NSG210 Hinkle Ch. 19: Management of Patients With Chest and Lower Respiratory Tract Disorders
Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 19, pp. 526-598 (textbooks/HINKLE_MS_CH19.pdf, also in textbooks/exam03/). Week 09 reading (lung cancer and chest tubes); on Exam 3. Numbering note: the syllabus lists “Ch. 20,” but Ch. 20 is chronic pulmonary disease (already covered for Exam 1, nsg210-hinkle-ch20-chronic-pulmonary-disease); lung cancer, thoracotomy, chest trauma, and chest drainage are in Ch. 19.
Learning Outcomes
Identify patients at risk for atelectasis and nursing interventions for prevention and management.
Compare pulmonary infections by cause, manifestations, management, complications, prevention.
Identify nursing care for a patient with an endotracheal tube, mechanical ventilation, or tracheostomy.
Relate ARDS management to its pathophysiology.
Describe prevention of occupational lung disease.
Discuss therapy and nursing management for lung cancer.
Use the nursing process for pneumonia, mechanical ventilation, and thoracotomy.
Describe complications of chest trauma.
Explain principles of chest drainage and nursing responsibilities.
I. Atelectasis
Collapse of alveoli; most common after thoracic and upper abdominal surgery and in immobilized patients with shallow, monotonous breathing
Obstructive (most common): secretions, mucus plug, tumor, foreign body - trapped air is absorbed; compressive: pleural effusion, pneumothorax, hemothorax, tumor, elevated diaphragm
Signs: increasing dyspnea, cough, sputum; tachycardia, tachypnea, pleural pain, central cyanosis (late); decreased breath sounds and crackles over area; SpO2 under 90%
Safety alert: tachypnea, dyspnea, and mild-to-moderate hypoxemia are hallmarks of severity
Prevention: turn frequently, early mobility, deep breathing at least every 2 hours, incentive spirometry, judicious opioids and sedatives, secretion management
Incentive spirometry (Chart 19-1): semi-Fowler or upright, seal lips on mouthpiece, inhale SLOWLY and deeply, hold about 3 seconds, exhale slowly; 10 times every hour while awake; cough afterward, splint incision
ICOUGH: Incentive spirometry, Coughing and deep breathing, Oral care twice a day, Understanding (education), Getting out of bed 3 times a day, Head-of-bed elevation
Treatment: same as prevention first; PEEP mask, CPAP, bronchoscopy for plugs; thoracentesis or chest tube for compression
II. Acute Tracheobronchitis
Inflammation of trachea and bronchi, usually after a viral URI (S. pneumoniae, H. influenzae, Mycoplasma)
Treatment mostly symptomatic: fluids to thin secretions, cool vapor or steam, moist heat to chest; antibiotics only if bacterial; avoid antihistamines (dry secretions); finish antibiotics; rest
III. Pneumonia
Pneumonia and influenza together are the 8th leading cause of US death
Classification (Chart 19-4):
Community-acquired (CAP): in community or within 48 hours of admission
Health care-associated (HCAP): recent hospitalization within 90 days, nursing home, dialysis, IV therapy, wound care - risk of multidrug-resistant organisms (MDRO)
Hospital-acquired (HAP): 48 hours or more after admission; mortality up to 33%
Ventilator-associated (VAP): 48 hours or more after intubation; up to 27% of ventilated patients
Organisms: S. pneumoniae (most common bacterial CAP), H. influenzae, Mycoplasma (atypical, younger people, milder), Legionella (water sources, confusion, high fever), viruses; HAP: Pseudomonas, Klebsiella, E. coli, MRSA (contact precautions)
Relative bradycardia (pulse slower than expected for fever) suggests viral, Mycoplasma, or Legionella
Rusty, blood-tinged sputum with pneumococcal, staph, Klebsiella
Orthopnea; flushed cheeks; central cyanosis (late)
Consolidation signs: increased tactile fremitus, dullness on percussion, bronchial breath sounds, egophony (“E” sounds like “A”), whispered pectoriloquy, crackles
In COPD, purulent sputum may be the only sign
