Pneumothorax and Chest Tubes
2nd ICS
Needle Decompression
Intercostal space midclavicular line
<200 mL
Removal Criteria
Drainage in 24 hours for tube removal
0
CXR Needed
For tension pneumo, treat immediately
Types of Pneumothorax
tension is the one that kills, recognize it fastSimple
Small collection of air, may resolve spontaneously, monitor with serial CXR
Tension
One-way valve mechanism, progressive pressure, mediastinal shift, cardiovascular collapse
Open
Chest wall defect allowing atmospheric air in, "sucking chest wound," seal with 3-sided dressing
Hemothorax
Blood in pleural space, often from trauma, may need thoracotomy if >1500 mL initial or ongoing loss
Tension Pneumothorax Presentation
Absent breath sounds (affected side)
Tracheal deviation (LATE sign)
Hypotension and tachycardia
JVD (from obstructed venous return)
Hyperresonance to percussion
Cyanosis
Do NOT wait for chest x-ray in tension pneumothorax. Needle decompression immediately. This is a clinical diagnosis based on presentation.
Chest Tube Management
Water seal chamber maintains one-way valve (allows air out, prevents air in)
Suction chamber provides negative pressure to evacuate air and fluid
Tidaling (fluctuation with respiration) indicates patent system
Continuous bubbling in water seal = persistent air leak
Assess drainage color, amount, and rate every 1-2 hours
Keep drainage system below chest level at all times
Removal criteria include air leak resolved, drainage less than 200 mL in 24 hours, lung re-expanded on CXR, and no respiratory distress on water seal trial.
Key Values to Memorize
Needle at 2nd ICS MCL
Tube at 4th-5th ICS MAL
<200 mL/24h for removal
>1500 mL initial = consider OR
Tidaling = normal
Continuous bubbling = air leak
chest tube questions are classic CCRN, know your alarms
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Practice CCRN QuestionsExam Traps
Do NOT wait for CXR in tension pneumothorax
Tension pneumothorax is a clinical diagnosis. Tracheal deviation, absent breath sounds on one side, hypotension, and JVD tell you everything. Waiting for imaging delays treatment and the patient can deteriorate rapidly. Needle decompression at the 2nd intercostal space midclavicular line is immediate.
Never clamp a chest tube when an air leak is present
Clamping a chest tube with an active air leak traps air in the pleural space and can create a tension pneumothorax. The only time to briefly clamp is to locate the source of an air leak (tube vs system) or during a water seal trial before removal.
Tidaling is NORMAL and expected
The fluctuation of fluid in the water seal chamber with respiration (tidaling) means the system is patent and functioning. If tidaling stops, assess for tube obstruction, kinking, or dependent loops. The absence of tidaling is the problem, not its presence.
Tracheal deviation is a LATE sign of tension pneumothorax
By the time the trachea shifts away from the affected side, significant pressure has built up. Earlier signs include absent breath sounds, hypotension, and tachycardia. Do not wait for tracheal deviation to act.
Never Clamp with Air Leak
NEVER clamp a chest tube when an air leak is present. You risk creating a tension pneumothorax. The air has nowhere to go.
Tidaling is Good
Tidaling (fluctuation in water seal) is NORMAL. It means the system is patent. No tidaling = check for kink or obstruction.
Your lung is like a balloon inside a sealed box (the chest wall). Negative pressure in the box keeps the balloon inflated. When you breathe in, the box expands and the balloon fills with air.
A hole lets air leak INTO the box but OUTSIDE the balloon. The balloon starts to collapse because the negative pressure is lost. This is a simple pneumothorax.
Now the hole acts like a one-way valve. Air keeps entering the box with each breath but cannot escape. Pressure builds. The inflated side starts pushing everything (heart, trachea, other lung) to the opposite side. This is tension pneumothorax and it is immediately life-threatening.
Needle decompression pokes a hole in the box to release the trapped air. A chest tube then provides a continuous exit for air, connected to a drainage system that lets air out but not back in (water seal).
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