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Adult Critical Care > Test 3 > Flashcards

Test 3 Flashcards

1
Q

Reasons for chest tube

A 
Fluid in Pleural space
Pneumo
Hole in lung
Surgical
Rib Fracture
MVA
CABG
Loculated infusion
Trauma
High positive pressure
Empyema
Infection
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2
Q

Indications for chest tube

A 
To remove air (pneumo) or fluid from the pleural space in the chest wall
Pneumo
hemothorax
Hemo-pneumothorax
hole in lung
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3
Q

Chest wall anatomy

A

Visceral pleura
Parietal Pleura
-The parietal and visceral pleura are connected at the lung hilum

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4
Q

Norm Pleural fluid in a healthy adult is

A

approx 8ml hemi-thorax

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5
Q

Mediastinum

A

Portion of the thoracic cavity lying in the middle of the thorax between the two cavities. It extends from the vertebral column to the sternum and contains the trachea, esophagus, heart, and great vessels of the circulatory system

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6
Q

Lungs Position

A

located in the thoracic cavity by both sides of mediastinum

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7
Q

Apex of lung

A

Rises 2-3 cm above the medial third of clavicle into neck

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8
Q

Diaphragmatic surface

A

base of lung. Concave, related to diaphragm

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9
Q

Costal Surface

A

large, convex, related to thoracic wall

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10
Q

The pleura

A

serous membrane forming closed sacs
Two layers:
-Visceral pleura: adheres to lung; continuous with parietal pleura at root of lung
-Parietal pleural- lines the thoracic cavity

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11
Q

Good xray

A
  • Good exposure of spine, cardiac borders, aortic arch: tube placement
  • Good heart border- otherwise fluid (1/3 space)
  • Clavicles: Semetricle, straight
  • Trachea: midline, deviated=bad
  • Costaphrenic angles-sharp
  • hila region- where veins/ vessels go into lungs, pulm vascular whispy looking
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12
Q

Stomata

A

Normally pleural fluid is drained through small holes in the parietal pleura

  • Connected to intercostal lymphatic vessels and drain to mediastinal lymph system (creating and draining pleural fluid
  • Eventually emptying into left subclavian vein
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13
Q

Pleural Effusions results when

A

the capacity of pleural lymphatic drainage is overcome with transudative or exudative occurance

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14
Q

Pleural effusion: Transudative

A

Occurs when the integrity of the pleural space is undamaged

  • “train” fluid has to come from something else
  • CHF
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15
Q

Pleural Effusion: exudative

A

Caused by inflammation in the lung or pleura

  • “Devil” comes from something nasty
  • Pleural lung cancer: Mesothelioma
  • Infection
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16
Q

Airbronchograms

A

Airways stick out , tissue around it has increase densities

-CHF

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17
Q

Causes of Transudative

A

CHF, Cirrhosis of the liver, Atelectasis, CVP line in pleural space, Lymphatic obstruction, Renal Failure, Urinothorax

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18
Q

Causes of Exudative

A

Carcinoma, lymphoma, Mesothelioma, TB, Pneumonia, Drug induced (amiodarone), Yellow nail syndrome??

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19
Q

CHF

A
  • Elevation of pulmonary venous pressure increases the amount of interstitial fluid in the lung
  • With RAPID flooding of the alveoli, you will have pulmonary edema
  • With pleural effusion, the interstitial “lung water” decompresses into the pleural space. SLOW
  • Must correct underlying problem (pump)
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20
Q

Left ventricle fails….

A

=plumbing problem- back up of blood
-Pulm. vasodilation
-Compress and move-pleural space
-Pulmonary effusion
-Hydrostatic Pressure can no longer hold blood in vessel
-Extra Vascular fluid-> interstitial / alveolar: pulmonary edema
=Pink frothy secretions
add pressure: CPAP BIPAP BVM and PEEP VALVE
-Gives the patient and staff time until pump fixed

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21
Q

Therapeutic PEEP

A

10cmH2O

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22
Q

Pneumothorax

A

-Accumulation of air in the pleural space

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23
Q

How pneumothorax happens (Etiology)

A
  1. Air passes through the vessels pleura through the lungs and into the pleural space
  2. Perforation of chest wall and parietal pleura
  3. Gas forming microorganisms (empyema) in the pleural space
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24
Q