Older adults: confusion, weakness, falls, anorexia, tachycardia, tachypnea; classic signs (cough, fever) may be absent - chest x-ray needed to distinguish from heart failure
C. Diagnosis
History, exam, chest x-ray, blood cultures, sputum culture (rinse mouth with water first, deep breaths, deep cough, sterile container), bronchoscopy if needed
D. Treatment
Antibiotics guided by culture and guidelines; start promptly (HCAP especially); reassess at 72 hours; antibiotic stewardship
Switch IV to oral when hemodynamically stable, improving, can take PO
Clinical stability for discharge: temp 100 F (37.8 C) or less, HR 100 or less, RR 24 or less, SBP 90 or more, SpO2 90% or more, normal mental status
Viral: supportive (hydration, antipyretics, rest); antibiotics only for secondary bacterial infection; oseltamivir for influenza
Vaccines: PCV13 and PPSV23 for all adults 65 or older (PCV13 first, PPSV23 at least 1 year later; not given together); PPSV23 for 19-64 who smoke or have chronic heart, lung, liver disease, alcoholism; annual influenza vaccine
E. Nursing process for bacterial pneumonia
Airway: fluids 2-3 L/day (thin secretions), humidification, directed cough, chest physiotherapy, suction if too weak to cough, oxygen titrated to SpO2
Rest: semi-Fowler, frequent position changes, avoid overexertion
Fluids: at least 2 L/day (increased insensible loss from fever and tachypnea) - cautiously in heart failure
Nutrition: electrolyte drinks, supplements, small frequent meals
Complications: should respond within 24-48 hours of antibiotics; watch for persistent fever (drug allergy, resistance, effusion, unusual organism), sepsis and shock, respiratory failure, atelectasis, pleural effusion, delirium (CAM screening)
Acidic gastric contents destroy alveoli and capillaries; food particles cause obstruction
Silent aspiration common with a nonfunctioning NG tube
Prevention (Chart 19-9): HOB 30-45 degrees; minimize sedation; confirm feeding tube placement before feeding and every 4 hours; check residuals (hold if over 150 mL); avoid bolus feedings in high-risk patients; swallow screen before oral intake after intubation more than 2 days; ET cuff pressure over 20 cm H2O (under 30) and suction above cuff before deflating
Swallowing strategies: upright, soft diet, small bites, chin tuck, no straws; remove oral airway if patient gags
V. Pulmonary Tuberculosis
M. tuberculosis: acid-fast aerobic rod, slow growing, killed by heat and UV light; airborne droplet nuclei
Risk factors: close contact, immunocompromise (HIV), substance use, homelessness, poverty, immigration from high-prevalence countries, institutions (prisons, long-term care), health care workers doing aerosol procedures
Pathophysiology: infection 2-10 weeks after exposure; granulomas form Ghon tubercle (cheesy, caseous necrosis); may calcify and become dormant (latent); about 10% develop active disease; reactivation when immunity falls
Symptoms (insidious): low-grade fever, cough, night sweats, fatigue, weight loss, hemoptysis; upper-lobe lesions on x-ray; older adults may show only behavior change
Extrapulmonary in up to 20%; miliary TB spreads through bloodstream to all organs
Diagnosis
Mantoux PPD: 0.1 mL intradermal on inner forearm, bevel up, raises 6-10 mm wheal; read at 48-72 hours; measure INDURATION, not redness
Positive thresholds: 5 mm or more (HIV, close contacts, x-ray consistent with TB, immunosuppressed); 10 mm or more (normal or mildly impaired immunity, high-risk groups)
Positive skin test means infection or BCG exposure, not necessarily active disease; negative test does not rule out TB in immunosuppressed (anergy)
Older adults: two-step test (repeat in 1-2 weeks - booster/recall)
IGRA blood tests (QuantiFERON-TB Gold, T-SPOT): preferred after BCG vaccine or if patient may not return; results in 24-36 hours
Sputum AFB smear suggests; CULTURE confirms; test for drug resistance
Baseline and monthly visual acuity and red-green color vision
Nursing management
