What to do next when a ventilator alarms about high ventilatory pressures in an intubated patient with a chest tube inserted for suspected pneumothorax?

From the Guidelines

When a ventilator alarms for high pressures in an intubated patient with a chest tube for suspected pneumothorax, the first step is to check the chest tube drainage system and ensure it is placed below the chest tube and functioning properly, as improper placement or malfunction can lead to increased intrathoracic pressure and worsen the patient's condition. This is crucial because the patient is already requiring high positive end-expiratory pressure (PEEP) for oxygenation, and any additional increase in intrathoracic pressure can compromise lung expansion and oxygenation further.

The next steps should include:

• Assessing the patient for clinical signs of worsening pneumothorax or tension pneumothorax, such as decreased breath sounds, tracheal deviation, hypotension, and distended neck veins 1.
• Notifying the physician immediately if the chest tube appears to be malfunctioning, as a new chest tube may be needed.
• Considering obtaining a stat portable chest X-ray to evaluate pneumothorax resolution and tube placement.
• Adjusting ventilator settings by decreasing tidal volume (to 4-6 mL/kg ideal body weight) and respiratory rate if possible, while maintaining adequate minute ventilation, to avoid exacerbating the condition and potentially converting a simple pneumothorax to a tension pneumothorax, which is life-threatening and requires immediate intervention 1.

It's also important to note that the application of suction to the chest drain should be considered with caution and typically not applied immediately after tube insertion, but rather after 48 hours for persistent air leak or failure of the pneumothorax to re-expand, using high volume, low pressure (–10 to –20 cm H2O) suction systems 1.

Therefore, the most appropriate next step among the provided options is to check the chest tube drainage system and make sure it is placed below the chest tube, as this directly addresses a potential cause of the high ventilatory pressures and is a critical step in managing the patient's condition effectively.

From the Research

Next Steps for Ventilator Alarm and Chest Tube Management

The patient's situation involves a ventilator alarm due to high ventilatory pressures and a chest tube inserted for suspected pneumothorax. Considering the provided evidence, the following steps can be taken:

• Checking the Chest Tube Drainage System: It is crucial to ensure that the chest tube drainage system is functioning correctly and is placed below the level of the chest tube to prevent backflow and ensure proper drainage 2.
• Assessing Ventilatory Pressures: The high ventilatory pressures indicated by the ventilator alarm could be due to various factors, including the patient's respiratory condition, the settings on the ventilator, or issues with the endotracheal tube or chest tube 3, 4.
• Management of the Chest Tube: The management of the chest tube, including its placement, suction, and monitoring, is critical for the patient's outcome. Ensuring that the chest tube is properly secured and that its drainage system is functioning can help in managing the pneumothorax and reducing the risk of further complications 5, 2.
• Patient Care and Monitoring: Continuous monitoring of the patient's vital signs, respiratory status, and the function of the chest tube and ventilator is essential. This includes checking for any signs of complications such as air leaks, bleeding, or blockage of the chest tube 6.

Key Considerations

• The patient's condition and the functioning of the ventilator and chest tube require close monitoring.
• Ensuring the proper placement and functioning of the chest tube drainage system is vital.
• Adjustments to the ventilator settings or the management of the chest tube may be necessary based on the patient's response and the clinical situation.

Potential Actions

• Option D: Check the chest tube drainage system and make sure it is placed below the chest tube. This is a critical first step to ensure that the chest tube is functioning properly and that there are no issues with drainage that could be contributing to the high ventilatory pressures.
• Other options, such as paralyzing the patient, advancing the present chest tube, or inserting a second chest tube, may be considered based on the patient's specific condition and the clinical judgment of the healthcare team, but they are not directly supported by the provided evidence as the immediate next steps.