Chest Tube Drainage Systems

Exchange of oxygen and carbon dioxide in the lungs depends on effective ventilation and adequate circulation of blood through both lungs. The amount of surface areas available for diffusion greatly affects gaseous exchange. Ventilation brings oxygen into the lungs where it is released into the alveoli in exchange for the carbon dioxide, which has been deposited by the capillaries. If ventilation is not uniform throughout both lungs, the rate of oxygen replenishment is reduced, leading to hypoxia. This situation occurs in the presence of air in the pleural cavity called pneumothorax. Air in this normally closed space will disrupt the negative pressure that keeps the lung from collapsing at the end of exhalation. Under normal conditions, the thoracic cavity is a closed, airtight space. Any disruption will result in a loss of negative pressure, within the intrapleural space. Air and/or fluid collect, taking up the space within the pleural cavity that the lungs need in order to expand. The result is partial or total collapse of the lung. Conditions that disrupt the normally negative pressure within the pleural space, either because of disease, injury, surgery, or iatrogenic causes, will result in loss of negative pressure. The introduction of air into the pleural cavity can quickly lead to lung collapse. The evacuation of air or fluid or both from the pleural cavity is accomplished through a closed drainage system.

Anatomy and Physiology

It is important to review the normal anatomy and physiology of the thorax to understand what can goes wrong in the structure and function of the chest and how these problems can be treated. The thoracic cavity is divided into three compartments: one compartment for each of the lungs and the mediastinum that lies between the lungs. The ribs, sternum, and intercostal muscles protect these structures. The main muscles of the chest wall are the external and internal intercostals. Each extends from one rib to the rib below. The function of the external intercostals is to draw the ribs together and elevate the rib cage, which enlarges the thoracic cavity, while the internal intercostals decrease the dimension of the thoracic cavity. The main muscle of respiration is the diaphragm. It stretches across the bottom of the thorax, separating the thoracic cavity from the abdominal cavity. The mediastinum contains the thymus gland, the great vessels, the thoracic duct and small lymph nodes, the heart, a branch of the phrenic nerve, and parts of the trachea and esophagus. The two membranes surrounding the lungs are the parietal pleura, which lines the chest cavity and the visceral pleura, which covers the lungs. These two membranes are lubricated so that they glide against each other. The space between these two membranes has a negative pressure and contains neither air nor fluid. Collection of either of these substances can interfere with breathing and may cause the lung to collapse. Problems in the pleural cavity include pneumothorax (air in the cavity, hemothorax (blood in the cavity), hemo-pneumothorax (both blood and air in the cavity and Atelectasis (the collapse of lung tissue). Between these two membranes is the pleural space, which is not a true space but rather contains a thin layer of serous fluid. This fluid acts as a lubricant to keep the parietal and visceral membranes in contact with each other during respiration, allowing them to slide smoothly over one another. The potential exists for a space between these two membranes; hence it is called the pleural space. The lungs and chest wall contain elastic tissue that tends to pull in opposite directions, the lungs pulling inward and the chest wall pulling outward. Air moves in and out of the thorax based on pressure changes. When the phrenic nerve stimulates the diaphragm, it contracts and moves downward. The external intercostal muscles also move the rib cage up and out. The lung itself expands because of the movement of the diaphragm and the chest wall. The surface tension of the pleural fluid holds the pleura together, thus keeping the lungs from collapsing. As these opposing forces try to pull the parietal and visceral pleura apart, a negative pressure is created within the pleural space. This negative intrapleural pressure keeps the pleural surfaces in contact, holding the lung against the chest wall and expanding the lungs to fill the pleural compartment completely. The intrapleural pressure must remain negative at all times in order to keep the lungs fully expanded. The extent of negative intrapleural pressure depends on the phase of respiration. At rest, the intrapleural pressure is 5 cmH2O and the intrapulmonary pressure (pressure in the alveoli) equal atmospheric pressure. During inspiration, the thoracic cavity enlarges, decreasing intrapleural pressure to 6 to 12 cm H2O and lowering intrapulmonary pressure 2 to 3 cm H2O less than the atmosphere, causing air to be drawn into the lungs. During expiration, the intrapleural pressure increases to 4 to 8 cm H2O and intrapulmonary pressure

increases 2 to 3 cm H2O greater than the atmosphere, causing air to be passively forced out of the lungs.

Pneumothorax
Pneumothorax is the presence of air in the pleural cavity. Air in this normally closed space will disrupt the negative pressure that keeps the lungs from collapsing at the end of exhalation. The introduction of air into the pleural cavity can quickly lead to lung collapse. There are two main types of pneumothorax: closed and open. A closed pneumothorax occurs when the outer chest wall and parietal pleura remain intact, but damaged visceral pleura allows air to enter the pleural cavity from the lung, An open pneumothorax occurs when an opening in the outer chest wall allows air to enter the pleural cavity from the outside rather than (or in addition to) from the lung. This can result from damage to either the parietal pleura alone or to both pleural membranes. Spontaneous pneumothorax is usually caused by the rupture of a small bleb (an enlarged air sac) on the lungs surface. It most typically occurs in young tall males and may be caused by the mechanical stresses that occur at the top of a long, upright lung. It may also result from intrapulmonary disease processes that weaken the lung, making it more prone to rupture. Such diseases include emphysema, cystic fibrosis, tuberculosis, and necrotizing pneumonia. Iatrogenic pneumothorax has two major causes. One is the use of positive pressure ventilation such as intermittent positive pressure breathing (IPPB) treatments. In patients with weakened lung tissue, the addition of positive pressure to the lung can overstretch damaged, friable lung tissue and cause rupture. High-pressure mechanical ventilation sometimes used to treat respiratory failure such as adult respiratory distress syndrome (ARDS) can also cause pneumothorax. The positive end expiratory pressure (PEEP) used to prevent alveolar collapse can cause alveolar rupture. The second major iatrogenic cause is unintentional lung perforation during invasive procedures such as thoracentesis and central venous catheter placement, especially placement through the subclavian access. Tension pneumothorax can be caused by patients receiving positive pressure ventilation, especially with high levels of PEEP (over 15 cm H2O). Tension pneumothorax occurs when air rapidly accumulates in the pleural cavity and cannot be evacuated as quickly. Pressure builds up, which not only collapses the lung, but can also shift the mediastinum and severely impede venous return and cardiac output. A tension pneumothorax is life threatening and must be relieved promptly. Signs of tension pneumothorax in a mechanically ventilated patient include shortness of breath, decreased breath sounds on one side, hyperresounance to percussion, sudden sustained increase in the inspiratory pressure on the ventilators manometer (with simultaneous sounding of the high pressure alarm), a deviated trachea, and lack of movement on that side of the chest. Patients with chronic lung disease should be given positive pressure ventilation with caution. Open pneumothorax occurs when the outer chest was has been penetrated. The most common cause is trauma gunshot wounds, stab wounds, and crushing chest injuries. Blunt trauma to the chest wall can cause rib fractures that can, in turn, puncture the lung and cause pneumothorax by allowing air to leak out of the lung into the pleural cavity. Penetrating trauma such as gunshot or stab wounds cause open pneumothorax, commonly called sucking chest wounds. A patients signs and symptoms will vary greatly with the magnitude of the injury and the damage to underlying structures. The pneumothorax is often less serious than the damage to major structures such as a ruptured aorta or other vascular damage. Another type of open pneumothorax occurs with intentional chest trauma, as with thoracic surgery. The pleural cavity is disrupted as soon as the chest wall is opened. Pneumo-mediastinum is the term given to the presence of air in the mediastinum. It can be seen as a complication of alveolar rupture near the hilus, when air dissects along the bronchovascular plane instead of directly extravasating into the pleural cavity. The diagnosis is made by X-ray since patients exhibit few signs or symptoms. It may cause some chest pain, but usually does not affect pulmonary function. In some cases, the air may dissect up into the soft tissues of the neck and may produce subcutaneous emphysema. This is easily visible on physical exam, and palpation of the affected area will reveal crepitus. Other pleural abnormalities that may require intervention are pleural effusion and empyema. Pleural effusion is the accumulation of fluid within the pleural cavity. The presence of blood is called a hemothorax; the presence of lymph fluid, chylothorax. Clear, serous fluid can be from a number of sources. For example, a displaced central venous catheter allows IV fluids, serum, or total

parenteral nutrition to be infused into the pleural space. It must be withdrawn and examined if the source is not readily apparent or the patient is experiencing respiratory distress. Empyema is a pleural effusion that involves purulent material in the pleural cavity. It is caused by pneumonia, lung abscess, and iatrogenic contamination of the pleural cavity or contamination from the original injury.