Take meds on empty stomach or 1 hour before meals; adherence is the main reason for treatment failure - directly observed therapy (DOT)
Airborne isolation: private negative-pressure room (at least 6 air exchanges per hour), N95 or fitted respirator, patient wears surgical mask when transported; continue until cough decreases and smears improve
Teach cough and sneeze covering, tissue disposal, hand hygiene; TB is reportable - contacts screened
Small frequent meals, nutrition support, progressive activity
VI. Lung Abscess
Localized pus with cavity of at least 2 cm; usually from aspiration of anaerobes
IV clindamycin, ampicillin-sulbactam, or carbapenem for about 3 weeks then oral for 4-12 weeks; postural drainage; high-protein, high-calorie diet; good dental hygiene prevents
VII. Sarcoidosis
Multisystem noncaseating granulomas; age 20-40; more common in African Americans and women
Corticosteroids tapered over about 12 months; follow-up every 3-6 months
VIII. Pleural Disorders
A. Pleurisy
Inflammation of both pleural layers; sharp, knifelike, one-sided pain worse with deep breath, cough, sneeze; eases when breath held; pleural friction rub early (disappears as fluid accumulates)
Treat cause; NSAIDs, heat or cold; splint chest with pillow when coughing; turn onto affected side
B. Pleural effusion
Normal pleural fluid 5-15 mL; effusion is usually secondary (heart failure, TB, pneumonia, nephrotic syndrome, PE, cancer - bronchogenic carcinoma most common malignant cause)
Findings: dyspnea if large, decreased or absent breath sounds, decreased fremitus, dull/flat percussion, tracheal deviation AWAY from a large effusion; lateral decubitus x-ray shows layering
Thoracentesis to drain and analyze fluid; watch afterward for pneumothorax
Recurrent malignant effusion: chemical pleurodesis (talc instilled, tube clamped 60-90 minutes, patient turned to spread agent); PleurX indwelling catheter for home drainage; pleuroperitoneal shunt
C. Empyema
Thick pus in pleural space; complication of pneumonia or lung abscess
Drain (thoracentesis, chest tube with fibrinolytics, open drainage, decortication) plus 4-6 weeks of antibiotics; may go home with tube
IX. Acute Respiratory Failure
PaO2 under 60 mm Hg and PaCO2 over 50 mm Hg with pH under 7.35
Cuff pressure 20-25 mm Hg (24-30 cm H2O), check every 6-8 hours: too high causes tracheal necrosis; too low causes aspiration
Always give warmed humidified oxygen (upper airway bypassed)
Secure tube, mark lip line, bite block; reposition every 2 hours; oral care; sterile suction
Use up to 14-21 days, then consider tracheostomy
Extubation: explain, have bag-valve-mask ready, suction trachea and oropharynx, deflate cuff, give 100% O2, remove at peak inspiration; afterward high-Fowler, humidified oxygen, watch for STRIDOR, NPO or ice chips for a few hours
B. Tracheostomy
Opening between 2nd and 3rd tracheal rings; for long-term ventilation, airway obstruction, secretion removal, aspiration prevention
Early complications: dislodgement, bleeding, pneumothorax, air embolism, subcutaneous emphysema; late: obstruction, infection, innominate artery rupture, tracheoesophageal fistula, tracheal stenosis
Care: semi-Fowler, sterile suctioning only when needed (adventitious sounds or visible secretions - not routinely), trach care at least every 8 hours, communication tools always within reach
In-line (closed) suction keeps PEEP and reduces hypoxemia
Fenestrated tube or one-way speaking valve (Passy-Muir) allows speech
Decannulation: smaller or cuffless tube, capping, fenestrated tube, or stoma button; occlusive dressing over stoma
XI. Mechanical Ventilation
A. Indications (Chart 19-14)
PaO2 under 55 mm Hg; PaCO2 over 50 with pH under 7.32; vital capacity under 10 mL/kg; negative inspiratory force weaker than -25 cm H2O
Apnea or bradypnea, respiratory distress with confusion, increased work of breathing, need for airway protection, shock
