If you intubate somebody and you don’t hear breath sounds clearly on the left side, first thing you should say is, how deep is the endotracheal tube? It it’s at 18 or 16 cm at the lips it probably can NOT be pulled back in an adult, and a main stem intubation is probably not the problem. Most endotracheal tubes will be at 22 to 24 at the lips. So, if you’re going to pull any endotracheal tube back, you need to check where it is first.
Ask “where is it at the lips” and if the respiratory therapist say 16cm, you should think, “I’ve got some breath sounds on that side, and the oxygen saturations are stable (if they’re over 90%), let me get a chest x-ray and see what’s going on. If it’s at 28cm at the lips then clearly, you pull it back.
Next, should you slam a chest tube into a patient who has decreased breath sounds? The simple answer is, not unless they are dying. Remember I do not recommend putting in a chest tube without a chest x-ray unless the patient is moribund or they have clear signs of tension pneumothorax. And clear signs of tension pneumothorax are not the absence of breath sounds on one side. Its tracheal deviation, hypotension, jugular venous distention, etc., and an effect on pulmonary function reflected by a decreased oxygen saturation or increasing end tidal CO2. I do not believe it is logical care if you get called into a room and somebody says, “I’ve got decreased breath sounds on the right side, but their sats are 98%, they’re normotensive, they have a normal pulse” and you just slam in a chest tube. You need to have more data before you do that.
Key Point: You might say, “Youngie, what’s the big deal, its just a chest tube?” My answer is: procedures tend to distract everyone working with the patient! If you have a patient, and you say “I’m putting in a chest tube” you very likely have just taken 2-3 people’s attention off the patient. One person is getting your supplies, the other is setting up the pleurovac and the tray, and you are getting involved in the procedure. I have seen patients code during chest tube placements where there was no pneumothorax or hemothorax because the draping towel was put over their face, and everyone started watching the person who was putting in the chest tube, and didn’t continue the evaluation and treatment plan. Chest tubes can be lifesaving, but a case of true tension pneumothorax is rare (I have only seen about a dozen in 15,000 trauma patients). In a hospital patient, who is not a trauma victim, and who has not gotten a central line attempt recently, it is very likely NOT the cause of their problems.