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Interventions 3 > Thoracic Drainage Unit > Flashcards

Thoracic Drainage Unit Flashcards

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1
Q

Pleural

A

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

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2
Q

Visceral Pleura

A

The visceral pleura covering the lungs

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3
Q

Parietal Pleural

A

The parietal pleura covers the ribs and tissue of the chest wall

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4
Q

Where does the Pleural Mett

A

The pleura will meet at the hilium of the lungs

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5
Q

Fluid in the Pleural Space

A

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

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6
Q

How does the body remove the fluid from the pleural space

A

The fluid is removed via the stomata in the parietal pleura

Intercostal lymphatics ►mediastinal ►thoracic duct ►left subclavian vein

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7
Q

Pleural Effusion

A

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.

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8
Q

Transudative Pleural Effusion

A

No damage to the pleural space

<50% of serum protein levels

LDH <2/3 expected normal

Lactate dehydrogenase <60% of serum levels

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9
Q

Causes of Tansudative Pleural Effusion

A

Things that cause transudative pleural effusion will increased hydrostatic or decrease oncotic pressure

CHF

Nephrosis

Hypoalbuminea

Liver disease

Lymphatic obstruction

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10
Q

Causes of Exudative Pleural Effusion

A

Inflammation of lung or pleura -> inflammatory cells & protein

Pleurisy

TB

Cancers

Postoperative

Chylothorax

Hemothorax

70% of all pleural effusions

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11
Q

Physiological Important of Pleural Effusion

A
  • 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
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12
Q

Diagnostic Tools for Pleural Effusions

A
  • 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
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13
Q

Pneumothorax

A

Air moving outside in (sucking chest wound)

Can also be air moving inside out

Can be thoracic or spontaneous

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14
Q

Traumatic Pneumothorax

A

Penetrating or blunt

Iatrogenic (caused by us)

  • Mechanical ventilation
  • Needle aspiration lung biopsy
  • Thoracentesis
  • Central Venous Catheter (IJ, SC)
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15
Q

Primary Spontaneous Pneumothorax

A

No underlying lung disease

Common in people who are tall and slender

If the pneumothorax is small then observe and send home

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16
Q

Secondary Spontaneous Pneumothorax

A

COPD

Asthma Exacerbation

CF Exacerbation

Usually results in being admitted to the hospital

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17
Q

Tension Pneumothorax

A

Pleural Space > Atmospheric

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18
Q

Complications of Pneumothorax

A

Mediastinal Shift

Impaired venous return

Decreased CO

Hypotension with tachycardia

Diaphragm is pressed down

Rub bulge

Hypoxemia

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19
Q

Signs and Symptoms of Tension Pneumothorax

A

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

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20
Q

Diagnosis of Pneumothorax

A

Chest X-Ray

Requires a high quality film not the typical ICU x-ray which is low quality and supine

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21
Q

Size of Pneumothorax

A

< 20 % small of lung space-Left to reabsorb 1-2% /day

20-40 % moderate

> 40 % large

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22
Q

Pneumothorax Therapy

A
  • 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
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23
Q

Pneumothorax Emergent Decompression

A

Needle into 2ndintercostal space, superior edge of rib, mid-clavicular line

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24
Q

Chest Tubes

A
  • 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
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25
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
26
Thoracic and Chest Drainage Can Consist Of
One bottle system Two bottle system Three bottle system Thoracic Drainage Unit- “all-in-one systems”
27
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
28
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
29
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
30
Normal level for suction control chamber
Normal level for suction control chamber is ~20 cmH2O
31
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
32
Water Level in Suction
Water level checked routinely to ensure prescribed suction maintained
33
Three Bottle Suction Diagram
34
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
35
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
36
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
37
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
38
Monitoring the Underwater Seal Tidaling
39
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.
40
Intermittent Bubbling
Intermittent bubbling in the underwater seal with expiration and coughing is generally seen until a pneumothorax has been resolved
41
Continuous Bubbling
Continuously bubbling in the underwater seal is indicative of air being continuously supplied to the system which could be the result of
42
Causes of Continuous Bubbling
Large active pneumothorax Bronchopleural fistula Tension pneumothorax Leak in the drainage unit itself
43
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
44
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
45
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
46
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.
47
If there is no tidaling, what may be the cause?
Obstruction Check the UWS periodically to ensure there is water in it!
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
What Do You Document when Monitoring Chest Tubes
Presence or absence of air leak Color and consistency of drainage Amount of drainage
56
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
57
Clamping the Chest Tube
Clamp only momentarily, as clamping halts air and fluid evacuation from pleural space
58
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
59
Possible Negative Side Effects of Chest Tubes Drainage
Too quick may result in vessel rupture on the unaffected side
60
Possible Negative Side Effects of Chest Tubes Chest Tube Insertion
Trauma Puncture the visceral pleura, mediastinum, organ, vessels, nerve tissue, sub-Q emphysema

Interventions 3 (34 decks)

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