Thoracic Drainage Unit Flashcards
Pleural
The pleural is a serous membrane meaning it is composed of two layers the visceral and parietal pleura that is filled with fluid, and negative except on forced expiration
Visceral Pleura
The visceral pleura covering the lungs
Parietal Pleural
The parietal pleura covers the ribs and tissue of the chest wall
Where does the Pleural Mett
The pleura will meet at the hilium of the lungs
Fluid in the Pleural Space
The fluid will allow for the lungs to glide over the ribs requiring little energy and produces little friction due to the lubrication the fluid provides
Both the lungs and the chest wall will produce fluid
This fluid is very similar in composition to the interstitial fluid elsewhere in the body
How does the body remove the fluid from the pleural space
The fluid is removed via the stomata in the parietal pleura
Intercostal lymphatics ►mediastinal ►thoracic duct ►left subclavian vein
Pleural Effusion
When there is an abnormal amount of fluid which can be due to either an increased production or impaired removal
Pleural effusions are classified by the content s it is influenced by the cause
Because the pleural space is usually maintained at a negative pressure, fluid moves readily into it.
Transudative Pleural Effusion
No damage to the pleural space
<50% of serum protein levels
LDH <2/3 expected normal
Lactate dehydrogenase <60% of serum levels
Causes of Tansudative Pleural Effusion
Things that cause transudative pleural effusion will increased hydrostatic or decrease oncotic pressure
CHF
Nephrosis
Hypoalbuminea
Liver disease
Lymphatic obstruction
Causes of Exudative Pleural Effusion
Inflammation of lung or pleura -> inflammatory cells & protein
Pleurisy
TB
Cancers
Postoperative
Chylothorax
Hemothorax
70% of all pleural effusions
Physiological Important of Pleural Effusion
- Mechanics of Ventilation
- Enough fluid may result in the collapse of the lung
- Will appear as a restrictive lung disease
- Dyspnea
- Activation of stretch and irritant receptor
- Hyoxemia
Diagnostic Tools for Pleural Effusions
- Chest X-Ray
- Upright will see meniscus at the costophrenic angles
- Most common is to get a lateral decubitus x ray
- Portable ultrasound
- Thoracentesis (aka pleural tap)
- Can be therapeutic and diagnostic
Pneumothorax
Air moving outside in (sucking chest wound)
Can also be air moving inside out
Can be thoracic or spontaneous
Traumatic Pneumothorax
Penetrating or blunt
Iatrogenic (caused by us)
- Mechanical ventilation
- Needle aspiration lung biopsy
- Thoracentesis
- Central Venous Catheter (IJ, SC)
Primary Spontaneous Pneumothorax
No underlying lung disease
Common in people who are tall and slender
If the pneumothorax is small then observe and send home
Secondary Spontaneous Pneumothorax
COPD
Asthma Exacerbation
CF Exacerbation
Usually results in being admitted to the hospital
Tension Pneumothorax
Pleural Space > Atmospheric
Complications of Pneumothorax
Mediastinal Shift
Impaired venous return
Decreased CO
Hypotension with tachycardia
Diaphragm is pressed down
Rub bulge
Hypoxemia
Signs and Symptoms of Tension Pneumothorax
Dyspnea
Cyanosis
Restlessness & agitation
Chest pain
Tachypnea (grunting, nasal flaring & retractions in infants)
Tachycardia (brady as it worsens)
JVD
Hypertensive (hypo as worsens)
Tracheal deviation to the unaffected side
Decreased breath sounds to the effected side
Hyper percussive note over effected side
Unequal chest expansion
Pulsus paradoxus
Diagnosis of Pneumothorax
Chest X-Ray
Requires a high quality film not the typical ICU x-ray which is low quality and supine
Size of Pneumothorax
< 20 % small of lung space-Left to reabsorb 1-2% /day
20-40 % moderate
> 40 % large
Pneumothorax Therapy
- Administer oxygen
- Chest tubes
- Large or small bore catheter
- One way valve Heimlich or under water seal
- Larger catheter insertion require a blunt dissection aka percutaneous thoracostomy
Pneumothorax Emergent Decompression
Needle into 2ndintercostal space, superior edge of rib, mid-clavicular line
Chest Tubes
- 7F-40 F based on physician preference
- Large bore allows for higher flows and are less likely to become blocked
- Fluid
- Gravity dependent
- 5th6thor 7thintercostal space, superior edge of rib, posterior axillary line
- Air:
- Apices
- Large bore 3rdor 4thintercostal space, superior edge of rib, anterior axillary line
- Small bore 2ndintercostal space mid-clavicular line
- Zone of safety: pec/lat triangle