Noninvasive (NIPPV) by mask: CPAP (continuous pressure; obstructive sleep apnea; must breathe on own); BiPAP (separate inspiratory and expiratory pressures; COPD, sleep apnea); contraindicated in respiratory arrest, serious arrhythmias, cognitive impairment, facial trauma
Assist-control (continuous mandatory ventilation): every breath, patient- or machine-triggered, gets the full preset volume
SIMV: preset number of full breaths synchronized with patient’s; spontaneous breaths at patient’s own volume; used for weaning
Pressure support (PSV): pressure boost on spontaneous breaths to reduce work of breathing; weaning
PEEP: pressure kept at end of expiration to open collapsed alveoli (ARDS); lowers needed FiO2
APRV: allows spontaneous breathing with periodic pressure release
C. Initial settings and monitoring
Tidal volume 6-10 mL/kg ideal body weight (4-8 mL/kg in ARDS); rate 12-16; FiO2 lowest to keep PaO2 over 60 or SpO2 over 92%
ABGs 20 minutes after starting or changing settings
Peak inspiratory pressure normal 15-20 cm H2O; I:E ratio usually 1:2
Check mode, settings, water in tubing (drain away from patient), kinks, humidifier, alarms ON at all times (prevent alarm fatigue)
D. Troubleshooting (Table 19-5)
HIGH pressure alarm: secretions or coughing (suction), patient biting or fighting ventilator, kinked tubing, water in circuit, decreased compliance, pneumothorax, bronchospasm
LOW pressure or volume alarm: disconnection, leak in circuit or cuff
If the cause cannot be found or patient is in distress: disconnect and manually ventilate with bag at 100% O2
Cardiac: positive pressure reduces venous return and cardiac output (hypotension)
Barotrauma and pneumothorax: sudden fall in SpO2 or respiratory distress is an emergency
E. VAP bundle (Chart 19-6)
HOB 30-45 degrees; daily sedation vacation and readiness-to-extubate assessment; peptic ulcer prophylaxis; DVT prophylaxis; daily oral care with chlorhexidine 0.12%
Subglottic suction ET tube for intubation expected over 72 hours
F. Nursing care
Assess lungs every 2-4 hours; suction only as needed (not routinely every 1-2 hours)
Prevent self-extubation: explain, distract, comfort; least restrictive restraints only if needed (with order)
Mobility: out of bed to chair as soon as stable; ROM every 6-8 hours
Communication: yes/no questions, writing board, tablet, lip reading; IV in nondominant arm so writing hand is free; glasses and hearing aids
ABCDEF bundle: Awakening and breathing trials, Coordination, Delirium monitoring (CAM-ICU every 2-4 hours), Early mobility, Family engagement - reduces delirium and post-intensive care syndrome (PICS)
Home ventilation: family taught suctioning, trach care, CPR, power-failure plan (battery backup about 1 hour, manual bag)
G. Weaning (Chart 19-19)
Criteria: stable, cause reversing; vital capacity 10-15 mL/kg; maximum inspiratory pressure at least -20 cm H2O; tidal volume 7-9 mL/kg; minute ventilation about 6 L/min; rapid shallow breathing index under 100; PaO2 over 60 on FiO2 under 40%
Methods: CPAP/pressure support, SIMV with decreasing rate, T-piece spontaneous breathing trials; reduce sedation 25-50% before; dexmedetomidine for agitation
Monitor closely first 20-30 minutes; ABG at 20 minutes
STOP if: HR up 20, SBP up 20, SpO2 under 90%, RR under 8 or over 20 (texts also cite over 35), ventricular arrhythmias, fatigue, panic, cyanosis, paradoxical breathing
Extubation usually within 2-3 hours of successful wean; long-term patients weaned by day, rested on vent at night
Order: ventilator, then tube, then oxygen (wean O2 to keep PaO2 70-100 on room air; home O2 if PaO2 55 or less or SaO2 88% or less)
Nutrition: protein about 25% of calories (1.2-1.5 g/kg/day); avoid overfeeding (raises CO2)
XII. Acute Respiratory Distress Syndrome (ARDS)
Severe inflammatory diffuse alveolar damage: sudden progressive pulmonary edema, bilateral infiltrates, hypoxemia REFRACTORY to oxygen, no elevated left atrial pressure (noncardiogenic)
Severity by PaO2/FiO2: mild 200-300; moderate 100-200; severe under 100
