From the Guidelines
When a patient with a chest tube and on mechanical ventilation with PEEP develops high ventilatory pressures, the first step is to check the chest tube drainage system and ensure it is placed below the chest tube and functioning properly. This is crucial to prevent any obstruction or kinking that may be causing the high ventilatory pressures. According to the most recent guidelines 1, adjusting ventilator settings to deliver full breaths with asynchronous chest compressions and assessing the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return is essential.
Some key considerations include:
- Checking if the chest tube is kinked, clogged, or if there's water in the tubing
- Ensuring the drainage system is functioning properly and positioned below chest level
- Evaluating the patient for pneumothorax, which can present with decreased breath sounds, hypoxemia, and asymmetrical chest movement
- Temporarily disconnecting the patient from the ventilator and manually ventilating while assessing for improvement
- Adjusting ventilator settings by decreasing tidal volume to 6-8 mL/kg ideal body weight, reducing respiratory rate, or decreasing PEEP incrementally by 2-3 cmH2O while monitoring oxygen saturation, as suggested by 1.
It is also important to note that paralyzing the patient to avoid biting the endotracheal tube (option A) may not be the most appropriate initial step, as it does not address the underlying cause of the high ventilatory pressures. Similarly, advancing the present chest tube (option B) or inserting a second chest tube at the base (option C) may not be necessary if the issue is with the drainage system. Therefore, option D, checking the chest tube drainage system and making sure it is placed below the chest tube, is the most appropriate initial step.
From the Research
High Ventilatory Pressures in a Patient with a Chest Tube
When a patient with a chest tube and on mechanical ventilation for respiratory failure develops high ventilatory pressures, it is crucial to address the issue promptly to avoid further complications. The following steps can be considered:
- Check the chest tube drainage system: Ensure that the drainage system is functioning correctly and that the tube is not kinked or obstructed 2.
- Verify the position of the chest tube: Confirm that the chest tube is properly positioned and that the side holes are not obstructed 3.
- Monitor for air leaks: Check for air leaks around the chest tube insertion site or in the drainage system 4.
- Adjust the suction pressure: If the patient is on suction, adjust the pressure according to the patient's needs and the hospital's policy 5.
- Consider inserting a second chest tube: If the patient has a large air leak or a significant amount of fluid drainage, inserting a second chest tube may be necessary 4.
Management of the Chest Tube
The management of the chest tube is critical to prevent complications and ensure effective drainage. The following points should be considered:
- Monitor the chest tube drainage: Regularly check the drainage system for any blockages, kinking, or other issues that may affect drainage 6.
- Maintain a water seal: Ensure that the water seal is maintained to prevent air from entering the pleural space 3.
- Avoid unnecessary clamping: Avoid clamping the chest tube unless absolutely necessary, as this can lead to a buildup of pressure in the pleural space 2.
- Follow hospital protocol: Follow the hospital's protocol for chest tube management, including the use of suction and the removal of the tube 5.