Therapeutic Intervention
Any time the negative pressure in the pleural cavity is disrupted by the presence of air or fluid resulting in pulmonary compromise, the medical treatment is to drain the air or fluid. Fluid can be drained intermittently by thoracentesis (a needle is placed through the chest wall and fluid is withdrawn). If the fluid remains or reaccumulates, the procedure must be repeated. Patients with continuous air or fluid leaks that compromise ventilation and gas exchange may need to have a chest tube inserted for constant drainage. The chest tube (also called a thoracotomy tube or thoracic catheter) is sterile, flexible, vinyl, silicone, latex, or medical grade plastic nonthrombogenic catheter that is approximately 20 inches (50 cm) long and varies in size. Adults usually require a 16- to 24-guage chest tube for a simple pneumothorax, whereas a 28- to 36-guage tube is used to drain liquid accumulations. Smaller chest tubes are available for children. The end, which will be in the patients pleural space, has a number of drainage holes to prevent tip occlusion from clots or tissue, and the distal end connects to a chest drainage system. The drainage holes can usually be detected on chest x-ray as intermittent breaks in a radiopaque line. Once the chest tube has been properly positioned and secured, the x-ray should be checked to ensure that all drainage holes are inside the chest wall. The location of the chest tube will depend on what is being drained. If air must be drained, the tube will be placed near the apex of the lung at the second intercostals space in the mid-clavicular line, since free air in the pleural cavity will rise to the highest point possible. If fluid must be drained, the tube will be placed near the base of the lung, usually in the fourth to sixth intercostals space along the midaxillary line. This is because gravity will pull fluid down to the lung bases. In the event of a hemo pneumothorax, two chest tubes may be inserted, one anteriorly in the apex to remove air and one laterally at the base of the lung to drain fluid. When two chest tubes are used, they are frequently attached to a single chest drainage system by a Y connector. After open-heart surgery, one or two mediastinal tubes may be placed to drain blood in front of and behind the heart, positioned directly under the sternum. The specific technique of chest tube insertion depends on the operator and the clinical conditions. Generally though, the procedure starts with administration of pain medication and local anesthesia (unless the tube must be placed under emergency conditions or is inserted at the end of a surgical procedure). For a pleural tube, the incision is made in the chest wall where the tube will be inserted, and dissection is carried out through the intercostals muscles and over the rib to the parietal pleura. The parietal pleura is punctured with a hemostat, a finger is used to create the intrapleural tract and the chest tube is guided through the opening. This method is referred to as the blunt-dissection method. The trocar method uses a pointed trocar to penetrate the thoracic cavity. The chest tube is passed through the hollow trocar, which is then removed, and the chest tube is left in place.

Once the tube is in place, it may be sutured to the chest wall to minimize the risk of dislodgement and connected to a drainage device. The insertion site can be wrapped with petrolatum gauze depending on operator preference, and an airtight dressing will cover the site. Placement should be checked by chest x-ray as soon as possible. With lung or cardiac surgery, chest tubes are placed through the chest wall before closing, and the patient is sent to the recovery room or intensive care unit with the tube in place. Again, a chest x-ray will be taken and examined to check placement.

Drainage Systems
Closed chest drainage systems use gravity and/or suction to restore negative pressure and remove air, fluid, and/or blood from the pleural space so that the collapsed lung can re-expand. Whenever a chest tube is inserted it must be connected to a one-way mechanism that allows air to escape from the pleural space while preventing air to enter from the atmosphere. This can be accomplished by using an underwater seal mechanism. Traditionally, chest drainage was accomplished with a three-bottle chest drainage system. The three-bottle system has been replaced by various disposable units that incorporate the traditional functions of the three-bottle system and integrates them into one plastic unit. Disposable chest drainage systems have a number of safety advantages over glass bottle systems as well as ease in set-up. Air or fluid can exit the pleural space as a result of gravity, but the water seal prevents it from being drawn back into the cavity. The collection chamber is at the right side of the unit. The 6-foot tubing connects directly to the chest tube. Any fluid drainage from the chest goes into this chamber. It is usually calibrated in 1 ml increments up to 100 ml, 2 ml increments from 100 ml to 200 ml and 5 ml increments from 200 ml to 2500 ml. It has a surface that can be marked with the time and date of drainage. The water seal chamber is the middle chamber. When this chamber is filled with fluid up to the 2 cm line, a 2 cm water seal is established. A short latex tube at the top of this chamber is either left open to air for gravity drainage or attached to a suction source. The water seal chamber should have fluid gently bubbling immediately upon insertion of the chest tube, during expiration and with coughing. In addition to maintaining the original purpose of the water seal keeping air from entering the pleural cavity

the system has a calibrated manometer in the water seal chamber to measure the amount of negative pressure referred from the pleural cavity. The water level in the water seal manometer rises as intrapleural pressure becomes more negative. The water level in the water seal should be monitored routinely to check for evaporation. Continuous bubbling in this chamber indicates a leak in the system. Fluctuations in the water level in the water-seal chamber of 5 to 10 cm, rising (during inhalation) and falling (during expiration), should be observed with spontaneous respirations. If the patient is on mechanical ventilation, the pattern of fluctuation will be just the opposite. Additionally, if suction is being applied, this must be temporarily disconnected to correctly assess for fluctuations in the water-seal chamber. The systems have high negativity float valves in the top of the water seal chamber. This maintains the water seal in the event of high negative intrapleural pressures, as may occur with the deep breath taken before vigorous coughing, or with forced inspiration from an upper airway obstruction. High negativity can also occur if the chest tubing is stripped. High negativity is indicated by rising water in the water seal chamber. Depressing the high negativity relief valve will allow filtered air into the system, relieving negativity and allowing the water level to return to baseline in the water seal. In instances of falsely imposed high negative pressure, such as stripping chest tubes, water will continue to rise, filling the high negativity relief chamber at the top of the water seal chamber. This relief chamber will automatically vent excessive negative pressure, which will prevent respiratory compromise from accumulated negativity. Water spillover into the collection chamber is also minimized.

The systems also have positive pressure relief valves. They remain closed when suction is applied to the system, but open whenever pressure within the system becomes positive. Since the only way for air to leave the system is through the suction port, obstruction of the suction line (by rolling the bed on top of the tubing, for instance) could cause accumulation of air in the system

leading to tension pneumothorax. This safety feature not present in the glass-bottle system, allows venting of the positive pressure, minimizing the risk of a tension pneumothorax. The patient air leak meter is made up of a number of numbered columns, reading from 1 (low) to 7 (high). As air flow through the system increases, bubbling will occur toward the higher end of the scale. Decreasing flow will result in bubbling on the lower end of the scale. This feature provides an indication of air leak magnitude, allowing the clinician to monitor air leak increase or decrease as therapeutic interventions (such as adding or increasing PEEP) are made. The suction control chamber is the chamber on the left side of the unit. The units come with two mechanisms to regulate the amount of suction transmitted to the pleural space: wet or dry suction. Wet suction regulates the amount of suction by the height of a column of water in the suction control chamber. Note, it is the height of a column of water, not the setting of the suction source that actually limits the amount of suction transmitted to the pleural cavity. A suction pressure of 20 cm H2O is commonly recommended, but lower levels may be required for infants and for patients with friable lung tissue, or if ordered by the physician. To use wet suction, the suction control chamber is filled with sterile water to the desired height. Connect the tubing supplied with the unit to suction tubing, and then to the suction source. Adjust the source suction to produce gentle bubbling in the suction control chamber. The appearance of gentle bubbling assures you that the amount of suction set (by the height of the column of water) is the amount of suction being applied to the chest cavity; excess suction is vented through the bubbling. Increasing suction at the suction source will increase airflow through the system; it will have minimal effect on the level of suction imposed on the chest cavity. Excessive source suction will not only cause loud bubbling (which can disturb patients and caregivers), but will also hasten evaporation of water from suction control chamber; decreasing the suction applied to the chest cavity. Self-sealing diaphragms are provided to adjust the water level in this chamber should overfilling or evaporation occurs. The dry suction control chamber is even easier to use. Instead of regulating the level of suction with a column of water, suction is controlled by a self-compensating regulator. A dial on the side of the suction control chamber allows for the desired level of suction to be set according to the physicians order. As with the wet unit, the short tubing supplied with the unit is connected to the suction source. The source must provide a minimum of 20 LPM of airflow. Once connected to suction, increase the level of suction until the float appears in the suction indicator window. The visual confirmation of suction pressure provides the same assurance as the gentle bubbling (patient air leak) or changes in suction pressure (surge/decrease at the suction source). With the dry suction unit, the level of suction set can be increased at any time. Not all patients require suction. Suction may be discontinued to transport a patient; it may be discontinued 24 hours before chest tube removal. If suction is discontinued, make sure the suction tubing remains open to atmosphere to allow air to leave the drainage system unless suction is discontinued at the same time as the clamping of the chest tube.

