Chest Tube Flashcards
Describe the Visceral
-Serous membrane investing the lung
-No pain nerves
Describe the Parietal
-Lines the wall of the thoracic cavity
-Pain nerves
Describe the Pleural space
Airtight space with only a small amount of fluid to allow the surfaces to move smoothly over one another
When the pleural space is experiencing abnormality what is this called?
Pleurisy
Define pleurisy
(inflammation of the pleura) can alter the movement of the chest by causing pain on inspiration
What are the two types of pleurisy?
Wet & Dry
Describe Wet Pleurisy
Abnormal Fluid Increase!
this excess fluid that becomes infected may cause pus formation, aka. empyema.
What is another name for wet pleurisy?
pleural effusion
(so if wet pleurisy is described on the exam understand that it is another name for pleural effusion)
Describe Dry Pleurisy
membranes become congested and
swollen and rub against each other causing pain on inspiration
If asked, what breath sound would you hear that indicate dry pleurisy?
Pleural Friction Rub
(if this is described in the exam understand that dry pleurisy is what your dealing with)
What causes more pain dry or wet pleurisy?
Wet pleurisy is less likely to cause pain since there is no chafing (rubbing).
What reason may the pleural space may be violated/disrupted
Due to trauma or surgery
In what ways can a pneumothorax be accumulated? HINT (3)
Spontaneous, Chest trauma, or surgery
True or False
When a pneumothorax percentage is greater than 20% this indicates a need for a chest tube
True
(<10% typically means a pneumo that normally resolves on its own)
What can air or fluid in the pleural space cause?
collapse of the lung or mediastinal shift
Describe thoracentesis.. What’s the purpose and procedure of a thoracentesis?
surgical puncture of the chest wall and pleural space with a needle or catheter to aspirate pleural fluid for therapeutic or diagnostic purposes
Describe a tension pneumothorax..whats the purpose and procedure of a relieving it?
Done by placing a large bore needle (16
gauge or larger) through the 2nd or 3rd
intercostal space midclavicurly & anteriorly
So what’s the difference b/w the procedure for a tension pneumo & plueral effusion
Ask Ebong because I don’t think there is one… Only difference found is that a tension pneumo will be removing air while plueral effusion will be removing fluid
What can a thoracentesis cause? In other words, what are some complications? aka Disadvantanges
HINT (8)
Infection
Hemothrox
Subcutaneous empysema
Air Embolism
Pneumothorax
Sudden mediastinal shift from removal of large amount of pleural fluid.
Unstable vital signs
Pulmonary edema from the sudden re-expansion of the lung and mediastinal shift
List some advantages of thoracentesis procedure HINT (3)
May relieve symptoms
Allow collection of specimens for lab analysis
Prevent need for chest tube and continuous drainage (REMEMBER JUST BCUS IT CAN DOES NOT MEAN IT WILL)
Exudate vs Transudates
Exudates are fluids, CELLS, or other cellular substances that are slowly discharged from BLOOD VESSELS usually from inflamed tissues.
Transudates are fluids that pass through a membrane or squeeze through tissue or into the EXTRACELLULAR SPACE of TISSUES.
Diseases/Defects causing Transudates
CHF
Cirrhosis
Nephrotic syndrome
Hypoproteinemia
Diseases/Defects causing Exudates
inflammatory infectious, or
neoplastic diseases of the pleura or lung EXAMPLE: Hemothorax, Chylothorax, Empyema SL 14
*Other causes: pulmonary infarction, chest trauma, drug hypersensitivity, and collagen vascular disease
Test Understanding:
When discussing transudate fluid, which disease would be associated with it?
A. Cirrhosis
B. Tension Pneumothorax
C. Hemothorax
D. Empyema
A. Cirrhosis
TIP: Do NOT try to memorize both exudate and transudate causes/associations, memorize one category to know what the other would not be.
Exudate: Pleural space & Lung diseases
Transudate: Heart & Kidneys
During a thoracentesis, what should the site be disinfected with?