Rapid onset of severe dyspnea within 72 hours of the insult; “stiff lungs” (low compliance); “white-out” x-ray; BNP helps distinguish from cardiogenic edema; mortality 27-50%
Treatment: treat cause; intubation with low tidal volume and PEEP; careful fluids; prone positioning (12-16 hours/day in moderate-severe); sedation; neuromuscular blockers; nutrition 35-45 kcal/kg/day (enteral first)
Neuromuscular blockade nursing: patient is paralyzed but AWAKE and feels pain - always give sedation and analgesia; ventilator alarms always on (apneic if disconnected); eye care (cannot blink); train-of-four monitoring; VTE, skin, and stress ulcer prevention; explain to family
Pulmonary hypertension: mean pulmonary artery pressure over 25 mm Hg at rest; dyspnea on exertion (main symptom), chest pain, syncope, signs of right heart failure; right heart catheterization confirms
Treatment: oxygen, diuretics, anticoagulation, digoxin, exercise; calcium channel blockers if vasoreactive; prostanoids (epoprostenol continuous IV through central line - never interrupt; treprostinil, iloprost inhaled, selexipag oral); endothelin antagonists (bosentan - hepatotoxic); PDE-5 inhibitors (sildenafil, tadalafil); riociguat; lung transplant
Cor pulmonale: right ventricular enlargement and failure from pulmonary hypertension
Pulmonary embolism: see Ch. 26
XIV. Occupational Lung Disease (Pneumoconioses)
Silicosis (glass, foundry, stone cutting), asbestosis (shipbuilding, demolition - increases lung cancer and mesothelioma; may appear 10-40 years after exposure), coal worker’s pneumoconiosis (black lung)
Irreversible, not curable, but preventable: masks, respirators, ventilation, screening; smoking magnifies risk
Assess occupational history and veterans’ burn pit and sand exposures
XV. Lung Cancer (Bronchogenic Carcinoma)
Leading cancer killer in US men and women (about 1 in 4 cancer deaths); 5-year survival about 21.7%; about half have spread at diagnosis
Cause: inhaled carcinogens - cigarette smoke in over 85% (85-90%); also secondhand smoke, radon (test homes), asbestos, arsenic, air pollution, genetics (EGFR, KRAS, ALK mutations)
Risk 23 times higher in men and 13 times higher in women who smoke; pack-years = packs per day x years smoked
Chest x-ray (coin lesion, atelectasis), CT, PET, bronchoscopy with biopsy and brushings, CT-guided fine-needle aspiration for peripheral lesions, mediastinoscopy or endobronchial ultrasound for nodes, brain MRI and bone scan for metastases
Screening: annual low-dose CT for ages 55-80 (USPSTF) with 30 pack-years who smoke or quit within 15 years
NSCLC: surgery for localized disease with adequate cardiopulmonary function (preferred), radiation, chemotherapy, immunotherapy, targeted gene therapy (EGFR, ALK, ROS1)
SCLC: chemotherapy and radiation; surgery only if one lung and no metastasis; prophylactic brain irradiation
Radiation: may cure a few; shrinks tumors; palliates cough, hemoptysis, dyspnea, bone pain, SVCS, spinal cord compression; SABR (stereotactic, 1-5 days) for early disease in nonsurgical patients; complications esophagitis, pneumonitis, fibrosis
Chemotherapy: neoadjuvant or adjuvant; palliation; can cause pneumonitis
What to expect: chest tubes, oxygen, possible ventilator and ICU 1-2 days
Practice incentive spirometry, diaphragmatic and pursed-lip breathing, cough with splinting (pillow, towel, hands), huff coughing (forced expiratory technique) if pain limits coughing
Pain plan: PCA or epidural; preemptive nonopioids (acetaminophen, NSAIDs)
B. Postoperative care (Chart 19-23)
Vital signs frequently; continuous ECG (atrial fibrillation and flutter common, especially after pneumonectomy)
HOB 30-45 degrees once stable
POSITIONING: pneumonectomy - turn every hour from back to OPERATIVE side only, never fully to the unoperated side (prevents mediastinal shift and lets fluid consolidate); lobectomy - either side; segmental resection - usually not onto operative side unless ordered
Cough and deep breathe hourly first 24 hours, incentive spirometer every 2 hours; suction until able to cough