Nursing Responsibilities
The Nurse has eight responsibilities: maintain an airtight system; prevent complications and infection; relieve the clients anxiety and discomfort;

teach the importance of turning, deep breathing and coughing; prevent postural deformities and contractures; record observations accurately; promote adequate gaseous exchange; and patient preparation by reinforcing patient information provided by the physician. If the patients chest tube insertion is performed under non-emergency conditions, it might be the nurses responsibility to ensure that adequate analgesia is provided and sterile technique is maintained throughout the procedure. Once the tube is in place, the dressing is secured, and the patient is safe, attention will focus on the chest tube and drainage system. The chest tube will be connected to the drainage system by approximately six feet of tubing. These tubing connections must be airtight; secure them with adhesive tape so they do not come apart. The tubing and the drainage system should be positioned below the patients chest at all times for gravity drainage and to prevent fluid backflow. It may be desirable to coil the long tubing and secure it to a draw sheet with a safety pin (allowing enough tubing so that the patient can move in bed comfortably) to prevent dangling loops of tubing. Check tubing connections periodically as directed by facility policy.

Documentation
During the first 2 hours after insertion of the chest tube, observe the fluid every 15-minutes. Observe the drainage every hour during the first 24 hours. After that time, observe the color consistency and amount of drainage every 8 hours. The amount can be estimated by marking the drainage chamber each time it is measured. Include the amount of drainage on the intake and output record. Documentation should include amount, color and presence of clots in the drainage. Document any abnormalities in the system and all interventions. The current respiratory status, including rate, rhythm, and breath sounds should be noted. Note the reaction of the client to the procedure as well as the amount of explanation and appropriate level of understanding and acceptance by client and family. The following is an example of documentation. Respiratory assessment is within normal limits. No complaint of shortness of breath; no signs of increased work of breathing. Breath sounds clear and equal bilaterally, but difficult to assess due to transmitted sounds from suction on drainage system. No evidence of subcutaneous emphysema; no hyper resonance to percussion. Drainage in collection chamber 10 ml of straw-colored fluid past 2 hours. Bubbling noted in water seal chamber. Assessment of drainage system and inspection of chest tube insertion site show no leaks. Fluid level in the suction control chamber is at 20 cm with gentle bubbling present. Clamping of chest tubes is generally not indicated, but it may be ordered prior to removing the chest tube or to locate the source of an air leak (indicated by continuous bubbling in the water-seal chamber). To clamp a chest tube, two covered or rubber-tipped Kelly clamps are attached to the tube in opposite directions near the insertion site. Once clamped, air and fluid will accumulate in the pleural space, and with no method to escape, a tension pneumothorax may result. Therefore, clamps should only be left on for less than a minute. To locate a leak, clamp the tubing at various points along its length. Once a clamp is located between the air leak and the water seal, the bubbling will stop. If the bubbling stops when the clamp is placed close to the chest, air may be escaping from the pleural space or from around the insertion site, and this should be reported. If the bubbling stops as the tubing is clamped along its length, check the connections to make sure they are airtight. If the bubbling does not stop, the chest drainage system may be defective and may need to be replaced. The chest tube may be clamped to keep air from entering the pleural space while the collection unit is being replaced, but it is safer to immerse the distal end of the tubing into a container of sterile water or normal saline to create a temporary water seal during replacement.

Assessment
Assess the respiratory status. Auscultate both lungs to assess the presence or return of breath sounds. Assess color (e.g., discoloration of the fingernails or around the lips) to detect signs of hypoxia. Observe for bilateral chest expansion. Because a disruption in the drainage system can cause a pneumothorax and/or a pleural effusion, assessment must be on-going. There are seven symptoms: shortness of breath; decreased breath sounds on one side; hyper resonance to percussion; lack of movement on that side of the chest; sustained increase in the inspiratory pressure on ventilators manometer; deviated trachea; and cardiovascular collapse. Chest tube assessment begins at the insertion site. Ensure that the dressing is intact, clean, and dry. Follow the tubing from the chest tube to the drainage system; making sure there are no kinks or leaks. Check that all tubing connections are taped securely. Make sure there are no hanging, dependent loops of tubing that could get caught on anything or, if the loops contain fluid, cause resistance to flow out of the chest. It is important to educate the patient and family about the importance of not kinking or catching the tubing on anything. Inspect the drainage system first looking at the collection chamber. Note the level and assess the character of the drainage; is it bloody, straw-colored, or purulent? What is the rate of drainage? Next look at the water seal chamber. Is the water level correct at 2 cm? Is there bubbling? It means air is getting into the system. It could mean a leak from the lung, from somewhere in the tubing, or at the chest wall insertion site. Investigate any significant increase or decrease in the bubbling. The air leak meter provides an objective indication of magnitude of airflow through the system. If there is no bubbling, the water level should rise and fall with the patients respiration. During spontaneous respirations, the water level should rise during inhalation and fall during exhalation. If the patient is receiving positive pressure ventilation, the oscillation will be just the opposite. The water level should fall with inhalation and rise with exhalation. The magnitude of the oscillation will also depend on how stiff the patients lungs are and how much of the intrapulmonary pressure is transmitted to the pleural cavity. Positive end expiratory pressure (PEEP) may dampen the oscillations. Again, it depends on how stiff the lungs are and how much PEEP is used. Oscillations may be absent if the lung is full expanded and suction has drawn the lung up against the holes in the chest tube. Inspect the suction control chamber. Make sure the water level is where it should be as determined by the doctors order or facility policy. Water can evaporate from this chamber so the level may drop; refill the chamber as necessary (turn off suction to refill). Make sure the suction source is set so you see the gentle bubbling in the suction control chamber. If suction is not being used, or the patient is being transported check to make sure the suction tubing is open to the atmosphere. The tubing should not be capped or clamped, nor should it be left connected to the suction device with the suction source turned off. The patients diagnosis and need for chest drainage will determine how often to repeat assessments. Assessment for patients with mediastinal drainage will be somewhat different. In addition to a respiratory assessment, a thorough cardiac assessment is essential. Signs of cardiac tamponade reflect decreased venous return; so much fluid collects around the

heart that it cannot expand to accept venous return. Subsequently, cardiac output drops severely. Jugular venous distention, increased central venous pressure (CVP), and falling blood pressure are ominous signs. As with all patients having chest drainage, dressings and tubing should be checked but with this patient the attention must be directed more toward the collection chamber, since the main purpose of mediastinal tube is to drain fluid from the mediastinum following heart surgery. It is important to monitor the rate of drainage from the mediastinum. A patient with only mediastinal tube should have no bubbling or fluctuations in the water seal chamber, since the tubes are not in contact with the pleural cavity. Bubbling usually indicates either a leak in the tubing or displacement of the chest tube. The water seal chamber should still be monitored for levels of negativity. Milking or striping of the chest tube is not done since both can create significant high negative pressures. Not only can this negativity pull the water up in the water seal chamber, but it can also put the patient at risk for mediastinal trauma and graft trauma depending on the precise location of the distal end of the chest tube within the mediastinum. Milking and stripping is the term used to mean gentle kneading of the tubing. The tube is alternately compressed and released in short sections, which causes momentary bursts of suction within the tubing. Stripping is a much more vigorous procedure during which long segments of the tubing are compressed and released. Stripping has been shown to cause dangerously high negative pressures (up to -400 cm H2O). This can cause damage to lung tissue and disruption of suture lines and should only be used with extreme caution. Many facilities no longer permit nurses to use routine milking or stripping to remove clots. Infection control concerns with chest tubes are varied. Gloves should be worn and hand washing should be done before and after handling the chest drainage system. The chest drainage procedure should be carried out under sterile conditions. The opening into the chest wall provides a means of access for pathogenic organisms. Cover the wound with an antiseptic ointment and sterile dressing. The water in the chest drainage system must be sterile to prevent the chance of contamination. If the tube becomes disconnected, use sterile scissors to trim off the contaminated ends and insert a sterile 5-in-1 connector. Care must be used when collecting drainage specimens from a chest tube drainage system. Auto-transfusion-capable units have a self-sealing sampling port in the connectors on the six-foot patient tube. Fresh specimens for laboratory analysis can be withdrawn using a blunt or needle-less access device. Units not used for auto-transfusion have a self-sealing diaphragm on the back of the collection chamber that allows removal of drainage fluid safely and easily. A blunt or needle-less system can be used to withdraw fluid. Do not take a specimen from the connecting tubing. The tubing is not self-sealing, and a needle puncture could create a leak. If a hemothorax is draining through a thoracostomy tube into a collection system containing sterile normal saline the blood is available for auto transfusion.