Empyema

A

pus

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25
Q

Bleb

A

Small collection of air between the lung and outer surgace of lung (visceral pleural) usually found in the upper lobe of the lung

  • When bleb ruptures= pneumothorax
  • Small subpleural 1-2cm
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26
Q

Bullae

A

no discernible wall more than 1cm

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27
Q

Open pnuemothorax

A

opening in chest wall

  • Stab wound, surgery, gunshot, impalement
  • with or without lung puncture (usually always lung puncture)
  • Exposes pleural space to atmospheric pressure
  • sucking chest wound
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28
Q

Closed pneumothorax

A

Rupture inside

  • Chest wall intact
  • leak through lung and visceral pleura
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29
Q

Pleural pressure

A

-5 (exp/ resting lung)
-8 (inspired)
Vented-> if paralyzed= positive pressure on inspiration

30
Q

Iatrogenic from

A
  • Thoracic Surgery
  • MV
  • Bronchoscope
  • Central line
  • intubation
  • Thoracentesis
  • CPR
31
Q

Pneumothorax types

A
  1. Spontaneous
  2. Traumatic
  3. Iatrogenic- due to med. procedure
32
Q

Spontaneous Pneumo

A

Primary
-No underlying lung disease (blebs in 80%)
-Young patients 20’s: rapid growth spirts, not all required cx tube, tall thin males
Secondary
-Underlying lung disease, COPD/CF/Asthma

chest pain is seen in nearly every patient with a pneumo. Palpation of the chest wall does not worsen the pain

33
Q

Pulmonary contusion

A

bruising

34
Q

Traumatic Pneumo

A 
Penetrating
- gunshot, knife puncture, auto or industrial accident
-Pleural space is in direct contact with atmosphere
Blunt 
-bat, airbag
-rib fracture, non piercing chest trauma
-Piercing into lung parenchyma
-alveolar rupture
35
Q

Tension pneumothorax

A
  • Occurs when air pressure in pleural space is greater than atmospheric pressure
  • lung depressed toward mediastinum
36
Q

50% are diagnosed at bedside, clinical sings of tension pneumo are:

A
  1. Diminished BS on effected
  2. Hyper-resonance to percussion (tap)
  3. Tachycardia
  4. Hypotension
37
Q

Iatrogenic

A

Inadvertently caused by medical tx/ procedure
-Most common causes: Needle aspiration lung biopsy, thoracentesis, CVP catheter placement, Positive pressure ventilation (barotrauma)

-Usually small and self resolve (30 days), monitored with repeated chest xray

38
Q

Flail chest

A

Result of multiple adjacent rib fractures that cause a portion of the chest wall to become free floating

  • Paradoxical movement
  • pulmonary contusion, effusion, pneumothorax are the underlying concerns
  • will have O2 issue
39
Q

Pulmonary Contusion

A

Brusing

  • develops with blunt chest trauma
  • pt history
  • CXR
  • Physical developments
40
Q

Concerns with flail chest

A 
Atelectasis
Hypoxemia
pneumonia
ARDS
Inflammation
Increased mucus production
41
Q

Flail Chest Tx

A 
-Mechanical Ventilation
PEEP stabilizes chest wall from inside
Inhibits atelectasis
Treat pain associated
Correct hypoxemia
improve ventilation
Monitor and assist with secretion clearance

Decrease Vt and increase RR = low chest wall movement and less pressure changes

42
Q

Contraindications for chest tube

A

-No absolutes
-Relative
Infection over insertion site
if it will cause severe bleeding

43
Q

Chest tube complications include

A
  • Bleeding at insertion site
  • Laceration of lung parenchyma or intra abdominal organs
  • Infection
  • formation of blood clots inside chest tube (can cause tension pneumo)
44
Q

Catheter Sizes

A

Adult: 36-40 fr
Teens/ small adults: 28-32 fr
Children/ infants: 12-18 fr

For pneumothoraces size 16-20 may be used for adults

45
Q

Pleurodesis

A

Fuse visceral and periodal pleura- tx chronic pleural effusions

46
Q

Decortication

A

scrape out lung infection

47
Q

Thoracentesis

A

-Needle aspiration
-May contain indwelling catheter
Position sitting up, leaning forward, tripod position) end goal