Iodine (Betadine)
SL 11
What is the mediastinal space?
heart, trachea, esophagus, the thymus, and lymph nodes— aka area between the lungs
Indications for a chest tube for the mediastinal space
Free air, blood, or fluid in the space
What is the pericardial space?
fluid-filled space between the two layers of the pericardium, a sac that surrounds the heart
think of it as the pleural space but for the heart
Now that we know what the pericardial space is, what are the indications for a chest tube for this space?
1. Cardiac Tamponade
2. Pneumopericardium
3. Plueral Effusion
4. Chylothorax
1 and 4
True or False
When placing a chest tube (NOT THE DRAINAGE SYSTEM the TUBE) , It is not indicated to place the tube higher – 2nd or 3rd midclavicular space anteriorly– to exudate due to air rising to upper areas
True
Tubes are placed higher in the thorax as air rises to the upper anterior area in the supine position and is placed in 2nd and 3rd intercostal space, midclavicular line,
anteriorly
When placing a TUBE not the SYSTEM, where would be the place to insert the tube for fluid removal? Why?
A. 2nd and 3rd intercostal space, midclavicular line, anteriorly because fluid rises
B. 2nd and 3rd intercostal space, midclavicular line, posteriorly because fluid fluid is gravity dependent and will settle in the lower posterior aspect of the chest in the supine position
C.5th & 6th intercostal space, mid-axillary line slightly posterior placed lower in the thorax as fluid is gravity dependent and will settle in the lower posterior aspect of the chest in the supine position
D.5th & 6th intercostal space, mid-axillary line slightly anterior fluid is gravity dependent and will settle in the lower posterior aspect of the chest in the supine position
C.5th & 6th intercostal space, mid-axillary line slightly posterior placed lower in the thorax as fluid is gravity dependent and will settle in the lower posterior aspect of the chest in the supine position
*8th & 9th intercostal space is also used but with greater risk of diaphragmatic penetration upon insertion
Describe Mediastinal Chest Tubes–
Remember what the mediastinal space consists of, use that to help you brainstorm.
Anterior placement to remove blood from
mediastinum post cardiac surgery or
chest trauma
Will there be tidaling in a medistinal drainage system? why or why not?
No tidaling with these chest tubes because they are not in the pleural space
*Frequent cardiac assessment with these
tubes needed obvi
True or False
The one-bottle system only consists of a water seal
False
the ONE Bottle serves as both collection chamber and water seal
The water seal should consist of how much water?
A. 3cm
B. 2 cm
C. 7cm
D. 5 cm
B. 2cm
What is the purpose of the water seal? What happens if too much water is added?
Tube immersed beneath water to prevent
air from entering BACK INTO pleural space,
- if too much water is added the patient will have a harder time overcoming resistance of the water – due to high low pressure gradient–
Does the water continuously bubble in the water seal? Why or Why not?
No, however, it does bubble intermittently due to air leaving the pleural space
What is tidaling/fluctuation?
the normal rise and fall of fluid in the water seal chamber due to change in intrathoracic pressure
True or False
When a patient is spontaneously breathing tidaling of the water seal column moves up with inspiration and down with expiration
True
*will be reversed with mechanical ventilation – water level will fall during inspiration (pos. pressure) and
rise during exhalation
No Tidaling/Fluctuations indicate all of the following except:
1. The lung has re-expanded
2. The tube is occluded
3. Suction is applied
4. Air leak
5. Dependent fluid filled loop
4.
Air leak will be indicated with continuous bubbling in the water seal
SL 23 and 25
What is the disadvantage of the one bottle drainage system?
As drainage fills the bottle, more of the tube is immersed which means more force is needed to push water or air out of the way to allow for continued drainage.
True or False
The two-bottle system consists of a separate water seal bottle and a collection bottle
True
Describe the way the two bottle system works
Drainage falls into the collection bottle, air flows into water seal system and exits through the vent
True or False
Bubbling from air leak and
fluctuations in the water seal tube is
the same as the one bottle system
True SL 33
Which are disadvantages to the two bottle systems?