Complications
Critical situations can occur in patients with chest tubes. In pleural cavity drainage, the major hazard is tension pneumothorax. The most likely cause is obstructed tubing between the water seal chamber and the patient. Most collection systems have a positive pressure relief valve in the water seal chamber that allows venting of excess pressure in the pleural cavity, so any blockage causing symptoms will be proximal to the valve, that is, between the patient and the drainage system. Rapid assessment and intervention is required. The physician should be notified and if the source of the obstruction cannot be found the entire drainage system may need to be replaced. The physician may need to do a needle thoracostomy to vent the pleural pressure and prevent mediastinal shift while the cause of the pneumothorax is determined. Two critical situations likely to be encountered in patients with mediastinal tubes are either sudden hemorrhage or sudden cessation of drainage. Sudden hemorrhaging in a postoperative cardiac patient is likely caused by a ruptured suture line or blown graft. The patient can lose 1000 1500 ml of blood in a matter of minutes. The surgeon should be called immediately and the patient should be prepared to return to the operating room. The other problem, a sudden (not gradual) cessation of drainage can be caused by the accumulated clotted blood, which has occluded the mediastinal tube. This situation can lead to cardiac tamponade. Another concerning situation is the disruption of the chest tube drainage system. The decision whether to clamp a chest tube when the drainage system has been knocked over and disconnected or otherwise disrupted is based on the initial assessment of the water seal chamber. If there has been no bubbling in the water seal, you can deduce there is no air leak from the lung.

Therefore, the tube may be clamped for the short time it takes to reestablished drainage (either by reconnecting the tubes or by replacing the drainage system if contamination has occurred). If there has been bubbling and the assessment has determined there is an air leak from the lung, the chest tube MUST NOT BE CLAMPED. Doing so will cause air to accumulate in the pleural cavity since the air has no means of escape. This can rapidly lead to tension pneumothorax. The entry of a small amount of air into the pleural cavity is not as dangerous as the potential for tension pneumothorax if the tube is clamped. A patient with mediastinal tubes should also be evaluated before clamping. If the patient has copious drainage, clamping the tube could lead to cardiac tamponade. If there is minimal drainage, the tube may be clamped only for the short time it takes to set up a new drainage system. Tubing clamps must be used. Standard clamps can be used after first covering them with rubber or taping the teeth to prevent damage to the chest tube. The chest tube should not be clamped during transport or ambulation unless the drainage system becomes disrupted during patient movement. Even then, clamping the tube is only appropriate if there has been no evidence of an air leak. Clamping a tube through which there has been an air leak. Clamping a tube through which there has been an air leak can cause tension pneumothorax. Some physicians prefer to clamp a patients pleural chest tube before it is removed. The patient is then monitored for respiratory distress, which may indicate reaccumulation of pneumothorax. A chest X-ray may also be taken to assess how well the patient will tolerate chest tube removal. The clamp should be removed and drainage re-established if the patient develops respiratory distress.

Summary
Exchange of oxygen and carbon dioxide in the lungs depends on effective ventilation and adequate circulation of blood through both lungs. The amount of surface area available for diffusion greatly affects gaseous exchange. Ventilation brings oxygen into the lungs where it is released into the alveoli in exchange for carbon dioxide, which has been deposited by the capillaries. If ventilation is not uniform throughout both lungs, the rate of oxygen replenishment is reduced, leading to hypoxia. This situation occurs in pneumothorax. Chest drainage systems evacuate air and or fluid and permit re-expansion of the lungs.

References
Aherns, T. & Prentice, D. (2002). McGraw-Hill Medical Publishing Divisions, New York. Critical Care Certification 4th Edition (2002) Preparation, Review and Practice Exams. Nettina, S. M. (21996). Lippincott Manual of Nursing Practice (6th Ed.). Philadelphia, PA: J. B. Lippincott Wieck, L., King E. & Dyer, M. (1999). Illustrated Manual of Nursing Techniques (4th Ed.). Philadelphia, PA: J. B. Lippincott

Chest Tube Care and Monitoring

TERMINAL LEARNING OBJECTIVE

Given a scenario in a holding or ward setting, involving a patient with a chest tube, identify procedures for chest tube care and monitoring IAW the Textbook of Basic Nursing, Lippincott

Introduction Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing the lung to collapse. Air or fluid may leak into the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to promote drainage of air and fluid. Chest tubes are used after chest surgery and chest trauma and for pnuemothorax or hemothorax to promote lung re-expansion

Terms and definitions

a. b.

Pneumothorax collection of air in the pleura space Hemothorax an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually as the result of trauma Chest tubes a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures

c.

Chest Tube Systems

a.

Pleur-Evac chest drainage system (1) (2) (3) One-piece molded plastic unit that duplicates the three-chambered system Cost effective There must be bubbles flowing in the suction control portion of the unit to provide suction to the patient

b.

Pleur-Evac Set Up (1) (2) (3) (4) (5) Fill water seal chamber Fill suction control chamber Attach tube to suction source Tape all the connections Provide sterile tube for connection to patient

c.

Procedure for Proper Usage of the Heimlich Valve (1) Heimlich valve is a plastic, portable one-way valve used for chest drainage, draining into a vented bag Equipment (a) (b) (c) (d) (e) (f) (3) Heimlich valve Kelly clamps - 2 (rubber-tipped) Vented drainage bag or ostomy bag Ostomy tape or rubber band Suction setup (if applicable) Clean scissors

(2)

Procedure Steps (a) (b) (c) Gather equipment and bring to patient area Wash hands Don gloves. Nonsterile gloves are acceptable as long as sterile technique is maintained while the connection is being made.

(4)

Heimlich Valve To Chest Tube (a) Place rubber-tipped Kelly clamps in opposite directions on the proximal end of the chest tube as near to the patient as possible Connect the chest tube to the blue end of the Heimlich valve using sterile technique

(b)

CAUTION:

Only the blue end of the Heimlich valve can be connected to the chest tube. If the clear end is connected, the one-way valve will be in the wrong position and no drainage will take place.

(c)

Tape the connection site at both ends of the valve using 2 inch cloth tape.

CAUTION:

When two chest tubes are present, two Heimlich valves must be used to ensure proper functioning of chest tubes.

(d)

Monitor and record character of drainage and patency of valve in nursing progress notes.

CAUTION:

Measure all drainage in a calibrated cylinder for accurate readings.

(e)

Record drainage output on I & O graphic every 8 hours. If conditions permit.

Care of patients with chest tubes

a.

Assess patient for respiratory distress and chest pain, breath sounds over affected lung area, and stable vital signs Observe for increase respiratory distress Observe the following:

b. c.

(1) (2) (3) d.

Chest tube dressing, ensure tubing is patent Tubing kinks, dependent loops or clots Chest drainage system, which should be upright and below level of tube insertion

Provide two shodded hemostats for each chest tube, attached to top of patients bed with adhesive tape. Chest tubes are only clamped under specific circumstances: (1) (2) To assess air leak To quickly empty or change collection bottle or chamber; performed by soldier medic who has received training in procedure To change disposable systems; have new system ready to be connected before clamping tube so that transfer can be rapid and drainage system reestablished To change a broken water-seal bottle in the event that no sterile solution container is available To assess if patient is ready to have chest tube removed (which is done by physicians order); the solider medic must monitor patient for recreation of pneumothorax

(3)

(4)

(5)

e.

Position the patient to permit optimal drainage (1) (2) Semi-Flowers position to evacuate air (pneumothorax) High Flowers position to drain fluid (hemothorax)

f.

Maintain tube connection between chest and drainage tubes intact and taped (1) (2) Water-seal vent must be without occlusion Suction-control chamber vent must be without occlusion when suction is used

g.

Coil excess tubing on mattress next to patient. Secure with rubber band and safety pin or systems clamp Adjust tubing to hang in straight line from top of mattress to drainage chamber. If chest tube is draining fluid, indicate time (e.g., 0900) that drainage was begun on drainage bottles adhesive tape or on write-on surface of disposable commercial system (1) (2) Strip or milk chest tube only per MD/PA orders only Follow local policy for this procedure

h.

Problems solving with chest tubes a. Problem: Air leak (1) Problem: Continuous bubbling is seen in water-seal bottle/chamber, indicating that leak is between patient and water seal (a) (b) (c) (d) (2) Locate leak Tighten loose connection between patient and water seal Loose connections cause air to enter system. Leaks are corrected when constant bubbling stops

Problem: Bubbling continues, indicating that air leak has not been corrected (a) Cross-clamp chest tube close to patients chest, if bubbling stops, air leak is inside the patients thorax or at chest tube insertion site Unclamp tube and notify physician immediately! Reinforce chest dressing

(b) (c)

Warning:

Leaving chest tube clamped caused a tension pneumothorax and mediastinal shift

(3)

Problem: Bubbling continues, indicating that leak is not in the patients chest or at the insertion site (a) Gradually move clamps down drainage tubing away from patient and toward suction-control chamber, moving one clamp at a time When bubbling stops, leak is in section of tubing or connection distal to the clamp Replace tubing or secure connection and release clamp

(b)

(c) (4)

Problem: Bubbling continues, indicating that leak is not in tubing (a) (b) Leak is in drainage system Change drainage system

b.

