Two sutures are usually inserted—the first to assist later closure of the wound after drain removal, and the second a stay suture to secure the drain which needs to be removed. Care must be taken to avoid air entering the pleural cavity. Clamping prior to removal is not recommended on the basis of the latest evidence. The patient should be instructed to exhale while the tube is being removed. Once the tube has been removed the closure suture should be tied and an occlusive dressing applied.
The patient should be monitored for signs of respiratory distress. Disposal of the chest drain must include safe disposal of the fluid absorbent gels can be used to avoid spillage of the contents. Frazer C. Managing chest tubes. MedSurg Matters! Maslove DB et al. The diagnosis and management of pleural effusions in the ICU. Journal of Intensive Care Medicine ; 28 : 24— A pneumothorax occurs when there is air in the pleural space surrounding the lungs, and it requires a chest tube to allow the air to escape.
Similarly, a haemothorax occurs when blood collects within the pleural cavity. A tension pneumothorax occurs when there is communication between the lung and the pleural space. Air is able to enter during inspiration, but is prevented from exiting on expiration. As a result the accumulation of air in the pleural space will cause displacement of the mediastinum and obstruction of blood vessels, and will restrict ventilation.
The causes can be classified as spontaneous or traumatic see Table 4. Subpleural bullae rupture—usually in tall young males. Emphysema bullae rupture—usually in middle-aged or elderly patients with generalized emphysematous changes. Iatrogenic—central venous catheter insertion, high positive airway pressures with mechanical ventilation. The tube is attached to suction and may remain in situ for several days.
Pleural Disease Guideline. Haynes D and Baumann M. Management of pneumothorax. Seminars in Respiratory and Critical Care Medicine ; 31 : — Asthma is a chronic respiratory condition with the following features:. Any one of the following in a patient with severe asthma:. It is typified by cough, wheeze, dyspnoea, chest tightness, and decreasing expiratory flow. Status asthmaticus is a medical emergency that can be identified by failure to respond to nebulized bronchodilators see Box 4.
A combination of severe asthma , recognized by one or more of the following:. A patient may have more than one cause of airway obstruction—for example, COPD and asthma often coexist. Both genetic and environmental factors have been implicated in the aetiology of asthma.
Immunoglobulin E IgE appears to be involved in the characteristic airway inflammation and hyper-responsiveness, with the allergens in the local environment determining the level of antibody response. Triggers for asthma can be non-specific e. Reserve the intravenous route for patients in whom the inhaled route is unreliable. Use prednisolone 40—50 mg daily or parenteral hydrocortisone mg daily mg 6-hourly.
Add nebulized ipratropium bromide 0. If given to patients taking oral aminophylline or theophylline, blood levels should be checked on admission and daily. British Guideline on the Management of Asthma: a national clinical guideline.
Exacerbations and comorbidities contribute to the overall severity in individual patients. Exacerbations are often precipitated by a viral upper respiratory tract infection, heart failure, or retained secretions. The chronic airflow limitation that is characteristic of COPD is caused by a mixture of small airways disease obstructive bronchiolitis and parenchymal destruction emphysema.
Chronic inflammation causes structural changes and narrowing of the small airways. Destruction of the lung parenchyma, also by inflammatory processes, leads to the loss of alveolar attachments to the small airways and decreases lung elastic recoil. In turn these changes reduce the ability of the airways to remain open during expiration. Use a dose of 30—40 mg prednisolone per day for 10—14 days. The decision to ventilate a patient with an exacerbation of COPD must take into consideration the stage of lung disease, the aggressive treatment, and the weaning process, together with the wishes of the patient.
Cleaning the Air: a national study of chronic obstructive pulmonary disease. GOLD: Clinical concise review: mechanical ventilation of patients with chronic obstructive pulmonary disease. Critical Care Medicine ; 36 : — Wildman MJ et al.
British Medical Journal ; : Pulmonary oedema is an accumulation of fluid in the interstitial space of the lung tissue. This excess fluid will impair gas exchange at the alveolar—capillary membrane. Fluid accumulation within the lung itself has either a cardiogenic cause failure of the heart to remove fluid from the lung circulation or a non-cardiogenic cause direct injury to the lung parenchyma see Table 4. The role of noninvasive ventilation in acute cardiogenic pulmonary oedema. Critical Care ; 14 : Embolization of a venous thrombosis to the lungs will lead to pulmonary artery occlusion, obstruction of the pulmonary circulation, and sudden death.
The effect of the obstruction will cause inflammatory changes, which will lead to pulmonary hypertension and subsequent coronary oedema. Most pulmonary embolisms result from lower limb, pelvic, or inferior vena cava thrombus. Immobility is the main cause. British Thoracic Society: London, Miller A and Boldy D.
Pulmonary embolism guidelines: will they work? Thorax ; 58 : TB is a contagious bacterial infection that mainly affects the lungs, although the pathogen Mycobacterium tuberculosis can infect other parts of the body, such as the gastrointestinal tract, cerebrospinal fluid, and other organs. Exposure is through aerosol droplets from coughing, sneezing, or speaking. Duration and intimacy of contact determine the likelihood of transmission. Four outcomes are possible following exposure—immediate clearance of bacteria, primary disease, latent infection, and reactivation disease.
Latent infection refers to the presence of TB without the disease. Conduct a focused interview related to history of respiratory disease, smoking, and environmental exposures. Inspect: For use of accessory muscles and work of breathing Configuration and symmetry of the chest Respirations for rate 1 minute , depth, rhythm pattern Skin colour of lips, face, hands, feet O 2 saturation with a pulse oximeter.
Assess respiration rate With hypoxemia, cyanosis of the extremities or around the mouth may be noted. Coarse crackles may indicate pulmonary edema. Wheezing may indicate asthma, bronchitis, or emphysema. Low-pitched wheezing rhonchi may indicate pneumonia. Pleural friction rub creaking may indicate pleurisy. Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation.
Check room for contact precautions. Introduce yourself to patient. Conduct a focused interview related to cardiovascular and peripheral vascular disease. Cyanosis is an indication of decreased perfusion and oxygenation. Assess capillary refill Assess bilateral lower legs Alterations and bilateral inconsistencies in colour, warmth, movement, and sensation CWMS may indicate underlying conditions or injury.
Auscultate apical pulse at the fifth intercostal space and midclavicular line. Palpate the radial, brachial, dorsalis pedis, and posterior tibialis pulses.
Absence of pulse may indicate vessel constriction, possibly due to surgical procedures, injury, or obstruction.
Assess tibial pulses Assess pedal pulses. Conduct a focused interview related to gastrointestinal and genitourinary systems. Ask relevant questions related to the abdomen, urine output, last bowel movement, flatus, any changes, diet, nausea, vomiting, diarrhea. Inspect: Abdomen for distension, striae, scars, contour, and symmetry Observe any abdominal movements associated with respiration, or any pulsations or peristaltic waves.
Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction. Auscultate abdomen for bowel sounds in all four quadrants. Palpate abdomen lightly in all four quadrants. Palpate to detect presence of masses and distension of bowel and bladder. Ask about shortness of breath and watch for signs of labored breathing.
Assess oxygen saturation. If it is below 90 percent, the patient likely needs oxygen. In infants and newborns: Check for flaring nostrils, which could indicate breathing problems. Signs of abnormal breathing include: Crackling, popping, or bubbling sounds, which may indicate pneumonia or pulmonary edema.
Wheezing, which can signal pulmonary disease, asthma, allergies, or an infection. Physical Examination A hands-on exam is critical for detecting abnormalities that simple observation and auscultation cannot. To examine the patient: Palpate the back at the tenth rib, positioning a thumb on each rib as the patient breathes deeply. Percussion Percussion can provide additional information about respiratory status.
Sounds to monitor for include: A short and high-pitched or very dull sound over muscle or bone. A loud, low-pitched sound over the stomach that can indicate pneumothorax or emphysema. About Sam D. Say Sam D. Most Popular Articles. Follow us on social media:. Updates Upcoming Events. All data and information provided on this blog is for informational purposes only.
All information is provided on an as-is basis. Advise — In a clear, strong, and personalized manner, urge every user to quit. Assist — For the patient willing to make a quitting attempt, use counseling and pharmacotherapy to help them quit. Arrange — Schedule follow-up contact, in person or by telephone, preferably within the first week after the quit date. The vital signs may be taken by the nurse or delegated to unlicensed assistive personnel such as a nursing assistant or medical assistant.
Evaluate the respiratory rate and pulse oximetry readings to verify the patient is stable before proceeding with the physical exam. Inspection during a focused respiratory assessment includes observation of level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.
Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration. As you move across the different lung fields, the sounds produced by airflow vary depending on the area you are auscultating because the size of the airways change. Correct placement of the stethoscope during auscultation of lung sounds is important to obtain a quality assessment.
The stethoscope should not be performed over clothes or hair because these may create inaccurate sounds from friction. The best position to listen to lung sounds is with the patient sitting upright; however, if the patient is acutely ill or unable to sit upright, turn them side to side in a lying position.
Avoid listening over bones, such as the scapulae or clavicles or over the female breasts to ensure you are hearing adequate sound transmission.
Listen to sounds from side to side rather than down one side and then down the other side. This side-to-side pattern allows you to compare sounds in symmetrical lung fields. See Figures It is important upon auscultation to have awareness of expected breath sounds in various anatomical locations.
Adventitious lung sounds are sounds heard in addition to normal breath sounds. They most often indicate an airway problem or disease, such as accumulation of mucus or fluids in the airways, obstruction, inflammation, or infection.
There are various respiratory assessment considerations that should be noted with assessment of children. As the adult person ages, the cartilage and muscle support of the thorax becomes weakened and less flexible, resulting in a decrease in chest expansion. Older adults may also have weakened respiratory muscles, and breathing may become more shallow.
The anteroposterior-transverse ratio may be if there is significant curvature of the spine kyphosis. Percussion is an advanced respiratory assessment technique that is used by advanced practice nurses and other health care providers to gather additional data in the underlying lung tissue.
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