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 and Chest Drainage Can Consist Of
One bottle system
Two bottle system
Three bottle system
Thoracic Drainage Unit- “all-in-one systems”
The three bottles in three bottle thoracic drainage
One control connect suction (vacuum) breaker bottle to the underwater seal bottle
One control connects suction breaker bottle to a suction regulator
The third tube has one end submerged and the other open to the atmosphere
Three bottle system How It Works
If sub-atmospheric pressure in the system is greater than the submerged depth of the tube then atmospheric air will draw into the bottle in order to relieve the vacuum
The tube acts as a vent to limit suction level in the system
As suction increase air is pulled into the tube from the atmosphere and displaces the water in the tube downward
Suction in the chamber will increase until all the water is displaced and air is pulled through the tube, creating bubbles in suction control chamber
What Happens When Air Enters the Three Bottle Thoracic Drainage Unit
Once air enters into the system suction cannot increase
The amount of suction in the system determines by how fat vent tube is in the water
Normal level for suction control chamber
Normal level for suction control chamber is ~20 cmH2O
Increasing the Level of Suction
Increase the amount of suction will increase the speed of bubbling and water loss by evaporation
Will not change the amount of suction
If additional suction is required additional fluid is placed in suction control chamber
Water Level in Suction
Water level checked routinely to ensure prescribed suction maintained
Three Bottle Suction Diagram
Where Should the Chest Drainage Unit Be Placed
Placed below chest level to enhance gravity drainage & minimize risk of drainage being drawn back into chest
Water Seal Chamber
Traditionally will be the middle chamber of the traditional chest drainage system
The main purpose of the water seal is to allow air to exit from the pleural space on exhalation and prevent air from entering the pleural cavity on the mediastinum on inhalation
When the water seal chamber is filled with sterile fluid up to 2 cm line, a 2 cm water seal is established
In order to maintain an effective seal it is important to keep the chest drainage unit upright at all times and to monitor the water level in the water seal to check for evaporation
One Way Valve
A one-way valve can replace the traditional water seal, and no water is required to establish the one way seal it just needs to be connected to the patient’s thoracic catheter and the patients seal is established for the patient protection
Monitoring the Underwater Seal
Bubbling
Bubbling in the water seal chamber indicates that there is an air leak
Make sure to check the patient history and see if there is an air leak
Monitoring the Underwater Seal
Tidaling
Bubbling That Flucuates With Respirations
If it fluctuates with respirations (i.e. occurs on exhalation in a patient breathing spontaneously), the most likely source is the lung.
Intermittent Bubbling
Intermittent bubbling in the underwater seal with expiration and coughing is generally seen until a pneumothorax has been resolved
Continuous Bubbling
Continuously bubbling in the underwater seal is indicative of air being continuously supplied to the system which could be the result of
Causes of Continuous Bubbling
Large active pneumothorax
Bronchopleural fistula
Tension pneumothorax
Leak in the drainage unit itself
No bubbling indicates that
- The lung has re-expanded
- Inadequate water in the water seal chamber and not covering the end of the tube resulting in
- No bubbles
- Air being sucked through the tube into the pleural space
- Knots, kinks, clots, clamp causing obstruction in the system
- Chest tube not able to drain pneumothorax as it is not in a good place
High negative pressure in thoracic drainage unit can be the result of
The patient in respiratory distress, coughing, vigorous, or crying
Chest tube stripping
Decreasing or disconnecting suction
Air Leak Meter
The air leak meter indicates the approximate degree of air leak from the chest cavity
The meter is made up of numbered column labeled from 1 (low) to 7 (high)
The higher the number column through which bubbling occurs the greater the degree of air leak
The number should be documented in order to see whether the air leak is getting smaller or bigger
Keeping the Drainage Tubes Patent
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.
