Procedures and Management for Supporting Ventilation

Clinical Note: Early tracheostomy (within 10–14 days) can reduce the number of ventilator-dependent days and shorten hospital stays.

Pleural Space Management and Chest Tubes

When the pleural space is compromised by air (pneumothorax) or fluid (pleural effusion), chest tubes are utilized to re-establish negative pressure and allow the lungs to expand.

Chest Tube Sizes and Selection

The size of the chest tube is determined by the type of drainage required:

• Large (36F–40F): Used for draining blood.
• Medium (24F–36F): Used for draining fluid.
• Small (12F–24F): Used for draining air.
• Pigtail Catheters (10F–14F): A safer, very small alternative for pneumothorax.

The Pleural Drainage System

A standard pleural drainage system consists of three basic compartments:

1. Collection Chamber: Receives fluid and air from the pleural space.
2. Water-Seal Chamber: Contains approximately 2 cm of water that acts as a one-way valve, preventing air from flowing back into the patient.
3. Suction Control Chamber: Applies suction to the unit. This can be a wet type (where water levels control the suction) or a dry type (controlled via a dial).

Critical Monitoring: Tidaling In the water-seal chamber, "tidaling" refers to the normal fluctuation of water with the patient's breathing. If tidaling suddenly stops, it may indicate that the chest tube is occluded and requires immediate intervention.

Specialized Valves and Complications

A Flutter or Heimlich valve is a one-way rubber valve used in a rigid tube that allows air to exit the pleural space during expiration but closes during inspiration to prevent air from re-entering. This device can facilitate patient mobility and home management.

When managing chest tubes, clinicians must monitor for subcutaneous emphysema. This occurs when air leaks into the surrounding tissue, creating a "crackling" sensation upon palpation. While small amounts may be harmless, large amounts around the head and neck can cause swelling and airway compromise.

Surgical Thoracic Approaches

Depending on the need for access to the heart, lungs, or esophagus, surgeons utilize different approaches:

• Median Sternotomy: The sternum is split; this is primarily used for heart surgeries.
• Lateral Thoracotomy: A posterolateral incision used for lung surgeries.
• Anterolateral Thoracotomy: Used for trauma victims or mediastinal operations.
• VATS (Video-Assisted Thoracoscopic Surgery): A minimally invasive procedure used for diagnosing and treating pleural disease, biopsies, or tissue removal. VATS offers benefits such as less pain, faster recovery, and fewer complications.

Postoperative Management

Postoperative care for thoracic surgery focuses heavily on pain management. Because thoracotomy incisions involve cutting respiratory muscles, pain can be intense. Effective pain control is not just for comfort; it is essential to prevent respiratory compromise by allowing the patient to breathe deeply, cough, and mobilize.

Nursing priorities include:

• Assessing respiratory function (rate, effort, breath sounds, and sputum).
• Monitoring chest tube function (drainage type and amount).
• Watching for signs of infection (fever, changes in sputum).
• Ensuring wound integrity.

Diagnostic and Therapeutic Procedures

Beyond mechanical support, other procedures may be necessary to manage the airway or pleural space:

• Bronchoscopy: Used for diagnosing obstructions and treating airway issues.
• Thoracentesis: A procedure to remove air or approximately 1000–1200 mL of fluid from the pleural space.