal body weight and decreasing PEEP if oxygenation allows, while maintaining plateau pressures below 30 cmH2O, as suggested by guidelines for managing patients on mechanical ventilation 1. A complete bedside assessment including auscultation for breath sounds, inspection for chest wall movement, and evaluation of vital signs is essential. The ventilator circuit should also be checked for condensation or obstruction. This approach addresses the most life-threatening causes first while systematically evaluating the patient-ventilator system to identify and correct the cause of high pressures, which could lead to barotrauma and further respiratory compromise if not promptly addressed. Considering the provided options, checking the chest tube drainage system and ensuring it is placed below the chest tube is a critical initial step that can be taken immediately at the bedside without delay, making option D a practical first choice in management.
From the Research
Next Steps in Management
The patient's situation involves a chest tube insertion and high ventilatory pressures, which requires careful consideration of the chest tube drainage system. The key factors to consider are:
- The proper functioning of the chest tube drainage system
- The positioning of the chest tube
- The patient's overall respiratory status
Considerations for Chest Tube Management
Based on the studies 2, 3, the management of a chest tube involves:
- Monitoring the chest-tube position and drainage
- Controlling fluid evacuation
- Identifying when to change or empty the containers
- Caring for the tube and drainage system during patient transport
- Ensuring the drainage system is properly connected and functioning
Potential Issues with the Current Setup
Given the ventilator's alarm about high ventilatory pressures, it is essential to:
- Check the chest tube drainage system to ensure it is not causing any obstruction or issue with the ventilator
- Verify that the chest tube is properly positioned and functioning correctly
Appropriate Action
The most appropriate next step would be to:
- Check the chest tube drainage system and ensure it is placed below the chest tube, as recommended by 2
- Verify that the system is functioning correctly and not causing any issues with the ventilator
- Consider advancing the chest tube or inserting a second chest tube if necessary, based on the patient's clinical status and the chest x-ray results
Options to Consider
The options provided are:
- Paralyze the patient to avoid biting the endotracheal tube (not directly related to the chest tube management)
- Advance the present chest tube (may be necessary if the tube is not properly positioned)
- Insert a second chest tube at the base (may be necessary if the first tube is not functioning correctly)
- Check the chest tube drainage system and make sure it is placed below the chest tube (the most appropriate initial step)