If there is no tidaling, what may be the cause?
Obstruction
Check the UWS periodically to ensure there is water in it!
Testing the Tube for Leaks
Use a padded clamp and begin at the dressing and progressively clamp and release the drainage tubing momentarily while you look at the water seal/air leak meter chamber
When you place clamps 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
Wet Suction Control
The chamber on the left side of the unit is the suction control chamber
Traditional chest drainage units will regulate the amount of suction by the height of the column of water in the suction control chamber
It is the height of the water not the suction source setting that limits the amount of suction transmitted into the pleural cavity
Gravity Drainage
Not all patients will require suction
Suction may be discontinued during transport or 24 hours before chest tube removal
If suction has been discontinued then the suction tube or port should remain UNCAPPED and free from OBSTRUCTIONS to allow air to exit and minimize the possibility of tension pneumothorax
Waterless (Dry) Suction Control Chambers
Most common today
A mechanical screw type valve or calibrated spring mechanism is used to regulate suction
Will place a precise amount of tension on the spring on top of the chamber, which is open to the atmosphere
The spring will pull on the rubber seal that closes off opening and prevents air from the atmosphere from moving into the chamber
The higher the suction setting the more tension place on the spring and the more firmly it will pull the seal to close opening
The suction source is connected to the bottom part of the chamber via the internal channel
When the level of suction matches the selected setting the negative pressure in the bottom of the chamber is high enough to pull rubber seal off opening
Allows air to enter from the top of the chamber and offset any further suction
Advantage of Dry Suction Control
Higher suction pressure can achieved
Set up is easy
No continuous bubbling allowing for quiet operation
No fluid to evaporate which would decrease the amount of suction applied to the patient
Setting Up Chest Drainage Systems
Fill water seal chamber to the appropriate level ~2 cmH2O
Adjust the suction control chamber to the appropriate suction level (physician specified)
While wearing sterile gloves, connect the chest drainage until to thoracostomy tube without contaminating the inner diameter of the tube
Secure the tube and chest drainage until connection with water proof tapes
Tighten all connection and secure them
Inspect the water seal chamber and observe fluctuation within the tube
Should be consistent with the patient breathing pattern
Slowly apply suction from the suction source
Ensure that moderate and gentle bubbling in suction control chamber
Observe initial drainage
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
Assessment of chest drainage system must therefore be part of routine patient assessment
What Do You Document when Monitoring Chest Tubes
Presence or absence of air leak
Color and consistency of drainage
Amount of drainage
Clamping Chest Tubes
Indications
If a chest tube falls out of position (knocked over) or is inadvertently pulled out (occlusive dressing)
Locate source of leak
When replacing full or cracked collection chamber
If the thoracic drainage unit gets knocked over and loses its seal
Before removing chest tube to assess if patient can tolerate removal of chest tube
Clamping the Chest Tube
Clamp only momentarily, as clamping halts air and fluid evacuation from pleural space
Possible Negative Side Effects of Chest Tubes
Maintenance
- Infections
- Sterile technique when possible
- Blockage
- Milking via compression and twisting will dislodge small clots etc
- Stripping can generate negative pressure of ~400 mmHg and cause tissue damage
- Changing insertion site is not uncommon in an extended case
Possible Negative Side Effects of Chest Tubes
Drainage
Too quick may result in vessel rupture on the unaffected side
Possible Negative Side Effects of Chest Tubes
Chest Tube Insertion
Trauma
Puncture the visceral pleura, mediastinum, organ, vessels, nerve tissue, sub-Q emphysema