Problem: Tension pneumothorax is present

(1)

Problems: Severe respiratory distress or chest pain (a) (b) Determine that chest tubes are not clamped, kinked, or occluded. Locate leak Obstructed chest tubes trap air in intrapleural space when air leak originates within patient

(2)

Problem: Absence of breath sounds on affected side (a) Notify physician immediately

(3)

Problems: Hyperresonance on affected side, mediastinal shift to unaffected side, tracheal shift to unaffected side, hypotenstion or tachycardia (a) (b) Immediately prepare for another chest tube insertion Obtain a flutter (Heimlich) valve or large-guage needle for short-term emergency release or air in intrapleural space Have emergency equipment (oxygen and code cart) near patient

(c) (4)

Problem: Dependent loops of drainage tubing have trapped fluid (a) (b) Drain tubing contents into drainage bottle Coil excess tubing on mattress and secure in place

(5)

Problem: Water seal is disconnected (a) (b) Connect water seal Tape connection

(6)

Problem: Water-seal bottle is broken (a) Insert distal end of water-seal tube into sterile solution so that tip is 2 cm below surface Set up new water-seal bottle If no sterile solution is available, double clamp chest tube while preparing new bottle

(b) (c)

(7)

Problem: Water-seal tube is no longer submerged in sterile fluid (a) (b) Add sterile solution to water-seal bottle until distal tip is 2 cm under surface Or set water-seal bottle upright so that tip is submerged

SUMMARY Caring for a patient with a chest tube requires problem solving and knowledge application. Remember, a chest tubes is a catheter inserted through the thorax to remove air and fluids from the pleural space and to reestablish normal intrapleural and intrapulmonic pressures. When caring for and maintaining a patient with a chest tube, it is important to note the patency of chest tubes, presence of drainage, presence of fluctuations, patient's vital signs, chest dressing status, type of suction, and level of comfort.

ung surgery
Page 1856 in Black Pulmonary resection: Wedge resection: removal of a small, localized area of diseased tissue. The tissue removed is minimal and contains no bronchioles or alveoli. Structure and function are often unchanged after healing Segmental resection: A section of lung is removed to include a part of a bronchiole and its alveoli. The remaining tissue over expands to fill the dead space. Lobectomy: An entire lobe of the lung is removed. Again the remaining space is filled by the over expansion of the remaining lung. Pneumoectomy: An entire lung is removed. The phrenic nerve is often severed to paralyze the diaphragm in an elevated position to help fill the empty space. Ribs may also be removed to help fill the empty cavity. The serous fluid that accumulates is left in the cavity to help prevent the shift of the mediastinum, heart and remaining lung.

Chest Tubes: Placed in the chest cavity during lung surgery. Once the pleural space is entered, atmospheric air changes the pressure of the pleural space from is normally negative pressure to a positive pressure. This causes a pneumothorax. To help correct that two chest tubes are placed during all chest surgery to exclude a pneumonectomy. (because we want that lung to stay collapsed). The first and usually smaller tube is placed between the the 2nd and 3rd intercostal space to permit the escape of air rising in the pleural space. The second and generally larger tube is to drain the serosanguineous fluid from the chest cavity. These tubes can be connected in a Y or left separate and then connected to a closed chest drainage system.

Page 1857 of Black

How to splint a chest wound to promote effective coughing and deep breathing: 1. Place one hand around the Pts back and the other around the incisional area.

2. Support the area below the incision with one hand while exerting downward pressure on the shoulder on the affected side with the other hand OR 3. Have the Pt hug a pillow during forced expiratory cough

Pages 1857-1866 of Black How to maintain closed-chest drainage: In closed-chest drainage the system is airtight, or closed, to prevent the inflow of atmospheric pressure. The basic principles are as follows. 1. Promote evacuation of air and serosanguineous fluid from the pleural space and prevent reflux of the atmospheric air into the pleural space. 2. Help reexpand the remaining lung tissue by reestablishing normal negative pressure in the pleural space. 3. Prevent mediastinal shift and pneumothorax by equalizing pressure on the two sides of the thoracic cavity. The closed drainage system has three main compartments 1. The collection chamber-collects the drainage and measures the volume, rate, and consistency. Measure and document the amount of drainage. Chest drainage is grossly bloody immediately after surgery. This should not continue for longer than several hours. Fluid volume should raise and tube patency should be check regularly to ensure proper drainage. 2. The water seal chamber- a one-way valve that allows air and drainage to leave the pleural space but not return. Air and fluid travel through the drainage tubes and enter the water seal chamber, bubbling up into the atmosphere on expiration. Constant bubbling indicates an air leak. Fluctuation of the water within the water seal chamber during respiration is called tidaling. Rise with inspiration and fall with expiration. All seals must be tight to ensure that atmospheric air does not enter the chamber and cause the lung to collapse. 3. The suction control chamber-using suction to assist drainage from the pleural cavity and help the lung reexpand. Suction at 10 to 20 cm H2O may be applied to the chest drainage system if gravity is not doing the trick. Suction is regulated by the

amount of water in the water seal chamber. The more water in the chamber the more pressure created. Closed-chest drainage systems should be placed lower than the pts chest so that gravity can assist in drainage. If suction is greater than 50 cm H2O this can cause lung damage. Milking-to squeeze or twist a chest tube intermittently to remove blood clots and promote drainage. Stripping-stabilize the tubing with the non-dominant hand and with the dominant hand gently squeeze and slide the drainage (blood, pus, blood clots) down the tubing to remove the obstruction and promote drainage.

What type of lung surgery does not require chest tube drainage? A. Wedge Resection B. Lobectomy C. Pneumonectomy D. Segmental Resection

neumothorax

y y y y y

What is the Definition of Pneumothorax? Description of Pneumothorax Symptoms of Pneumothorax Treatment for Pneumothorax What Questions to ask Your Doctor About Pneumothorax?

What is the Definition of Pneumothorax?

Pneumothorax is a collection of air or gas in the pleural space of the lung, causing the lung to collapse. Pneumothorax may be the result of an open chest wound that permits the entrance of air, the rupture of an emphysematous vesicle on the surface of the lung, a severe bout of coughing, or it may occur spontaneously without evident cause.

top ^

Description of Pneumothorax
The major types of pneumothorax are:

Open pneumothorax results when a penetrating chest wound enables air to rush in and cause the lungs to collapse. Closed pneumothorax results when the chest wall is punctured or air leaks from a ruptured bronchus (or a perforated esophagus) and eventually ruptures into the pleural space. Spontaneous pneumothorax occurs in a previously healthy individual with no prior trauma. This is thought to be due to rupture of a bleb (a blister containing air) on the surface of the lung. This spontaneous pneumothorax is most frequent in people under the age of 40. Pulmonary barotrauma occurs when a patient whose lung function is being maintained mechanically may have air forced into the lungs, which may rupture the pleural space. Other things can cause pneumothorax. Air can enter the mediastinum (the space in the center of the chest between the lungs), especially during an asthmatic attack, and then rupture into the pleural space, causing a pneumothorax. When a lung biopsy specimen is taken at the time of bronchoscopy or during thoracentesis (removal of fluid from the pleural space), the pleura lining the lung may be penetrated, causing a leak of air which may then cause a pneumothorax. top ^

Symptoms of Pneumothorax
There may be no symptoms if the pneumothorax is small (a small amount of air in the pleural space) or there may be shortness of breath if a large amount of air is in that space. If a physician suspects a pneumothorax, a chest x-ray may be taken to confirm the diagnosis and to determine the amount of air present.

top ^

Treatment for Pneumothorax

If the lung is less than 20 to 25 percent collapsed, the physician may choose to watch the progress by a series of chest x-rays until the air is completely absorbed or the lung completely re-expands.

If collapse of the lung exceeds 25 percent or if you are short of breath at rest, the physician may recommend removing the air through your chest wall. This can be done with a needle, but is better performed by inserting a tube and applying constant suction for 24 hours or more. The latter procedure also helps to prevent recurrence of pneumothorax. Pneumothorax in the Newborn Air leaks from the lungs into other parts of the chest cavity can occur in newborns, and it is a potentially serious problem. Small air leaks can occur in 1 to 2 percent of all births. Babies are normally born with collapsed lungs, and considerable pressure is generated as the newborn's body works to inflate them with the first few breaths. There is no problem whatsoever for 98 percent of all newborns, but in some babies, the lungs do not open completely at once, and the strong pressures generated to inflate the lung may cause small ruptures in the alveoli (the smallest, most plentiful breathing sacs). The leaked air may be removed from the chest cavity by the attending physician. Continuous removal of leaked air is necessary until the ruptures heal. top ^

What Questions to ask Your Doctor About Pneumothorax?

How much air is present in the lungs?

What percentage of the lung has collapsed? What type of treatment will you be recommending? Will treatment involve being hooked up to a machine and how often? Is the treatment painful? How long will full recovery take? What type of symptoms should be reported? If the lungs weaken, will they be susceptible to another type of pneumothorax? Will you be recommending any medication? Are there any side effects?

