A Previously Healthy, 22-Year-Old Farmer Is Brought to the Emergency

A previously healthy, 22-year-old farmer is brought to the emergency department after a tractor ran over his chest.  The patient was intubated in the field because of respiratory distress.  In the emergency department, blood pressure is 74/40 mm Hg, pulse is 132/min, and pulse oximetry is 84% on 100% FiO₂.  On examination, the trachea is deviated to the left and breath sounds are absent in the right lung.  A right-sided chest tube is placed, after which the patient's blood pressure and pulse oximetry normalize.  The rest of the trauma survey is notable for bruising over the anterior chest and crackling of the neck and chest skin on palpation.  Heart sounds are normal, and the abdomen is nondistended and soft.  Chest x-ray confirms appropriate endotracheal and chest tube placement and reveals multiple rib fractures, right pneumothorax, pneumomediastinum, and subcutaneous emphysema.  Two hours later, the chest tube drainage system has a persistent large air leak, despite an adequate seal at the chest wall and all connection points.  Which of the following is the best next step in management of this patient?

A) Increase ventilator positive end-expiratory pressure
B) Insert an additional chest tube
C) Perform bronchoscopy
D) Perform talc pleurodesis
E) Reposition endotracheal tube

Correct Answer:

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