48
Q

VATS Procedure stands for

A

Video, Assisted, Thoracic, surgery

49
Q

Placement of chest tube

A 
Draining air (pneumothorax)
-2nd or 3rd intercostal space midclavicular or midaxilary line
Draining fluid 
-4th through 6th, away from diaphragm
hemo-towards front
-all chest tubes
50
Q

Pleural effusion vs. Pulmonary edema

A

Effusion-surrounding lung pushing up lung

Edema- In lung, from heart (L), in pulmonary sacs/ alveolar space

51
Q

Treat ARDS on MV

A

Use high peep and low FiO2 or Low PEEP and High FiO2

52
Q

Chest tube point of entry

A
  • Directly over the rib
  • Arteries, veins, and intercostal nerves all lie below each rib
  • Have pt stretch ribs apart: Arm over head, leaning forward, better access/ spreads ribs
53
Q

Methods of Chest Tube placement

A
  1. Operative tube

2 Trocar Tube Thoracostomy

54
Q

Operative tube thoracostomy

A

Bedside

  • larger incision
  • finger/hemostat dissection (blunt disection)
  • safer
55
Q

Trocar tube thoracostomy

A
  • Small incision

- Chance of puncturing lung

56
Q

Trocar

A

Is a sharply pointed instrument for incision into the chest cavity. Needle through the catheter, similar to obturator

57
Q

Three bottle concept, chest tube

A

A. Suction control- attached to suction, filled 20cmH2O which draws in RA, and controls suction
B/C. Waterseal: set to -2cmH20, air cant return, see’s bubbles during pneumothorax
D. Collection Chamber: pneumo=dry, otherwise pulls in pleural fluid

58
Q

When patient is better?

A

Take off suction and leave on just water seal.

Look for zero bubbling and long rei

59
Q

Desired suction applied to pleural space

A

-10 to -20cmH2O

60
Q

Tidaling

A

=Patent Chest tube

  • Change of pressures in the chest cavity (pleural space) during inspiration and expiration
  • During inspiration a greater negative pressure is created in the pleural space sucking water back toward the pt. Intrapleural pressure
  • During expiration the negative pressure returns to resting pressures
61
Q

Intrapleural pressures=

A

-8cmH2O

62
Q

Resting pressures

A

-4cmH2O

63
Q

Good air leaks

A

Pneumothorax- we want the air to be evacuated

64
Q

Safety and trouble shooting

A

Pneumothorax
Bronchopleural fistula
Air leak between chest tube and drainage system
Chest tube is pulled out enough for drain hole to exposed to atmosphere
Insertion site is too large, air will leak into chest cavity
Kinking of the chest tube or loop
gravity dependent, keep chest tube drainage system below chest tube

65
Q

Bronchopleural fistula

A

Leads to large air leaks, tunnel that forms between two organs

66
Q

Kinking of the chest tube will

A

lower the suction level, hinder lung re-expansion, and can potentially cause the fluid to re-enter the pleural space

67
Q

Tx of Spontaneous pneumothorax

A
  • Bedrest or limited physical activity when pneumo is <20%
  • Chest tube when pneumothorax is greater than 20%
  • Gas is reabsorbed within 30 days
  • Monitor CXR, SaO2
  • Risk of atelectasis, alveolar capillary shunting
  • Treat with O2
68
Q

When chest tube is ready to be removed

A
  • Remove suction, place chest tube to water seal
  • Has drainage stopped or less than 100ml over the past 24 hours?
  • Chest Xray
  • Have pt cough or valsalva maneuver, check for leak
  • Undress and remove suture
  • Have pt perform valsalva maneuver
  • pull out tube
  • Cover with occlusive vaseline guaze dressing
  • CXR follow up 4hrs post
69
Q

Why post CXR

A

Check for/ confirm lung re expansion

Detect reoccurence of pneumothorax

70
Q

Which statement about the parietal and visceral pleurae is correct

A

A potential space exists between the two

71
Q

A tension pneumothorax occurs when:

A

Injured tissue forms a one way valve, enabling air to enter the pleural space

Adult Critical Care (5 decks)

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