Thoracic Drainage Flashcards
Pleural Space
Fluid filled space between the visceral and parietal pleura
Will be negtaive except during a forceful expiration(vasalva manuver, cough, maybe in PPV)
The pleura are serous membranes. The visceral pleura cover the lungs, while the parietal pleura covers the ribs and tissue of the chest wall. The pleura will meet at the hilum of the lungs
Fluid allows for a gliding motion, allows the lungs to slide over the ribs, takes little energy & produces little friction (lubricated).
Both the lung & chest wall produce fluid
Pleural Effusion
Abnormal/ Excessive amount of fluid; either increased production or impaired removal
Will be classified by the content, which is influenced by the cause. We will take a sample to see what is in the fluid (hemothorax, emphiema [infection])
Because the pleural space is usually maintained at a negative pressure, fluid moves readily into it.
Transudative Pleural Effusion
- There is no damage to the pleural space
- Increased hydrostatic or decrease oncotic pressure.
- The hydrostatic pressure will push normal pleural fluid pass the membrane shifting out proteins (excessive amount of normal pleural fluid.
- Can be caused by CHF, Nephrosis, hypoalbuminea, liver disease, and lymphatic obstruction.
- Latcate dehydrogenase will be < 60% serum levels
Exudative Pleural Effusion
There is inflammation on the lung or the pleura, which results on cells and proteins being in the pleural fluid.
Will disrupt the pleural membrane
70% of all pleural effusions.
If there is enough fluid it can collapse the lung and cause a restrictive PFT
Exudative Causes
- Parapneumonic: Fibrin loculated
- Pleurisy
- Postoperative
- Cancers
- Cylothorax
- Connective tissue diseases
- Hemothorax
- TB
Diagnostic Testing for Effusion
- Chest Xray
- Upright: meniscus at costophrenic angle
- Ultrasound: portable
- CT: definitive
- Thoracentesis aka pleural tap
- After we know there is fluid where it is not supposed to be we then do a thoracentesis
- Therapeutic & diagnostic
- When doing it go over a rib and not under do you don’t damage the vessel under the rib
Pneumothorax
Air
Outside -> in (sucking chest wound)
Inside-> out
Traumatic or spontaneous
TRAUMATIC PNEUMOTHORAX
Open “sucking” pneumothorax
Cause by an opening in the chest wall that is larger in diameter than trachea (for clinical compromise)
Communication between pleural space and atmosphere
To sustain ventilation the wound occluded or made smaller than diameter of trachea
In a chest x-ray there will be a tracheal shift
Can be penetrating or blunt
Iatrogenic Pneumothorax
Iatrogenic pneumothorax is a complication of medical or surgical procedures. It most commonly results from transthoracic needle aspiration.
Causes
- Mechanical ventilation
- Needle aspiration lung biopsy
- Thoracentesis
- Central venous catheter
- IJ
- SC
Spontaneous Pneumothorax
- Primary: no underlying lung disease
- Tall slender, late teens or early 20s
- If small, observed & sent home (will only be kept at ospital is there is other underlying diseases)
- Secondary: with underlying lung disease
- COPD (emphysema)
- Asthma exacerbation
- CF exacerbation
- Usually admitted to hospital
Complications of Pneumothoraxs
- Tension: pleural space > atmospheric
- Greatest risk from pleural effusion due to the time sensitivity
- There is no means of escape
- Mediastinal shift (from tension penuom)
- Torsion on IVC
- Impaired venous return
- Decreased CO
- Hypotension with tachycardia
- Diaphragm pressed down
- Ribs bulge
- Shunting through collapsed lung -> hypoxemia
Late Signs of Shock
Late signs of shock is decreased BP and tracheal shift
Recognition of a Tension Pneumothorax
- Dyspnea
- Cyanosis
- Restlessness & agitation
- Chest pain
- Tachypnea (grunting, nasal flaring & retractions in infants)
- Tachycardia (brady as worsens)
- JVD
- Hypertensive (hypo as worsens)
- Tracheal deviation to the unaffected side
- Decreased breath sounds to the effected side
- Hypertympanic percussive note over effected side
- Unequal chest expansion
- Pulsus paradoxus
- Sub q
Emergant Decompression
- Needle into 2nd intercostal space, superior edge of rib, mid-clavicular line
Re-Expansion Pulmonary Edema
- When you expand the lung too fast
- Fluid in the lung contains protein … vascular injury
- If not an emergency, reexpansion should be undertaken cautiously.
- Underwater seal without suction
- Pleural effusions
- 1000 mls at a time
Diagnosis of Pneumothorax
- High quality chest x-ray (not just the typical ICU xray)
- Size (American College of Physicians)
- < 20 % small of lung space
- Left to reabsorb 1-2% /day
- Maybe will leave it as long as it is not getting worse
- 20-40 % moderate
- > 40 % large
- < 20 % small of lung space
Therapy of Pneumothorax
- Administer oxygen
- Make sure to pre oxygenate pt.