Pneumothorax
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Chest X-ray of Left-sided Tension Pneumothorax

ICD-10 ICD-9 DiseasesDB MedlinePlus eMedicine MeSH

J93., S27.0 512, 860 10195 000087 emerg/469 D011030

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Overview
In medicine (pulmonology), a pneumothorax, or collapsed lung, is a potential medical emergency caused by accumulation of air or gas in the pleural cavity, occurring as a result of disease or injury.[1]

Epidemiology and Demographics

Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males. The reason for this association, while unknown, is hypothesized to be the presence of subtle abnormalities in connective tissue. Some spontaneous pneumothoraces however, are results of "blebs", blister like

structures on the surface of the lung, that rupture allowing the escape of air into the pleural cavity. Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).

Pathophysiology and Etiology

The lungs are located inside the chest cavity, which is a hollow space. Air is drawn into the lungs by the diaphragm (a powerful abdominal muscle). The pleural cavity is the region between the chest wall and the lungs. If air enters the pleural cavity, either from the outside (open pneumothorax) or from the lung (closed pneumothorax), the lung collapses and it becomes mechanically impossible for the injured person to breathe, even with an open airway. If a piece of tissue forms a one-way valve that allows air to enter the pleural cavity from the lung but not to escape, overpressure can build up with every breath; this is known as tension pneumothorax. It may lead to severe shortness of breath as well as circulatory collapse, both life-threatening conditions. This condition requires urgent intervention.

Natural History
If left untreated, hypoxia may lead to loss of consciousness and coma. In addition, shifting of the mediastinum away from the site of the injury can obstruct the superior and inferior vena cava resulting in reduced cardiac preload and decreased cardiac output. Untreated, a severe pneumothorax can lead to death within several minutes.

Classification Scheme
Pneumothoraces are divided into tension and non-tension pneumathoraces.
y

A tension pneumothorax is a medical emergency as air accumulates in the pleural space with each breath. The increase in intrathoracic pressure results in massive shifts of the mediastinum away from the affected lung compressing intrathoracic vessels. A non-tension pneumothorax by contrast is a less severe pathology because there is no ongoing accumulation of air and hence no increasing pressure on the organs within the chest.

The accumulation of blood in the thoracic cavity (hemothorax) exacerbates the problem, creating a pneumohemothorax.

Diagnosis

History and Symptoms

Sudden shortness of breath, dry coughs, cyanosis (turning blue) and pain felt in the chest, back and/or arms are the main symptoms. In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound. The flopping sound of the punctured lung is also occasionally heard.

Physical Examination
Neck

Tracheal deviation may be present.

Lungs
The absence of audible breath sounds through a stethoscope can indicate that the lung is not unfolded in the pleural cavity. This accompanied by hyperresonance (higher pitched sounds than normal) to percussion of the chest wall is suggestive of the diagnosis. If the signs and symptoms are doubtful, an X-ray of the chest can be performed, but in severe hypoxia, emergency treatment has to be administered first.

Chest X Ray
In a supine chest X-ray the deep sulcus sign is diagnostic[2], which is characterized by a low lateral costophrenic angle on the affected side.[3] In layman's terms, the place where rib and diaphragm meet appears lower on an X-ray with a deep sulcus sign and suggests the diagnosis of pneumothorax. Images shown below are courtesy of RadsWiki and copylefted

Inspiration film

PTX is accentuated on expiration film

Acute desaturation Acute desaturation

Right deep sulcus sign

Chest CT

Patient with known PCP Patient with known PCP Patient with known PCP presents with acute shortness of presents with acute shortness of presents with acute shortness of breath breath breath

Left-sided pneumothorax (on the right side of the image) on CT scan of the chest. A chest tube is in place--side of chest, the lumen (black) can be seen adjacent to the pleural cavity (black) and ribs (white). The heart can be seen in the centre.

Complete Differential Diagnosis of Underlying Causes of Pneumothorax

Causes
y y y

Acupuncture Bacterial pneumonia with abscess Barotrauma

y y y y y y y y y y y y y y y y y y y y y y y y y y y y y y

Blunt trauma Bronchial asthma Cancer Catamenial pneumothorax (due to endometriosis in the chest cavity) Central bronchial carcinoma Coccidiomycosis Cystic Fibrosis Ehlers-Danlos Syndrome Emphysema Eosinophilic Granuloma Hydatid lung disease Lung emphysema Marfan's Syndrome Mechanical ventilation Medastinal emphysema Paragonimiasis Positive end expiratory pressure or PEEP Pneumoconiosis Penetrating trauma Pneumocystis carinii pneumonia Pseudoxanthoma elasticum Primary spontaneous pneumothorax Pulmonary lymphangiomatoid granulomatosis Pulmonary hemosiderosis Rheumatoid lung disease Rupture of cysts Sarcoidosis Spontaneously (most commonly in tall slim young males and in Marfan syndrome) Sudden chest compression Tuberculosis

Differential Diagnosis of Conditions that Pneumothorax must be Distinguished From

y

Acute Myocardial Infarction: presents with shortness of breath and chest pain, though MI chest pain is characteristically crushing, central and radiating to the jaw, left arm or stomach. While not a lung condition, patients having an MI often happen to also have lung disease. Emphysema: here, delicate functional lung tissue is lost and replaced with air spaces, giving shortness of breath, and decreased air entry and increased resonance on examination. However, it is usually a chronic condition, and signs are diffuse (not localised as in pneumothorax).

A careful history, physical examination and a chest x-ray will allow the conditions to be differentiated.

Treatment

Emergency Care Chest wound

Penetrating wounds require immediate coverage with an occlusive dressing, field dressing, or pressure bandage made air-tight with petroleum jelly or clean plastic sheeting. The sterile inside of plastic bandage packaging is good for this purpose; however any airtight material, even the cellophane of a cigarette pack, can be used. A small opening, known as a flutter valve, needs to be left open, so the air can escape while the lung reinflates. Any patient with a penetrating chest wound must be closely watched at all times and may develop a tension pneumothorax or other immediately life-threatening respiratory emergency at any moment. They cannot be left alone.

Blast injury or tension

If the air in the pleural cavity is due to a tear in the lung tissue (in the case of a blast injury or tension pneumothorax), it needs to be released. A thin needle can be used for this purpose, to relieve the pressure and allow the lung to reinflate.

Pre-hospital care
Many paramedics can perform needle thoracocentesis to relieve intrathoracic pressure. Intubation may be required, even of a conscious patient, if the situation deteriorates. Advanced medical care and immediate evacuation are strongly indicated. An untreated pneumothorax is an absolute contraindication of evacuation or transportation by flight.

Clinical treatment
Small pneumothoraces often are managed with no treatment other than repeat observation via Chest X-rays, but most patients admitted will have oxygen administered since this has been shown to speed resolution of the pneumothorax. [4] Pneumothoraces which are too small to require tube thoracostomy and too large to leave untreated, have been aspirated with a needle to remove the pressure, although this technique is usually reserved for tension pneumothoraces Larger pneumothoraces may require tube thoracostomy, also known as chest tube placement. If a thorough anesthetizing of the parietal pleura and the intercostal muscles is performed, the only major pain experienced should be either the injury that caused the pneumothorax or the reexpanding of the lung. Proper anesthetizing will come about after the needle has been inserted

into the chest cavity and a negative pressure is created in the syringe. While air bubbles rise into the syringe, the needle should be pulled out of the cavity until the bubbles cease. The tip of the syringe that contains the anesthetic is now in the intercostal muscles. A proper and sizable injection should ensue. This will allow the patient to be fairly comfortable despite a hemostat or finger being inserted into the chest cavity. A tube is then inserted into the chest wall outside the lung and air is extracted using a simple one way valve or vacuum and a water valve device, depending on severity. This allows the lung to re-expand within the chest cavity. This reexpansion usually lasts for approximately 15-30 seconds depending on the size of the pneumothorax and feels as if your breath has been taken away. This response is normal and should pass fairly quickly. The pneumothorax is followed up with repeated X-rays. If the air pocket has become small enough, the vacuum drain can be clamped temporarily or removed. If during the time that the tube is still in the chest the lung manages to not contiue to collapse once suction is turned off, but will diminish if actually clamped off, a heimlich valve may be used. This flutter valve allows air and fluid in the pleural cavity to escape the pleura into a drainage bag while not letting any air or fluid back in. This method was developed by the military in order to get soldiers with lung injuries stable and out of the battle field faster. It is a rarely used medical device in treatment in patients these days, but will be used in order to allow the patient to leave the hospital. In the situation that the chest tube does not seem to be helping the healing of the lung or if CAT scans show the presence of "blebs" on the surface of the lung orthoscopic surgery may be done in order to staple the lung closed. Two small incisions are made in the back, one for a small camera and one for the tool used to seal the lung. When finished the wound is covered with a steri-strip and bandaged up. In case of penetrating wounds, these require attention, but generally only after the airway has been secured and a chest drain inserted. Supportive therapy may include mechanical ventilation. Recurrent pneumothorax may require further corrective and/or preventive measures such as pleurodesis. If the pneumothorax is the result of bullae, then bullectomy (the removal or stapling of bullae or other faults in the lung) is preferred. Chemical pleurodesis is the injection of a chemical irritant that triggers an inflammatory reaction, leading to adhesion of the lung to the parietal pleura. Substances used for pleurodesis include talc, blood]], tetracycline and bleomycin. Mechanical pleurodesis does not use chemicals. The surgeon "roughs" up the inside chest wall ("parietal pleura") so the lung attaches to the wall with scar tissue. This can also include a "parietal" pleurectomy, which is the removal of the "parietal" pleura; "parietal" pleura is the serous membrane lining the inner surface of the thoracic cage and facing the "visceral" pleura, which lies all over the lung surface. Both operations can be performed using keyhole surgery to minimise discomfort to the patient.