Fluids at low hourly rate - pulmonary edema risk (pink frothy sputum, crackles, dyspnea is an emergency)
Chest drainage: check for leaks; record drainage every 2 hours; notify provider if over 150 mL/hour
Arm and shoulder exercises (Chart 19-24) 5 times daily to restore range of motion and prevent frozen shoulder; out of bed to chair evening of surgery
C. Home teaching (Chart 19-25)
Expect weakness and fatigue for about 3 weeks; alternate activity and rest; walk gradually farther
Breathing exercises several times daily; arm and shoulder exercises
No lifting over 20 lb until healed (chest muscles weak 3-6 months)
Local heat and oral analgesia for intercostal pain
Stop activity causing fatigue, dyspnea, or chest pain
Avoid smoke, fumes, sprays, and people with infections; flu and pneumonia vaccines; stop smoking
Report increased dyspnea, fever, restlessness or confusion, increased pain, bleeding or drainage from incision or tube sites
XVII. Mediastinal Tumors
Neurogenic, thymus, lymphoma, germ cell, cysts; symptoms from pressure: cough, wheeze, dyspnea, chest pain, SVCS, dysphagia; CT is standard; surgery via sternotomy or thoracotomy
Primary survey for immediate threats: airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, cardiac tamponade
Assess: symmetry of chest movement and breath sounds, tracheal position, distended neck veins, subcutaneous emphysema, paradoxical motion, wounds, signs of shock; agitation and combativeness signal cerebral hypoxia
Undress completely; many have head and abdominal injuries; stab wounds below the 5th intercostal space risk abdominal injury
A. Sternal and rib fractures
Ribs 4-10 most common; ribs 1-3 rare but high mortality (subclavian vessel injury); lower ribs may injure spleen and liver
Severe pain, point tenderness, crepitus; patient splints with shallow breaths, leading to atelectasis and pneumonia
Treatment: pain control so the patient can deep breathe and cough (intercostal nerve block, epidural, PCA, ice); avoid oversedation; chest binder snug but not restrictive; pain eases in 5-7 days, heals in 3-6 weeks
Older adults with 3 or more rib fractures: fivefold mortality, fourfold pneumonia
B. Flail chest
Three or more adjacent ribs fractured in two or more places, creating a free-floating segment
PARADOXICAL movement: segment sucked IN on inspiration, bulges OUT on expiration; mediastinal shift; hypoxemia, respiratory acidosis, decreased cardiac output
Treatment: small segment - airway clearance, positioning, pain control; severe - intubation and mechanical ventilation (internal pneumatic stabilization); surgical rib plating within 72 hours
C. Pulmonary contusion
Bleeding and edema in lung tissue after rapid compression; most common potentially life-threatening chest injury; may not show on x-ray for 1-2 days
Airway, oxygen, pain control, careful fluids (avoid overload), secretion clearance, antibiotics; intubation with PEEP if moderate to severe
D. Pneumothorax
Air in pleural space destroys negative pressure; lung collapses
Simple/spontaneous: ruptured bleb, otherwise healthy person or emphysema
Traumatic: lung laceration or chest wall wound; often with hemothorax; also from thoracentesis, central line insertion, mechanical ventilation barotrauma
Open (“sucking chest wound”): air moves in and out through wound; mediastinal flutter - EMERGENCY: cover wound immediately (anything available, heel of hand); in hospital petrolatum gauze plus pressure dressing, chest tube, antibiotics; conscious patient strains against closed glottis
Tension: one-way valve traps air; pressure builds, collapses lung and SHIFTS trachea, heart, and great vessels to the UNAFFECTED side; decreased venous return and cardiac output
Signs: tracheal deviation away from affected side, absent breath sounds and hyperresonance on affected side, distended neck veins, hypotension, tachycardia, air hunger, cyanosis, diaphoresis