- Chest tubes
- Large or small bore catheter
- One way valve-Heimlich or underwater seal
- Larger catheter insertion requires blunt dissection aka percutaneous thoracostomy
Chest tubes
- 7 F- 40 F
- Physician preference
- Larger bore allows higher flows & less likelihood of blockage
- Fluid:
- Gravity dependant
- 5th 6th or 7th intercostal space, superior edge of rib, posterior axillary line
- Air:
- Apices
- Large bore 3rd or 4th intercostal space, superior edge of rib, anterior axillary line
- Small bore 2nd intercostal space midclavicular line
Chest Tube Insertion
Sterile Procedure: cleansed & draped
Local anesthetic injected into insertion site
Cut parallel to rib
Superior surface
Blunt forceps to separate muscle fibers
Puncture parietal pleura
Finger to palpate
Insert tube & connect to collection chamber
Suture
Dress
Thoracic/Chest Drainage
Can consist of a:
- One bottle system
- Two bottle system
- Three bottle system
Thoracic Drainage Unit
“all-in-one systems”
One Bottle System
Aka Under Water Seal
The distal end of the drainage tubing is placed ~ 2 cm beneath the surface of a sterile fluid
The fluid will prevent atmospheric air from being drawn into the pleural space
Air from the pleural space will displace the smll amount of water in tubing and escape by bubbling out into the liquid in the bottle and venting to the atmosphere
Liquid from the pleural space will drain into gravity
Provides a one way path as slightly positive pressure in pleural space during forced exhalation or coughing (> 2 cmH2O) moves air out of pleural space through tubing
Submerging the end establishes a water seal, allows the escape of air, and prevents the re-entry of air.
Problems with the One Bottle System
As the level of drainage rises there will in an increase in pressure required in the thorax in order to evacuate the air which in turn will result in a large increase in WOB
e.g. if tube 25 cm below surface of water, 25 cmH2O pressure required to empty air or fluid from pleural space
Frequent monitoring necessary to readjust depth of submerged tube (never be > 2 cms below surface of water)
A way to solve these problems is to add a second bottle
Two Bottle System
The two bottles are a collection chamber and an underwater seal
The patient tubing from the chest tube will connect to a collection chamber which then connects to an under water seal
Fluid/air removed from thoracic cavity is drained first into collection chamber
Fluid remains in the collection chamber while air rises and exits towards the underwater seal
Allows for more accurate observation and measurement of drained fluid
Tube venting to atmosphere never clamped
Three Bottle System
- Gravity drainage not enough to drain fluid and re-expand lung so suction is applied to assist drainage process
- Another bottle added to two bottle system called suction control bottle or vacuum- breaker bottle
- If sub-atmospheric pressure in system > submerged depth of tube, atmospheric air is drawn into bottle to relieve vacuum. So the tube will act as a vent to limit suction in the system
- Once air enters into the system suction is unable to increase
- Amount of suction will determine how far the vent tube is in the water
- The normal level for suction control chamver is ~20 cmH20
- Water level should be routinely check in order to ensure prescribed suction maintainance
- After initial insertion, volume should be checked every 15 minutes
Three Tubes in the Three Bottle System
The suction control or breaker bottle has three tubes
One tube connects suction (vacuum) breaker bottle to the underwater seal bottle
Another connects suction breaker bottle to a suction regulator
The third tube has one end submerged & the other open to atmosphere
What Happends when You Increase Suction in the 3 Bottle System
Increase suction will increase the speed of bubbling and water loss by evaporation
Does not change the amount of suction
If additional suction is required, additional fluid placed in suction control chamber
What is Something that need immediate reporting
Large volumes of 500- 1000cc of bright red blood with few clots is evidence of active bleeding thus should be reported ASAP
Surgical intervention may be required & IV volume or blood may be administered
Where Should Three Bottle System be Placed
Placed below chest level to enhance gravity drainage & minimize risk of drainage being drawn back into chest
Ensuring Proper Function & Trouble Shooting in 3 bottle System
- The collection chamber
- Lack of drainage into the collection chamber
- Getting a sample for C & S
- Changing the unit
- Monitoring the underwater seal
- Tidaling
- Is there bubbling or not?
What Might be the Cause if Drainage Has Suddenly Stopped
If the drainage has been tapering off over the past few shifts, lack of drainage may be normal.
To keep the tubes patent, or to dislodge clots, gently milk the tube.
Check tubing for kinks or bends. Make sure tube is not clamped.
The Under Water Seal
- In a patient with a pleural chest tube, “tidaling” is normal.
- On inspiration:
- Towards the pleural space in a spontaneously breathing patient
- Away from the pleural space in a mechanically ventilated patient
- On inspiration:
- Check the UWS periodically to ensure there is water in it!
If there is no tidaling, consider
1) An occlusion somewhere between the pleural cavity and the water seal,
2) Full expansion of the lung where suction has drawn the lung up against the holes in the chest tubes,
Bubbling in Underwater Seal
- Check patient history. Would you expect a patient air leak?
- If not, identify the source of the air leak:
- Check and tighten connections.
- If the leak may be at the insertion site, remove the chest tube dressing and inspect the site. Make sure the catheter eyelets have not pulled out beyond the chest wall.