Spontaneous Pneumothorax
Spontaneous Pneumothorax can be classified as primary spontaneous pneumothorax and secondary spontaneous pneumothorax. In primary spontaneous pneumothorax, it is usually characterized by a rupture of a bleb in the lung while secondary spontaneous pneumothorax mostly occurs due to chronic obstructive pulmonary disease (COPD).

Primary spontaneous pneumothorax

A primary spontaneous pneumothorax may occur without either trauma to the chest or any kind of blast injury. This type of pneumothorax is caused when a bleb (an imperfection in the lining of the lung) bursts causing the lung to deflate. If a patient suffers two or more instances of a spontaneous pneumothorax, surgeons often recommend a bullectomy and pleurectomy. Primary spontaneous pneumothorax is most evident to people without any previous history of lung disease and in tall, thin men whose age is between 20 to 40 years old. But it can often occur in teenagers and young adults.

Secondary spontaneous pneumothorax

A known lung disease is present in secondary spontaneous pneumothorax[5]. The most common cause is chronic obstructive pulmonary disease (COPD). However, there are several diseases that may lead to spontaneous pneumothorax:
y y y y y y y y

COPD Tuberculosis Pneumonia Asthma Cystic fibrosis Lung cancer Interstitial lung disease Marfan's Syndrome

History

Management of Pneumothorax
General

Observation should be the treatment of choice for primary spontaneous small closed pneumothoraces without significant breathlessness, in a spontaneously breathing patient. Inhalation of high concentrations of oxygen may speed the resolution of a pneumothorax by reducing the partial pressure of nitrogen in the pulmonary capillaries. This should increase the pressure gradient between the pleural cavity and pleural capillaries, so increasing the absorption of air from the pleural cavity. The rate of re-absorption of spontaneous pneumothoraces is 1.25 1.8% of the volume of hemithorax every 24 h.[11] Symptomatic patients should not be left without intervention regardless of the size of the pneumothorax on a chest radiograph. Other considerations include the need for positive pressure ventilation, impending anaesthesia and surgery (nitrous oxide diffuses into air collections and increases pressure/volume), transport in or outside the hospital, and altitude changes (including air transport).

Aspiration

Simple aspiration is recommended as first-line treatment for all primary pneumothoraces requiring intervention but is less likely to succeed in secondary pneumothoraces. In the latter situation, it is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients. Pleural aspiration is performed after strict aseptic precautions with the patient in the supine position. The aspiration is carried out in the fourth inter-costal space in the anterior axillary line. The site is infiltrated with lidocaine and an 18-G i.v. cannula is inserted into the pleural cavity. The needle is withdrawn and three-way stopcock connected to the i.v. cannula. A 50 ml syringe and i.v. tubing with its end under a water seal are connected to the cannula through the three-way tap. Air is aspirated and expelled by means of the tubing and its volume noted. The end point of the procedure is a feeling of resistance to aspiration or if the patient begins to cough excessively. The patient will usually get a sensation that the lung has expanded. The i.v. cannula is withdrawn and entry site sealed. Avoid using a needle alone, as the lung will become lacerated as it expands towards the needle. Advanced Trauma Life Support guidelines recommend the use of a cannula of 36 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. However, in 57% of patients with tension pneumothorax, the thickness of the chest wall has been found to be >3 cm. Therefore, it is recommended that a cannula length of at least 4.5 cm should be used in needle thoracocentesis of tension pneumothoraces.[12] The cannula should be left in place until bubbling is confirmed in a formal chest drain with underwater seal to indicate proper function of the intercostal tube. We encourage clinicians, wherever possible, to ascertain by imaging that a pneumothorax is present before inserting such cannulae. Otherwise, it is inevitable that the needle will enter the lung and produce an air leak.
Chest Drains and Closed Underwater Systems

If simple aspiration of any pneumothorax is unsuccessful in controlling symptoms, an intercostal tube should be inserted. Intercostal tube drainage is recommended in secondary pneumothorax except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax. Small bore drains are as effective for air drainage as large bore drains and are more comfortable for patients. If there is associated blood, a large bore drain will be required. There are no large randomized, controlled trials directly comparing small and large bore drains. The most common position for chest tube insertion is in the mid-axillary line, through the safe triangle illustrated in Figure 4. This position minimizes risk to underlying structures such as the viscera and internal mammary artery and avoids damage to muscle and breast tissue resulting in unsightly scarring. A more posterior position may be chosen if suggested by the presence of a loculated collection. While this is relatively safe, it is not the preferred site as it is more uncomfortable for the patient to lie on after insertion and there is more risk of the drain kinking.

Figure 4.

The 'safe triangle' for inserting a chest drain.

(Enlarge Image) [ CLOSE WINDOW ]

Figure 4. The 'safe triangle' for inserting a chest drain.

For apical pneumothoraces, the second intercostal space in the mid-clavicular line is sometimes chosen; it is not recommended routinely, as it may be uncomfortable for the patient, may leave an unsightly scar, and internal mammary vessels are at risk. If the drain is to be inserted into a loculated pleural collection, the position of insertion will be dictated by the site of the locule as determined by imaging. A common mistake is to insert drains too low in the chest risking damage to the diaphragm, liver, spleen, and heart. The drain should not be removed until bubbling has ceased, and chest radiography demonstrates lung re-inflation. There is no evidence that clamping a chest drain at the time of its removal is beneficial. The use of high-volume/low-pressure suction pumps has been advocated in cases of nonresolving pneumothorax or after chemical pleurodesis; however, there is no evidence to support its routine use in the initial treatment of spontaneous pneumothorax. If suction is required, this

should be performed through the underwater seal at a level of 1020 cm H2O. A high-volume pump is required to cope with a large leak.
Prevention Strategies

There are two methods used to prevent recurrence of pneumothoraces: (i) medical pleurodesis (installing talc/bleomycin by a chest drain) and (ii) surgical pleurodesis (parietal pleura is mechanically abraded/stripped). Both techniques produce fibrosis and scarring so that the visceral pleura adheres to the chest wall obliterating the pleural space and prevents further pneumothorax.
Bronchopleural Fistula

A bronchopleural fistula is a communication between the bronchial tree and pleural space. Clinically, it may be best described as a persistent air leak or a failure to re-inflate the lung despite chest tube drainage for 24 h. Causes include chest trauma, complications of diagnostic or therapeutic procedures (e.g. thoracic surgery with a failure of suture/staple line), chest drains inserted into the lung parenchyma, and complications of mechanical ventilation. The main problems with a large fistula in a ventilated patient are the loss of delivered tidal volume, inability to apply PEEP, persistent lung collapse, and delayed weaning from assisted ventilation. Management strategies include general conservative measures such as large bore chest drains (multiple if necessary) and the use of drainage system with adequate capabilities. In mechanically ventilated patients, the goal is to maintain adequate ventilation and oxygenation while reducing the fistula flow to allow the leak to heal. This includes reducing inspiratory pressures, tidal volumes, respiratory rate, PEEP, and inspiratory times, and accepting permissive hypercapnia and lower oxygen saturations. Most air leaks will settle spontaneously over a few days if the patient can be weaned onto spontaneous respiration without high levels of continuous positive airways pressure (CPAP). The size of the air leak is critical; small tears or punctures will heal quickly while larger structural damage to the lung or a major bronchus will not settle with conservative management, particularly if high inflation pressures are required for associated lung injury. The use of other modes of ventilation including high-frequency ventilation, oscillation, and differential lung ventilation through double-lumen tubes has been reported. For proximal leaks, fibreoptic bronchoscopy and direct application of sealants (e.g. cyanoacrylate, fibrin agents, gelform) have been tried with limited success. Refractory cases need surgical repair of the air leak by thoracoplasty, lung resection/stapling, pleural abrasion/decortication, or other techniques.

