From the Guidelines
The most appropriate next step when a patient with a chest tube in the right chest develops high ventilatory pressures on the ventilator is to check the chest tube drainage system and ensure it is placed below the chest tube and functioning properly, as recommended by recent guidelines 1. When a patient with a right chest tube develops high ventilatory pressures on the ventilator, immediately assess for tube patency and function. First, examine the chest tube system for kinks, clots, or fluid in the tubing, and ensure the drainage system is functioning properly. Perform urgent bedside assessment including auscultation of breath sounds, inspection for chest asymmetry, and palpation for subcutaneous emphysema. Check for air leaks in the drainage system during inspiration. If the tube appears obstructed, perform gentle tube milking or stripping if institutional protocol allows. Consider ordering an urgent chest X-ray to evaluate tube position and to rule out pneumothorax, hemothorax, or tube displacement. If the chest tube is malfunctioning, prepare for possible tube replacement. Meanwhile, temporarily adjust ventilator settings by decreasing tidal volume, increasing respiratory rate, and potentially increasing sedation to improve patient-ventilator synchrony, as suggested by recent studies 2. High ventilatory pressures may indicate worsening underlying lung pathology, tube malfunction, or patient-ventilator asynchrony, all of which can lead to barotrauma and hemodynamic compromise if not promptly addressed. Implementing permissive hypercapnia through reduced tidal volume ventilation may also be considered in mechanically ventilated patients with high inspiratory pressures or at risk for barotrauma/volutrauma, as recommended by earlier studies 3.
Some key considerations include:
- Ensuring the chest tube drainage system is functioning properly and placed below the chest tube to prevent backflow and reduce the risk of infection 1
- Adjusting ventilator settings to balance lung volumes and venous return, and to deliver full breaths with asynchronous chest compressions if necessary 2
- Assessing the need to adjust the positive end-expiratory pressure level to balance lung volumes and venous return 2
- Considering the use of non-wired pleural drainage and closed circuit systems to reduce the risk of aerosolization and infection 1
From the Research
Next Steps for Patient with Chest Tube and High Ventilatory Pressures
The patient has developed high ventilatory pressures on the ventilator after a chest tube was inserted in the right chest. To address this issue, the following steps can be considered:
- Check the chest tube drainage system to ensure it is functioning properly and placed below the chest tube to prevent backflow of fluid or air into the pleural space 4.
- Verify that the chest tube is not kinked or blocked, which could prevent adequate drainage and lead to increased ventilatory pressures.
- Consider checking the patient's position and ensuring that the chest tube is not being compressed or obstructed by the patient's body or bedding.
Management of Chest Tube
The management of the chest tube is crucial in preventing complications and ensuring effective drainage of the pleural space. According to recent studies, the use of small-bore chest tubes and conservative management approaches may be effective in reducing complications and improving patient outcomes 5, 6.
- The chest tube should be connected to a drainage system device, such as an underwater seal or electronic system, to facilitate drainage and monitoring of the pleural space 4.
- Regular monitoring of the chest tube drainage system and the patient's respiratory status is essential to identify any potential issues or complications.
Potential Complications
The patient is at risk for potential complications related to the chest tube, including: