CJ

Pulmonary Embolism, Chest Tubes, and Ventilator Modes: Comprehensive Study Notes

Pulmonary Embolism (PE): Risk, Prevention, and Treatments

  • Risk factors for PE

    • Inherited thrombophilias (e.g., Factor V Leiden)
    • Hormonal factors: use of oral contraceptives and hormone replacement therapies
    • Smoking
    • Other contributors may include immobilization, recent surgery, pregnancy, obesity (not all listed in the transcript but commonly relevant)

  • In-hospital prevention of PE

    • Early ambulation
    • Leg exercises (ankle pumps, calf strengthening)
    • Compression devices: compression stockings or sequential compression devices (SCDs)
    • Adequate hydration
    • Pharmacologic prophylaxis: low molecular weight heparin (LMWH) or other anticoagulants as ordered by physician/pharmacist

  • PE treatment options (three to know)

    • Systemic heparin therapy (anticoagulation)
    • Thrombolysis when indicated (accelerates clot breakdown)
    • Catheter-based approaches: thrombolectomy via angiography
    • EKOS (ultrasound-assisted catheter-directed thrombolysis): catheter delivers anticoagulant directly to the PE; ultrasound helps lysing the clot

  • Catheter-directed therapies (EKOS) specifics

    • EKOS is a targeted therapy using a catheter inserted (often via femoral or radial access) to the space of the PE
    • The device administers anticoagulant locally, guided by the physician/pharmacist choice
    • Nursing considerations after catheter placement: monitor insertion site for infection, vascular checks, assess for occlusion risk due to foreign device, and monitor complications
    • Common access sites: femoral artery or radial artery; assess for infection and thrombosis at access site

  • Post-procedure considerations for catheter-based PE therapies

    • Careful hemodynamic monitoring
    • Frequent site checks and neurovascular assessments of the access site
    • Watch for signs of bleeding, infection, or catheter-related complications

  • Trauma-related respiratory conditions to know

    • Tension pneumothorax
    • Hemothorax
    • Flail chest
    • All require rapid assessment and treatment planning to maintain oxygenation and ventilation

  • Tension pneumothorax: what's happening and signs

    • Air enters pleural space and is trapped, causing lung collapse
    • Mediastinal shift and tracheal deviation away from the affected side
    • Major vessels compressed -> severe hemodynamic compromise
    • Severe respiratory distress, hypoxia, cyanosis, reduced or absent breath sounds on affected side
    • Treatment: emergency needle decompression to evacuate trapped air, reinflate lung, followed by chest tube placement as needed
    • If tension pneumo develops, rapid action is required; intubation is not the immediate first step in this scenario
    • Post-decompression: chest tube insertion to re-expand the lung and prevent recurrence

  • Hemothorax: what it is and management

    • Blood in the pleural space usually from trauma (rib fractures, vessel injury, airbags, etc.)
    • Signs: diminished breath sounds on affected side, dullness to percussion
    • Management often includes chest tube drainage; assess for ongoing blood loss and hemodynamic instability
    • Differentiation from pneumothorax via percussion (hemothorax usually dull; pneumothorax hyperresonant)

  • Flail chest: hallmark features and implications

    • Two or more adjacent ribs fractured in two or more places
    • Paradoxical chest wall movement (inward movement during inspiration on the flail segment; outward on the opposite side)
    • Leads to hypoxia; risk of pulmonary contusion and respiratory failure
    • Initial management often includes aggressive pain control, oxygen therapy, and respiratory support (BiPAP/CPAP or mechanical ventilation) if needed
    • Rib fixation surgery may be considered; chest tube may be needed if pneumothorax/hemothorax is present

  • Chest tubes: overview and care

    • Indications: pneumothorax, hemothorax, pleural effusion, post-op drainage
    • Modes of suction management
    • Wet suction: uses a water column to regulate suction; a water seal chamber is typically present and often filled to a specific level (commonly around 27 cm of water in the suction chamber depending on device)
      • Continuous bubbling indicates suction is active
    • Dry suction: uses a self-regulating module rather than a water column; requires less maintenance and shows no bubbling
    • Key terms
    • Water seal chamber: provides a one-way seal to prevent air from traveling back into the chest; typically filled with sterile water
    • Suction control: determines the amount of negative pressure applied to assist drainage
    • Nursing considerations for chest tubes
    • Monitor output: typical removal planning when drainage is minimal
      • Consider chest tube removal when output is less than about <100 ext{ to } 150 ext{ mL} in the last 24 hours
    • Monitor for abrupt changes in drainage (e.g., sudden large bright red drainage) and notify the surgeon
    • Assess the patient’s respiratory status, oxygenation, and hemodynamics
    • Positioning after chest tube placement: pneumothorax patients often in semi- to high-Fowler's; hemothorax patients may be positioned on the affected side down if hemodynamically stable
    • Pain management is critical to allow deep breathing and coughing to prevent atelectasis and pneumonia
    • Cardiac and pulmonary status should guide activity and weaning from chest tube support
    • Chest tube removal procedure and precautions
    • Confirm lung re-expansion with imaging (chest X-ray) after removal
    • Use sterile dressing; apply an occlusive dressing after removal
    • Instruct the patient to perform deep breathing; sometimes Valsalva maneuver is used during removal to minimize air entry into the pleural space
    • Monitor for pneumothorax after removal; dyspnea or sudden chest pain may indicate recurrence
    • Nursing vigilance after chest tube removal
    • Watch for signs of pneumothorax and respiratory distress
    • Ensure wound care and documentation of sites

  • Ventilator basics and common modes you need to know

    • Key ventilator settings and concepts
    • Tidal volume (VT): volume of air delivered per breath
    • Respiratory rate (RR): breaths per minute
    • Fraction of inspired oxygen (FiO2)
    • Positive end-expiratory pressure (PEEP)
    • Ventilator modes
    • Assist-Control (AC / A/C / CMV)
      • Patient-initiated breaths; machine delivers a predetermined tidal volume
      • Good for patients with weak respiratory effort or heavy sedation
    • SIMV (Synchronized Intermittent Mandatory Ventilation)
      • Ventilator delivers a set number of breaths, synchronized with patient effort; patient can initiate additional breaths
      • Useful for weaning readiness assessment
    • Pressure Support Ventilation (PSV / PS)
      • Patient-triggered breaths with a preset pressure boost; patient controls rate and tidal volume
      • Reduces work of breathing; often used during weaning or when patient has partial respiratory drive
    • CPAP (continuous positive airway pressure)
      • Noninvasive mode delivering steady positive pressure; maintains airway patency and improves oxygenation
      • Commonly used for sleep apnea or as a bridge/noninvasive support in acute settings
    • BiPAP (bilevel positive airway pressure)
      • Two pressures: higher during inspiration (IPAP) and lower during expiration (EPAP)
      • Beneficial in CHF exacerbations and other conditions requiring positive pressure with spontaneous breathing
    • Practical notes on selecting modes
    • AC for patients who are unable to adequately generate tidal volume on their own
    • SIMV when weaning and assessing readiness for spontaneous breathing trials
    • PSV/BiPAP used to support patients while maintaining spontaneous breathing and reducing work of breathing
    • Common ventilator alarms and troubleshooting (what to do first)
    • High pressure alarm
      • Causes: circuit obstruction/kinking, secretions, bronchospasm, patient biting ET tube
      • Actions: check tubing, suction if needed, assess patient, consider sedation, contact RT if unresolved
    • Low pressure alarm
      • Causes: disconnection, cuff leak/deflation, accessory tubing leaks
      • Actions: inspect connections, reinflate cuff if needed, assess for air leak
    • Apnea alarm
      • Causes: tube dislodgement, severe sedation or paralysis, equipment fault
      • Actions: assess patient, prepare for manual ventilation if necessary, notify RT
    • Endotracheal tube (ETT) care and placement checks
    • Ensure tubing is secure and the tube is patent
    • Know the tube size and lip position (e.g., “lip” measurement, such as 26 at the lip)
    • Obtain chest X-ray to confirm tube position and lung expansion after intubation or repositioning

  • Airway and respiratory distress vs respiratory failure: definitions and nursing actions

    • Respiratory distress: increased work of breathing; may be reversible with noninvasive support or ventilation; may respond to bronchodilators and supplemental oxygen
    • Respiratory failure: inability to maintain adequate oxygenation or ventilation; requires advanced support (mechanical ventilation, hemodynamic support as needed)
    • Nursing interventions for respiratory distress
    • Upright positioning if tolerated; elevation of head of bed; encourage deep breathing; admin bronchodilators as ordered
    • Supplemental oxygen; monitor ABG and SpO2; frequent lung auscultation
    • Escalation for respiratory failure
    • Notify rapid response/CRRT/ICU team as per facility protocol
    • Prepare for advanced support (intubation and ventilation) and optimize hemodynamics (IV fluids, vasopressors) as needed

  • ABG interpretation basics (examples from the transcript)

    • Respiratory acidosis (uncompensated example)
    • pH < 7.35
    • PaCO2 > 45 mmHg
    • HCO3− approximately normal (if uncompensated)
    • Explanation: hypoventilation or gas exchange impairment leading to CO2 retention
    • Compensation (if it occurs) would involve increased HCO3− by the kidneys over time
    • Respiratory alkalosis (example implications)
    • pH > 7.45
    • PaCO2 < 35 mmHg
    • HCO3− normal or decreased if compensated
    • Use ABGs with clinical context and oxygenation status; ABG values guide ventilator adjustments and evaluation of gas exchange

  • Diagnostic and procedural considerations for respiratory issues

    • Bronchoscopy
    • Used for direct visualization and sample collection from the lungs
    • Pre-procedure: ensure NPO, obtain informed consent
    • Risks: bleeding, pneumothorax
    • CT chest with/without contrast
    • Useful for detecting masses, pulmonary embolism, and evaluating thoracic structures
    • Contrast precautions: allergy history, risk of nephrotoxicity, especially with metformin use
    • Metformin caution: potential risk of contrast-induced lactic acidosis; coordinate with prescribing clinician
    • Sputum and blood cultures
    • Obtain sputum cultures prior to antibiotics when possible to identify pathogens and tailor therapy
    • Ensure sample quality (avoid contamination by oral flora)
    • Chest X-ray (posterior/anterior views)
    • Identifies pneumothorax, pleural effusion, consolidations, and line/tube positions

  • Ethical, practical, and patient-care implications (practical nursing focus)

    • Effective communication with the physician team when patient status changes (e.g., sudden drainage changes, signs of instability)
    • Documentation and verification of device placement (ETT/Lip position, chest tube insertion site)
    • Safety and infection control around invasive devices (sterile technique for dressings, site care)
    • Patient comfort and analgesia to enable cooperative breathing and prevent hypoventilation or pneumonia

  • Quick reference practice questions (from end of transcript)

    • Q1: Chest tube placed for pneumothorax with continuous bubbling in the water-seal chamber. What is the priority nursing action?
    • Answer: Inspect for an air leak or disconnection in the chest tube system; ensure all connections are secure; assess the patient’s respiratory status; notify the physician if the air leak persists or if the patient deteriorates
    • Q2: A patient on mechanical ventilation suddenly becomes restless and the high-pressure alarm sounds. What is the priority action for the nurse?
    • Answer: Stop and systematically assess for causes of high airway pressure: check for kinks/occlusions in the tubing, secretions, bronchospasm, or patient biting the tube; suction if needed; attempt to bronchodilate if indicated; ensure ET tube position is secure; if unresolved, notify respiratory therapy and physician; consider manual ventilation if the patient is apneic or in distress

  • Summary of key numerical values to remember

    • Chest tube output threshold for considering removal: less than <100 ext{ to } 150 ext{ mL} in the last 24 hours
    • Water seal/suction specifics (typical): water column height related to suction pressure; commonly referenced in cm H2O (example given in transcript: 27 cm)
    • ABG quick reference (process-oriented): pH < 7.35 indicates acidosis; PaCO2 > 45 mmHg indicates hypercapnia and possible respiratory acidosis; PaO2 targets depend on patient status and oxygenation goals
    • Dull percussion suggests hemothorax; hyperresonance suggests pneumothorax

  • Equations and LaTeX formulas to memorize

    • Pressure from a water column (suction control): P =
      ho g h
    • Chest tube output thresholds for removal: ext{Output in last 24h} < 100 ext{ to }150 ext{ mL}
    • Respiratory acidosis indicator: ext{pH} < 7.35,\ PaCO_2 > 45~ ext{mmHg}
    • General acid-base relationships (conceptual): respiratory disturbances impact PaCO2; metabolic compensation alters HCO3− over time

  • Note on context for exam success

    • Be able to distinguish between respiratory distress and respiratory failure and identify when to escalate care
    • Recognize warning signs of pneumothorax, tension pneumothorax, and hemothorax and the corresponding emergency treatments
    • Understand basic ventilator modes (AC, SIMV, PSV) and when each is appropriate, plus the basic approach to troubleshooting alarms
    • Recall key nursing actions for chest tube care, removal, and prevention of ventilator-associated pneumonia