Management of Pneumothorax
General

Observation should be the treatment of choice for primary spontaneous small closed pneumothoraces without significant breathlessness, in a spontaneously breathing patient. Inhalation of high concentrations of oxygen may speed the resolution of a pneumothorax by

reducing the partial pressure of nitrogen in the pulmonary capillaries. This should increase the pressure gradient between the pleural cavity and pleural capillaries, so increasing the absorption of air from the pleural cavity. The rate of re-absorption of spontaneous pneumothoraces is 1.25 1.8% of the volume of hemithorax every 24 h.[11] Symptomatic patients should not be left without intervention regardless of the size of the pneumothorax on a chest radiograph. Other considerations include the need for positive pressure ventilation, impending anaesthesia and surgery (nitrous oxide diffuses into air collections and increases pressure/volume), transport in or outside the hospital, and altitude changes (including air transport).
Aspiration

Simple aspiration is recommended as first-line treatment for all primary pneumothoraces requiring intervention but is less likely to succeed in secondary pneumothoraces. In the latter situation, it is only recommended as an initial treatment in small (<2 cm) pneumothoraces in minimally breathless patients. Pleural aspiration is performed after strict aseptic precautions with the patient in the supine position. The aspiration is carried out in the fourth inter-costal space in the anterior axillary line. The site is infiltrated with lidocaine and an 18-G i.v. cannula is inserted into the pleural cavity. The needle is withdrawn and three-way stopcock connected to the i.v. cannula. A 50 ml syringe and i.v. tubing with its end under a water seal are connected to the cannula through the three-way tap. Air is aspirated and expelled by means of the tubing and its volume noted. The end point of the procedure is a feeling of resistance to aspiration or if the patient begins to cough excessively. The patient will usually get a sensation that the lung has expanded. The i.v. cannula is withdrawn and entry site sealed. Avoid using a needle alone, as the lung will become lacerated as it expands towards the needle. Advanced Trauma Life Support guidelines recommend the use of a cannula of 36 cm long to perform needle thoracocentesis for life-threatening tension pneumothorax. However, in 57% of patients with tension pneumothorax, the thickness of the chest wall has been found to be >3 cm. Therefore, it is recommended that a cannula length of at least 4.5 cm should be used in needle thoracocentesis of tension pneumothoraces.[12] The cannula should be left in place until bubbling is confirmed in a formal chest drain with underwater seal to indicate proper function of the intercostal tube. We encourage clinicians, wherever possible, to ascertain by imaging that a pneumothorax is present before inserting such cannulae. Otherwise, it is inevitable that the needle will enter the lung and produce an air leak.
Chest Drains and Closed Underwater Systems

If simple aspiration of any pneumothorax is unsuccessful in controlling symptoms, an intercostal tube should be inserted. Intercostal tube drainage is recommended in secondary pneumothorax except in patients who are not breathless and have a very small (<1 cm or apical) pneumothorax.

Small bore drains are as effective for air drainage as large bore drains and are more comfortable for patients. If there is associated blood, a large bore drain will be required. There are no large randomized, controlled trials directly comparing small and large bore drains. The most common position for chest tube insertion is in the mid-axillary line, through the safe triangle illustrated in Figure 4. This position minimizes risk to underlying structures such as the viscera and internal mammary artery and avoids damage to muscle and breast tissue resulting in unsightly scarring. A more posterior position may be chosen if suggested by the presence of a loculated collection. While this is relatively safe, it is not the preferred site as it is more uncomfortable for the patient to lie on after insertion and there is more risk of the drain kinking.
Figure 4.

The 'safe triangle' for inserting a chest drain.

(Enlarge Image) [ CLOSE WINDOW ]

Figure 4. The 'safe triangle' for inserting a chest drain.

For apical pneumothoraces, the second intercostal space in the mid-clavicular line is sometimes chosen; it is not recommended routinely, as it may be uncomfortable for the patient, may leave an unsightly scar, and internal mammary vessels are at risk. If the drain is to be inserted into a loculated pleural collection, the position of insertion will be dictated by the site of the locule as

determined by imaging. A common mistake is to insert drains too low in the chest risking damage to the diaphragm, liver, spleen, and heart. The drain should not be removed until bubbling has ceased, and chest radiography demonstrates lung re-inflation. There is no evidence that clamping a chest drain at the time of its removal is beneficial. The use of high-volume/low-pressure suction pumps has been advocated in cases of nonresolving pneumothorax or after chemical pleurodesis; however, there is no evidence to support its routine use in the initial treatment of spontaneous pneumothorax. If suction is required, this should be performed through the underwater seal at a level of 1020 cm H2O. A high-volume pump is required to cope with a large leak.
Prevention Strategies

There are two methods used to prevent recurrence of pneumothoraces: (i) medical pleurodesis (installing talc/bleomycin by a chest drain) and (ii) surgical pleurodesis (parietal pleura is mechanically abraded/stripped). Both techniques produce fibrosis and scarring so that the visceral pleura adheres to the chest wall obliterating the pleural space and prevents further pneumothorax.
Bronchopleural Fistula

A bronchopleural fistula is a communication between the bronchial tree and pleural space. Clinically, it may be best described as a persistent air leak or a failure to re-inflate the lung despite chest tube drainage for 24 h. Causes include chest trauma, complications of diagnostic or therapeutic procedures (e.g. thoracic surgery with a failure of suture/staple line), chest drains inserted into the lung parenchyma, and complications of mechanical ventilation. The main problems with a large fistula in a ventilated patient are the loss of delivered tidal volume, inability to apply PEEP, persistent lung collapse, and delayed weaning from assisted ventilation. Management strategies include general conservative measures such as large bore chest drains (multiple if necessary) and the use of drainage system with adequate capabilities. In mechanically ventilated patients, the goal is to maintain adequate ventilation and oxygenation while reducing the fistula flow to allow the leak to heal. This includes reducing inspiratory pressures, tidal volumes, respiratory rate, PEEP, and inspiratory times, and accepting permissive hypercapnia and lower oxygen saturations. Most air leaks will settle spontaneously over a few days if the patient can be weaned onto spontaneous respiration without high levels of continuous positive airways pressure (CPAP). The size of the air leak is critical; small tears or punctures will heal quickly while larger structural damage to the lung or a major bronchus will not settle with conservative management, particularly if high inflation pressures are required for associated lung injury. The use of other modes of ventilation including high-frequency ventilation, oscillation, and differential lung ventilation through double-lumen tubes has been reported. For proximal leaks, fibreoptic bronchoscopy and direct application of sealants (e.g. cyanoacrylate, fibrin agents,

gelform) have been tried with limited success. Refractory cases need surgical repair of the air leak by thoracoplasty, lung resection/stapling, pleural abrasion/decortication, or other techniques.

Table of Contents

Section Previous 7 of 7 Page

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Introduction Pathophysiology Causes of Pneumothorax Subcutaneous Emphysema, Pneumomediastinum, and Pneumopericardium Barotrauma and Mechanical Ventilation Investigations Management of Pneumothorax

[ CLOSE WINDOW ] References 1. Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med 2000; 342: 86874 2. Donahue DM, Wright CD, Viale G, Mathisen DJ. Resection of pulmonary blebs and pleurodesis for spontaneous pneumothorax. Chest 1993; 104: 17679 3. Ohata M, Suzuki H. Pathogenesis of spontaneous pneumothorax. With special reference to the ultrastructure of emphysematous bullae. Chest 1980; 77: 7716 4. Manning HL. Peak airway pressure: why the fuss? Chest 1994; 105: 2427 5. Ross IB, Fleiszer DM, Brown RA. Localized tension pneumothorax in patients with adult respiratory distress syndrome. Can J Surg 1994; 37: 4159 6. Macklin CC. Transport of air along sheaths of pulmonic blood vessels from alveoli to mediastinum: clinical implications. Arch Intern Med 1939; 64: 91326 7. Brander L, Ramsay D, Dreier D. Continuous left hemidiaphragm sign revisited: a case of spontaneous pneumopericardium and literature review. Heart 2002; 88: 55464 8. Petersen GW, Baier H. Incidence of pulmonary barotrauma in a medical ICU. Crit Care Med 1983; 11: 679 9. Gordon R. The deep sulcus sign. Radiology 1980; 136: 2527.3 10. Henry M, Arnold T, Harvey J. BTS guidelines for the management of spontaneous pneumothorax. Thorax 2003; 58: 3952 11. Northfield TC. Oxygen therapy for spontaneous pneumothorax. Br Med J 1971; 4: 868 12. Britten S, Palmer SH, Snow TM. Needle thoracocentesis in tension pneumothorax: insufficient cannula length and potential failure. Injury 1996; 27: 3212 [ CLOSE WINDOW ] Table 1. Common Causes of Secondary Pneumothorax

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Authors and Disclosures

Elankumaran Paramasivam, MRCP, Locum Consultant in Respiratory Medicine, Leeds General Infirmary, Leeds LS1 3EX, UK Andrew Bodenham, FRCA, Consultant in Anaesthesia and ICM, Anaesthetic department, Leeds General Infirmary, Leeds LS1 3EX, UK

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Correspondence: Andrew Bodenham, FRCA, Tel: +44 (0)113 392 2321 Fax: +44 (0)113 392 5682 E-mail: andy.bodenham@leedsth.nhs.uk Cont Edu Anaesth Crit Care & Pain. 2008;8(6):204-209. 2008 Oxford University Press