Test 3 Flashcards
Reasons for chest tube
Fluid in Pleural space Pneumo Hole in lung Surgical Rib Fracture MVA CABG Loculated infusion Trauma High positive pressure Empyema Infection
Indications for chest tube
To remove air (pneumo) or fluid from the pleural space in the chest wall Pneumo hemothorax Hemo-pneumothorax hole in lung
Chest wall anatomy
Visceral pleura
Parietal Pleura
-The parietal and visceral pleura are connected at the lung hilum
Norm Pleural fluid in a healthy adult is
approx 8ml hemi-thorax
Mediastinum
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
Lungs Position
located in the thoracic cavity by both sides of mediastinum
Apex of lung
Rises 2-3 cm above the medial third of clavicle into neck
Diaphragmatic surface
base of lung. Concave, related to diaphragm
Costal Surface
large, convex, related to thoracic wall
The pleura
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
Good xray
- 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
Stomata
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
Pleural Effusions results when
the capacity of pleural lymphatic drainage is overcome with transudative or exudative occurance
Pleural effusion: Transudative
Occurs when the integrity of the pleural space is undamaged
- “train” fluid has to come from something else
- CHF
Pleural Effusion: exudative
Caused by inflammation in the lung or pleura
- “Devil” comes from something nasty
- Pleural lung cancer: Mesothelioma
- Infection
Airbronchograms
Airways stick out , tissue around it has increase densities
-CHF
Causes of Transudative
CHF, Cirrhosis of the liver, Atelectasis, CVP line in pleural space, Lymphatic obstruction, Renal Failure, Urinothorax
Causes of Exudative
Carcinoma, lymphoma, Mesothelioma, TB, Pneumonia, Drug induced (amiodarone), Yellow nail syndrome??
CHF
- 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)
Left ventricle fails….
=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
Therapeutic PEEP
10cmH2O
Pneumothorax
-Accumulation of air in the pleural space
How pneumothorax happens (Etiology)
- Air passes through the vessels pleura through the lungs and into the pleural space
- Perforation of chest wall and parietal pleura
- Gas forming microorganisms (empyema) in the pleural space
Empyema
pus
Bleb
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
Bullae
no discernible wall more than 1cm
Open pnuemothorax
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
Closed pneumothorax
Rupture inside
- Chest wall intact
- leak through lung and visceral pleura
Pleural pressure
-5 (exp/ resting lung)
-8 (inspired)
Vented-> if paralyzed= positive pressure on inspiration
Iatrogenic from
- Thoracic Surgery
- MV
- Bronchoscope
- Central line
- intubation
- Thoracentesis
- CPR
Pneumothorax types
- Spontaneous
- Traumatic
- Iatrogenic- due to med. procedure
Spontaneous Pneumo
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
Pulmonary contusion
bruising
Traumatic Pneumo
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
Tension pneumothorax
- Occurs when air pressure in pleural space is greater than atmospheric pressure
- lung depressed toward mediastinum
50% are diagnosed at bedside, clinical sings of tension pneumo are:
- Diminished BS on effected
- Hyper-resonance to percussion (tap)
- Tachycardia
- Hypotension
Iatrogenic
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
Flail chest
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
Pulmonary Contusion
Brusing
- develops with blunt chest trauma
- pt history
- CXR
- Physical developments
Concerns with flail chest
Atelectasis Hypoxemia pneumonia ARDS Inflammation Increased mucus production
Flail Chest Tx
-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
Contraindications for chest tube
-No absolutes
-Relative
Infection over insertion site
if it will cause severe bleeding
Chest tube complications include
- Bleeding at insertion site
- Laceration of lung parenchyma or intra abdominal organs
- Infection
- formation of blood clots inside chest tube (can cause tension pneumo)
Catheter Sizes
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
Pleurodesis
Fuse visceral and periodal pleura- tx chronic pleural effusions
Decortication
scrape out lung infection
Thoracentesis
-Needle aspiration
-May contain indwelling catheter
Position sitting up, leaning forward, tripod position) end goal
VATS Procedure stands for
Video, Assisted, Thoracic, surgery
Placement of chest tube
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
Pleural effusion vs. Pulmonary edema
Effusion-surrounding lung pushing up lung
Edema- In lung, from heart (L), in pulmonary sacs/ alveolar space
Treat ARDS on MV
Use high peep and low FiO2 or Low PEEP and High FiO2
Chest tube point of entry
- 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
Methods of Chest Tube placement
- Operative tube
2 Trocar Tube Thoracostomy
Operative tube thoracostomy
Bedside
- larger incision
- finger/hemostat dissection (blunt disection)
- safer
Trocar tube thoracostomy
- Small incision
- Chance of puncturing lung
Trocar
Is a sharply pointed instrument for incision into the chest cavity. Needle through the catheter, similar to obturator
Three bottle concept, chest tube
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
When patient is better?
Take off suction and leave on just water seal.
Look for zero bubbling and long rei
Desired suction applied to pleural space
-10 to -20cmH2O
Tidaling
=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
Intrapleural pressures=
-8cmH2O
Resting pressures
-4cmH2O
Good air leaks
Pneumothorax- we want the air to be evacuated
Safety and trouble shooting
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
Bronchopleural fistula
Leads to large air leaks, tunnel that forms between two organs
Kinking of the chest tube will
lower the suction level, hinder lung re-expansion, and can potentially cause the fluid to re-enter the pleural space
Tx of Spontaneous pneumothorax
- 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
When chest tube is ready to be removed
- 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
Why post CXR
Check for/ confirm lung re expansion
Detect reoccurence of pneumothorax
Which statement about the parietal and visceral pleurae is correct
A potential space exists between the two
A tension pneumothorax occurs when:
Injured tissue forms a one way valve, enabling air to enter the pleural space