1. Second collection bottle adds dead air space that could be drawn into pl. space
2. Sometimes the pressure difference necessary for drainage isn’t enough
3. Drains too quickly
4. Greater spill potentional
1 and 2
*recall – to drain air or fluid
from the pl. space, pressure must be higher in the chest than in the bottles (sometimes in the two bottle system this is compromised.) Bottles are placed below the chest to maintain this–
What fixes the pressure graident that the two bottle system alone fails to meet?
Suction drainage system
We would have to apply a negative pressure in order to increase the pressure difference
How does the suction drainage system assist with fixing the pressure gradient?
Increases the pressure difference between the pleural space and the drainage bottles by pulling air from the bottles, causing the pressure inside to drop
Whats the normal suction level for adult patients?
-15 to -20 cm H2O
WATCH THOSE UNITS
What are two ways suctioning can be increased/adjusted in the suction bottle?
inserting the submerged control straw deeper in the chamber and adding more water SL 42
Does adjusting the level of suction pump increase suction in the suction chamber? Why or Why not?
turning the suction up pulls air from the
drainage bottles and also pulls outside air down into the control straw then this causes more bubbling but
CANNOT increase the level of suction in the system because the entering outside air will balance any further air removal by the pump
What is the purpose of a four-chamber drainage system?
to add another underwater seal not connected to wall suction and vented to the atmosphere in order to prevent the patient from a pneumothorax in the event of sudden suction failure
When does the fourth bottle/chamber actually take effect?
only ever vents when the
air pressure in the other two chambers exceeds the water seal pressure (i.e. about 2 cm H2O)
What can cause continuous bubbling in a water seal chamber? SPECIFICS PLEASE
1. Tear in the lung
2. Leak in drainage system
3. Loose connection, crack, hole
4. Obstruction
1,2, and 3 SL 56
True or False
Fluctuations will be present with a suction system on
False
With a suction system, water stays at a fixed level so No fluctuations!! SL 56
How do you check normal fluctuations if a drainage system is hooked up to suction?
Disconnect suction to check for normal
fluctuations
SL 56
Describe Wet Suction
Regulated by the height of water in the
suction control chamber when connected
to wall suction
Describe Dry Suction
No water column but uses a suction
monitor bellow that balances the wall
suction – a self-compensating regulator
Disadvantage of wet suction
Excessive source suction causes loud bubbling and hastens evaporation of water
Why is stripping/milking not recommended?
Causes pt. discomfort from the increased negative intrathoracic pressure, damages pleural tissue and prolongs patient recovery
If stripping is necessary, what technique should be used
first squeezing hand over hand along the tubing and releasing between each
squeeze (fan folding)
Indications for chest tube removal
HINT (6)
Diminished drainage
Absence of air leak
Fluctuations stop in water seal chamber and water
creeps part of the way up the chamber
Pt breathing easily
Auscultate normal soft vesicular sounds
CXR showing lung re-expansion
Why is the chest tube clamped for 24 hours before removal?
In order to assume normal intrapleural
pressure
*During 24 hrs, Patient is observed for respiratory distress. Any sign of distress or if x-ray indicates a pneumo or pl. effusion the tube is unclamped
What is the patient asked to do just before/during removal? hint: a breathing technique
the pt is instructed to take a deep breath, exhale and perform the valsalva maneuver
What is the valsava manuever
a breathing technique that involves forcefully exhaling against a closed airway (glottis)
How is the chest wound sealed upon removal?
Wound is sealed with petroleum jelly aka VASELINE dressing to cover opening and prevent air from entering pleural space
What to monitor after removal? HINT post op monitoring
Breathing, respiratory rate, WOB,
chest pain
Bilateral breath sounds
Every 15” for the first hour aka monitor these things every 15 minutes
