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Flashcards in Thoracic Drainage Deck (47):

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




Outside -> in (sucking chest wound)

Inside-> out

Traumatic or spontaneous



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.


  • 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


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




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
  • 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

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.



Variable practice

Egan’s: 48 hrs with no leak seen in UWS

Clamping 4 hrs & xray showing reexpansion