Emergency: high-flow oxygen; needle decompression with large-bore (14-gauge) needle at 2nd intercostal space, midclavicular line; then chest tube
Findings by type: simple - trachea midline, decreased expansion and breath sounds; tension - trachea shifted away, hyperresonance, absent sounds
Chest tubes: air - small tube near 2nd intercostal space; blood (hemothorax) - large tube (32 Fr or more) at 4th-5th intercostal space midaxillary line; suction usually 20 cm H2O
Thoracotomy if more than 1,500 mL drains initially or more than 200 mL/hour continues
Autotransfusion may return the patient’s drained blood
E. Cardiac tamponade
Blood or fluid in pericardial sac compresses heart; from trauma, catheterization, malignancy (see Ch. 25)
F. Subcutaneous emphysema
Air in tissues feels like crackling (crepitus) on palpation; usually absorbed once leak stops; tracheostomy only if airway threatened
Small-bore (7-12 Fr) with one-way valve; large-bore up to 40 Fr to a drainage system
A. Traditional (wet) water-seal system - three chambers
Collection chamber: measure and mark drainage
Water-seal chamber (2 cm water): one-way valve keeps air from re-entering
TIDALING (water rises with inspiration, falls with expiration in a spontaneously breathing patient) is normal and shows the system is patent; stops when lung re-expands or tubing is kinked or clotted
Intermittent bubbling is normal (air leaving the pleural space, especially with cough or exhalation)
CONTINUOUS bubbling = air leak (check connections; persistent leak may be from the lung)
Mediastinal tubes: no tidaling or bubbling expected; fluid may pulsate with heartbeat
Wet suction control chamber: amount of suction set by water HEIGHT (usually 20 cm H2O), not by the wall regulator; gentle continuous bubbling is expected
High-negativity relief vent: press to bring water seal back to 2 cm if excessive negative pressure
B. Dry suction water-seal system
Water seal filled to 2 cm; suction set with a regulator dial; indicator (bellows or orange float) shows adequate suction; quieter; if knocked over, water seal may be lost
Do not use the manual vent to lower water-seal level when on gravity drainage
C. Dry suction with one-way valve
No water seal; works even if knocked over (good for ambulation and transport); check for leak by injecting 30 mL water into air-leak indicator
Heimlich valve: one-way flutter valve for pneumothorax with little drainage
D. Key nursing safety points
Keep system BELOW chest level and upright; tubing without dependent loops or kinks
If wall suction is turned off, system must be open to air (disconnect suction tubing to vent) so air can escape
If tube disconnects from drainage system: immerse the open end of the chest tube in sterile water to create a temporary water seal
Do not clamp routinely (risk of tension pneumothorax)
Record amount, color, character of drainage; report over 150 mL/hour after thoracotomy (or as ordered); watch for subcutaneous emphysema at the insertion site
High-Yield Numbers
Incentive spirometry: hold about 3 seconds, 10 times every hour awake
Deep breathing at least every 2 hours to prevent atelectasis
CAP within 48 hours of admission; HAP and VAP 48 hours or more
Pneumonia clinical stability: T 100 F or less, HR 100 or less, RR 24 or less, SBP 90 or more, SpO2 90% or more
Fluids 2-3 L/day for pneumonia secretions
Tube feeding residual: hold if over 150 mL; HOB 30-45 degrees
PPD read 48-72 hours; positive 5 mm (high risk) or 10 mm (others); induration not redness
TB noninfectious after 2-3 weeks of therapy; initial 4-drug phase 8 weeks; total usually 6 months
Lung abscess cavity 2 cm or larger
Respiratory failure: PaO2 under 60, PaCO2 over 50, pH under 7.35
ET cuff 20-25 mm Hg (24-30 cm H2O); ET use up to 14-21 days
Vent tidal volume 6-10 mL/kg (4-8 in ARDS); PaO2 over 60 or SpO2 over 92%; ABG 20 minutes after change
Weaning: RSBI under 100; stop if SpO2 under 90%, HR or SBP up 20
ARDS P/F ratio: mild 200-300, moderate 100-200, severe under 100; prone 12-16 hours