Need help clarifying pt. positioning in pt with acute pulmonary complications

[bayoufrogg]

Okay, so I always get these mixed up to the point where I just forget. I know ARDS positioning is prone leaning more on affected lung OR on rotating bed. I believe ARF intervention is affected lung DOWN as well. I'm also reading that with pulmonary contusions, you put the pt. side-lying, increase HOB, and affected lung UP before surgery. Then you place them affected lung DOWN after surgery.

For a while, every acute lung problem I saw had patient positioning with affected lung DOWN, but now I'm running into a few that are not that way.

Can anyone spell out which lung injuries you would have pt with affected lung UP versus DOWN??? Thanks.

[Daytonite, BSN, RN]

With ARDS and ARF lying toward the affected side gives the "good" lung maximum room to do its work. If there is a pulmonary contusion there has been trauma and bleeding into the lung and I would expect a chest tube to be present. When a chest tube is present, you want any air trapped in the pleural space around that side to be removed. The best way to assist the chest tube to do that is to position the affected lung higher than the non-affected lung (air rises). After surgery, its just a drainage tube and as with the other conditions you want maximum expansion of the non-affected side.

[bayoufrogg]

Hmm.......I still have difficulty seeing the connection with chest tube in pulmonary contusion and bad lung up before surgery. I know you said because air rises etc. etc., but the chest tube in this situation is not for air. It is a drainage tube in the 5-6th ICS. Its purpose would not be for air, as the problem in pulmonary contusion is hemorrhage.

If I didnt know the answer that the book proposes, I would say that in pulmonary contusion(before surgery) the affected lung needs to go down to maximize ventilation in good lung and allowing gravity to position pulmonary drainage close to chest tube. The book doesnt go into explanation, it just says before surgery with pulm. contusion....affected lung up.

It does explain that POST-OP, you would want client with affected/surgery lung DOWN, as you dont want blood/drainage to affect good lung. But wouldnt that be the same PRE-OP??? You still have blood! Whether its hemorrhage(pulm. contusion) or surgically induced, you STILL HAVE BLOOD causing the main issue!!???!?!!?! Same situation, different positions??? I might be going a little too far with this, but you cant possibly do these interventions if you dont understand why you are doing them.

[Daytonite, BSN, RN]

When there is trauma, there is still a hole(s) or tears in the pleura from the trauma. Every time the patient takes a breath inspired air escapes from the internal lung tissue through those traumatically made holes or tears into the pleural space. So, the chest tube(s) are not only draining blood, but also preventing the injuring lung from collapsing due to a pneumothorax that could develop if the chest tube wasn't there. The holes will get repaired in surgery.