- Test the tubing for leaks.
- If leak is in the tubing, replace the unit.
Test the tubing for Leaks.
Using a padded clamp, begin at the dressing and progressively clamp & release the drainage tubing momentarily while you look at the water seal/air leak meter chamber.
When you place the clamp between the source of the air leak and the water seal/air leak meter chamber, the bubbling will stop. If bubbling stops the first time you clamp, the air leak must be at the chest tube insertion site or the lung.
No air leak indicates:
- Lung totally re- expanded
- Inadequate water in water seal chamber, not covering end of tube resulting in:
- No bubbles
- Air being sucked through tube into pleural space
- Knots, kinks, clots, clamp causing obstruction in system
Is the bubbling continuous or
intermittent?
It is important to note the pattern of bubbline
If the bubbling flucuates with respirations (occurs on exhalation in a patient breathing spontanesouly), then the most likely source is the lung
Document the magnitude of a patient air leak using the air leak meter. The higher the numbered column through which the bubbling occurs, the greater the degree of air leak. If bubbling is noted in the first two column of airleak meter, document “Airleak 2”
Intermittent Bubbling
Intermittent bubbling in underwater seal with expiration and coughing is generally seen until pneumothorax resolved
Continuous Bubbling
Continuous bubbling in underwater seal is indicative of air being continuously supplied to system
Large active pneumothorax
Bronchopleural fistula
Tension pneumothorax-When pressure can not escape
OR a Leak in the drainage system itself
Chest Tube With an Active Pneumothorax
Chest tubes with active pneumothorax not clamped unless to change unit or to rule out equipment leak
Activity in Under Water Seal Chamber
Activity in under water seal chamber will indicate if pneumothorax resolved
Usually chest tubes left in place until no air leak with cough for 24-48 hours
Waterless (dry) suction control chambers
Mechanical screw type valve used to regulate suction by varying size of its opening to suction source
Calibrated spring mechanism- suction set to various levels by turning dial on side of suction control chamber
It places precise amount of tension on spring on top of chamber, which is open to atmosphere
Spring pulls on rubber seal that closes off opening and prevents air from atmosphere moving into chamber
The higher the selection suction setting, the more the tension placed on spring and the more firmly it pulls the seal to close opening Suction source connected to bottom part of chamber via internal channel
When level of suction matches selected setting, negative pressure in bottom of chamber is high enough to pull rubber seal off opening
Allows air to enter from top of chamber and offset any further suction
Advantages of Dry Suction
One less chamber to fill with water
No problems with evaporation from suction control chamber
Quiet operation
Setting Up Chest Drainage Systems
- Thoracostomy tube insertion: sterile procedure (full PPE)
- Common procedures for most brands of chest drainage units:
- Fill water seal chamber to appropriate level ~ 2 cmH2O
- Adjust suction control chamber to appropriate suction level (physician specified) in dry system OR fill suction control chamber with sterile water to appropriate level in wet system
- Wearing sterile gloves, connect chest drainage unit to thoracostomy tube w/o contaminating ID of tube
Chest Drainage System Procedure
Secure tube and chest drainage unit connection with water proof tape
Tighten all connections and secure them
Inspect water seal chamber and observe fluctuations within tube
Should be consistent with patient’s breathing pattern
Slowly apply suction from suction source
Ensure moderate and gentle bubbling in suction control chamber
Observe amount of initial drainage
Too much drainage too quickly can lead to patient complications- shock
Clamping Chest Tubes
- Clamping chest tube is only indicated:
- If chest tube falls out of position or is inadvertently pulled out (occlusive dressing)
- To locate source of leak
- When replacing full or cracked collection chamber
- If thoracic drainage unit gets knocked over and loses its seal
- Before removing chest tube to assess if patient can tolerate removal of chest tube
- Clamp only momentarily, as clamping halts air and fluid evacuation from pleural space
Monitoring Chest Drainage Units
- Chest drainage system is extension of patient’s pleural space
- An improperly functioning system can prevent removal of fluid or air from pleural space
- It can also add air or fluid into pleural space
- Assessment of chest drainage system must therefore be part of routine patient assessment
- Performed every 12 hours and following documented:
- Presence or absence of air leak
- Color and consistency of drainage
- Amount of drainage
- Inspect tubing to determine:
- If all connections are tight and properly taped
- Any kinks or compressions of tubing or dependant loops exist
- Creat resistance to drainage
- Level of water in suction control chamber (wet)
- Level of water and water fluctuation in under water seal chamber
Possible Negative Side Effects
- Chest tube insertion:
- Trauma: puncture of visceral pleura, mediastinum, organs, vessels, nerve tissue, sub-Q emphysema.
- Drainage:
- Too quick can cause vessel rupture on unaffected side.
- Maintenance:
- Infections: Sterile technique when possible.
- Blockage: milking via compression and twisting will dislodge small clots etc. Stripping can generate negative pressures of –400 mmHg and cause tissue damage. Changing insertion site is not uncommon in an extended case.
Removal
Variable practice
Egan’s: 48 hrs with no leak seen in UWS
Clamping 4 hrs & xray showing reexpansion
