How to manage a patient with a collapsed right lung?

Management of Collapsed Right Lung

For a collapsed right lung (pneumothorax), insert a large-bore chest tube (24F-28F) connected initially to water seal drainage, then apply suction at -10 to -20 cm H₂O if the lung fails to reexpand within 48 hours or if the patient is mechanically ventilated. 1, 2

Initial Assessment and Stabilization

Determine three critical factors immediately: clinical stability (respiratory rate <24/min, heart rate 60-120/min, oxygen saturation >90% on room air), pneumothorax size (small if <3 cm apex-to-cupola distance, large if ≥3 cm), and whether underlying lung disease exists (primary vs secondary pneumothorax). 2 Treatment intensity escalates based on these factors, with secondary pneumothorax requiring aggressive management due to potential lethality. 2

For Mechanically Ventilated Patients

If the patient is intubated, immediately insert a 24F-28F chest tube and strongly consider applying suction from the start, as positive-pressure ventilation creates large air leaks that can rapidly progress to tension pneumothorax. 1, 3 Small-bore catheters (≤14F) are inadequate for ventilated patients and should never be used. 1 Never clamp a chest tube in a ventilated patient—this converts a simple pneumothorax into life-threatening tension pneumothorax. 3

Chest Tube Management Strategy

Initial Drainage Approach

Connect the chest tube to a water seal device without suction as the preferred initial strategy for stable, spontaneously breathing patients. 1 This allows assessment of the lung's ability to reexpand with gravity drainage alone. Observe for 48 hours while monitoring with serial chest radiographs. 1, 3

When to Apply Suction

Apply suction (-10 to -20 cm H₂O using high-volume, low-pressure systems) if: 1, 3

• The lung fails to reexpand after 48 hours on water seal
• Persistent air leak continues beyond 48 hours
• The patient requires positive-pressure ventilation
• The patient is clinically unstable with a large pneumothorax
• Bronchopleural fistula is suspected

Patients with underlying lung disease (COPD, secondary pneumothorax) require earlier suction application at 2-4 days rather than waiting 5-7 days. 1

Adjunctive Therapies for Lung Reexpansion

Administer high-flow oxygen at 10 L/min when feasible, as this accelerates pneumothorax reabsorption up to four times faster by reducing nitrogen partial pressure in pleural capillaries. 4, 2 Without intervention, spontaneous reabsorption occurs at only 1.25-1.8% of hemithorax volume per 24 hours. 4

Mechanical Ventilation Strategies (for ARDS or Perioperative Collapse)

For atelectasis or lung collapse in ventilated patients, apply PEEP (positive end-expiratory pressure) or CPAP (continuous positive airway pressure) to maintain functional residual capacity and prevent alveolar collapse. 5 CPAP during spontaneous breathing is preferable to PEEP during mechanical ventilation for reinflating collapsed lung segments. 5 Optimize PEEP to benefit alveolar patency while avoiding overdistension—sufficient PEEP prevents derecruitment, but excessive PEEP (>15 cm H₂O) causes right ventricular dysfunction and hemodynamic impairment. 4

Perform alveolar recruitment maneuvers (ARMs) using sustained inspiratory pressure holds of 40 cm H₂O for patients with BMI <35 kg/m², or up to 50 cm H₂O for BMI >35 kg/m², to reverse alveolar collapse. 4 However, ARMs provide only short-term benefit without adequate PEEP to maintain recruitment. 4

Specialized Care Requirements

Patients requiring suction must be managed in specialized lung units with experienced medical and nursing staff trained in chest drain management, as complex adjustments to suction pressure and drain repositioning may be necessary. 1, 3 Refer to a respiratory specialist at 48 hours if the pneumothorax fails to respond or persistent air leak continues. 1, 3

Escalation for Persistent Collapse

If air leak persists beyond 4 days despite chest tube and suction, consider chemical pleurodesis with talc slurry or doxycycline for patients who cannot undergo surgery. 3 Surgical intervention (thoracoscopy with bullectomy and pleurodesis) becomes necessary at 5-7 days for persistent air leak in patients without pre-existing lung disease, or earlier at 2-4 days for those with underlying disease. 1, 2

Critical Pitfalls to Avoid

• Never use chest tubes larger than 28F—they provide no additional benefit 2
• Never apply suction pressure exceeding -20 cm H₂O, as this causes reexpansion pulmonary edema or perpetuates air leaks 1, 3
• Never clamp a bubbling chest tube, especially in ventilated patients 3
• Avoid high-pressure suction systems—use only high-volume, low-pressure systems with 15-20 L/min air flow capacity 1
• Do not remove the chest tube until confirming complete air leak resolution and lung reexpansion on chest radiograph 2