Moffitt AM report PEARLS 10/23: management of hypoxic respiratory failure and chest tubes

Management of hypoxic respiratory failure

  • Nasal cannula (1-6L; 1L is approximately 3% FiO2 though it is very variable)
  • Face mask (6-15L)
  • High flow nasal cannula (>15L/min)
  • Non-rebreather
  • Noninvasive positive pressure ventilation (NIPPV)
    • 4 major indications:
      • COPD exacerbation
      • Cardiogenic pulmonary edema
      • Post-extubation (to prevent re-intubation)
      • +/- hypoxemic respiratory failure in immunocompromised patients (because of increased infection risk with intubation in these patients)
    • Major contraindications:
      • Altered mental status
      • Known aspiration/inability to protect airway or clear secretions
      • Upper airway obstruction or recent head/neck surgery
      • Cardiac or respiratory arrest
      • Hemodynamic instability
      • Pneumothorax
    • Intubation
    • Check out old PEARLS on management of refractory hypoxemic respiratory failure on our blog!

Management of chest tubes

  • Hard indications for chest tube placement: large/tension pneumothoraces, hemothorax, empyema
    1. Other indications to consider: recurrent pleural effusions (esp malignant), chylothorax (often in post-thoracic surgery patients)
  • A step by step guide for management of chest tubes once they are placed:
    1. Always start with wall suction (often start at -20mmHg; over time, can reduce the negative pressure because prolonged/high suction can increase risk of bronchopleural fistulas)
    2. Check for presence of an air leak (look for bubbles – see diagram below)
      • If present, ddx includes 1. air from pleura (i.e. pneumothorax), 2. Air from bronchopleural fistula, 3. air from outside environment (lack of airtight seal)
      • If a chest tube is placed for pneumothorax, you want to continue on wall suction until it resolves!
    3. If there is no air leak, think about when to change from wall suction to water seal (where drainage of fluid will depend on gravity instead of negative pressure). As an example, if you are draining a large, symptomatic effusion, you may want to start on wall suction initially and then switch to water seal for slow/steady drainage
      • Once you switch to water seal, first, make sure chest tube is still functioning (e.g. tube is not kinked, obstructed by thick pus, or stuck to expanding lung) by looking for tidaling (with inspiration, negative pressure increases so you can see water level in the tube go up (like sucking on a straw), and vice versa with expiration).
    4. If on water seal you confirm the chest tube is still functioning, think about when you want to clamp chest tube.
      • In general, think about clamping the chest tube when you have drained 1-1.5L of fluid (to reduce the risk of re-expansion pulmonary edema)
  • Removing the chest tube:
    1. Think about this when the underlying process has resolved and the patient’s clinical status has improved.
      • For pneumothorax, consider pulling the tube when there is no further air link
      • For pleural effusions, think about removal when it is draining <200cc/day (varies by provider)
      • For empyemas, think about removal when it is draining <20cc/day (varies by provider)
    2. Often, prior to removing chest tube, clamp it for 4-6h and repeat CXR to ensure that the underlying process has resolved prior to removal
  • chest tube


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