Chest Drains

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Chest Drains

  1. 1. CHEST DRAINS Presenter: Dr.Nishad.P.K Moderator :Prof: Lokesh AIIMS , NewDelhi
  2. 2. Anatomy <ul><li>Pleural fluid separates parietal and visceral pleural surfaces </li></ul><ul><li>Amount of pleural fluid in 24 hrs:0.3ml/kg or 25 ml </li></ul><ul><li>Natural tendency of lung to recoil v/s adherence of pleura </li></ul><ul><li>Negative intrapleural pressure keeps the lung expanded </li></ul><ul><ul><li>during inspiration :-8cmH2O </li></ul></ul><ul><ul><li>expiration:-4cmH2O </li></ul></ul><ul><li>Air, fluid or blood in pleural cavity disruption of –ve IPP </li></ul><ul><li>leads to lung collapse </li></ul>Lung Visceral pleura Parietal pleura
  3. 3. Physiology <ul><li>Inspiration </li></ul><ul><li>Expiration </li></ul>
  4. 4. Indications <ul><li>Emergency </li></ul><ul><li>Pneumothorax </li></ul><ul><ul><ul><li>Tension ptx after needle decompression </li></ul></ul></ul><ul><ul><ul><li>Pt on MV </li></ul></ul></ul><ul><ul><ul><li>Large </li></ul></ul></ul><ul><ul><ul><li>Clinically unstable </li></ul></ul></ul><ul><ul><ul><li>Recurrent/persistent </li></ul></ul></ul><ul><ul><ul><li>Secondary to chest trauma </li></ul></ul></ul><ul><ul><ul><li>Iatrogenic </li></ul></ul></ul><ul><li>Traumatic hemopneumothorax </li></ul><ul><li>Esophageal rupture </li></ul><ul><li>Nonemergency </li></ul><ul><li>Malignant pleural effusion </li></ul><ul><li>Tx with sclerosing agents or pleurodesis </li></ul><ul><li>Recurrent PE </li></ul><ul><li>Parapneumonic effusion or empyema </li></ul><ul><li>Chylothorax </li></ul><ul><li>Postop care (eg: after esophageal, cardiac,pulmonary,mediastinal or pleural) </li></ul><ul><li>Post pneumonectomy bronchopleural fistula </li></ul>
  5. 5. Pleural effusion
  6. 6. Pre-drainage risk assessment <ul><li>Careful clinical evaluation </li></ul><ul><li>Differentiate between </li></ul><ul><li>Pneumothorax and bullous disease </li></ul><ul><li>Collapse and pleural effusion </li></ul><ul><li>Risk of hem/g: correct any coagulopathy /platelet defect </li></ul><ul><li>Contraindications </li></ul><ul><li>Absolute </li></ul><ul><ul><ul><li>Lung completely adherent to chest wall </li></ul></ul></ul><ul><li>Relative </li></ul><ul><ul><ul><li>Bleeding diathesis </li></ul></ul></ul><ul><ul><ul><li>Pt on anticoagulants </li></ul></ul></ul>
  7. 7. <ul><li>Pneumothorax Lung bulla </li></ul>
  8. 8. Chest drainage systems <ul><li>Goals </li></ul><ul><li>Remove the fluid and/or air as quickly as possible </li></ul><ul><li>Prevent drained air and/or fluid from re entering the chest cavity </li></ul><ul><li>Re expand the lungs and restore normal negative intra pleural pressure </li></ul><ul><li>Components </li></ul><ul><li>Chest tube </li></ul><ul><li>Flexible patient tubing </li></ul><ul><li>Drainage system made up of three compartments </li></ul><ul><ul><li>collection chamber </li></ul></ul><ul><ul><li>water seal chamber </li></ul></ul><ul><ul><li>suction control chamber </li></ul></ul>
  9. 9. Chest tubes <ul><li>20 inches long,4-6 eyelets, radio opaque line </li></ul><ul><li>Three types </li></ul><ul><li>1.Thoracotomy chest tube- Straight, right angled </li></ul><ul><li>Silicon / PVC </li></ul><ul><li>2.Trocar chest tube (2-3 eyelets) </li></ul><ul><li>3.Malecot catheter </li></ul>
  10. 10. Chest tubes
  11. 11. Chest tube size <ul><li>Size : </li></ul><ul><li>Infants and young children :8-12 F </li></ul><ul><li>Children and young adults:16-20 F </li></ul><ul><li>Most adults :24-32 F </li></ul><ul><li>Large adults : 36-40 F </li></ul><ul><li>Diameter depends on </li></ul><ul><li>Size of pt </li></ul><ul><li>Type of drainage (air/fluid) </li></ul><ul><li>Duration of drainage </li></ul>
  12. 12. Patient tubing <ul><li>6 foot tube connects chest tube to collection chamber </li></ul><ul><li>Clear ,flexible and sufficiently strong </li></ul><ul><li>Adv: 1. pt can turn and move in bed </li></ul><ul><li>2.minimize the chance that a deep breath could draw drainage back up into chest </li></ul>b c a a b c
  13. 13. Physics and physiological aspects <ul><li>Flow depends on </li></ul><ul><li>1.Length of tube </li></ul><ul><li>2.Inner diameter of tube </li></ul><ul><li>3.Amount of negative pressure applied </li></ul><ul><li>Air : </li></ul><ul><li>laminar flow :Hagen–Poiseuille equation </li></ul><ul><li>V = π R 4 Δ P/8 η L </li></ul><ul><li>Hydropneumothorax : </li></ul><ul><li>Turbulent flow : Fanning equation </li></ul><ul><li>V = π 2 r 5 P/fl </li></ul>
  14. 14. One bottle chest drainage system <ul><li>Water seal –low resistance one way valve </li></ul><ul><li>Positive pressure > +2cm H2O </li></ul><ul><li>Tidalling –pressure changes in the pleural space with breathing seen as fluctuations </li></ul><ul><li>Combination of water seal and fluid collecton bottle </li></ul>Tube from patient Tube open to atmosphere vents air
  15. 15. Physics and physiological aspects <ul><li>Distal end of drainage tube 2 cm below water </li></ul><ul><li>( the depth determines the hydrostatic pressure needed to overcome during expiration ) </li></ul><ul><li>Collection chamber always 100 cm below the chest </li></ul><ul><li>( to prevent the chamber fluid getting sucked up the tube during obstructed inspiration) </li></ul><ul><li>Large diameter collection chamber (20 cm diameter) </li></ul><ul><li>( to prevent loss of under water seal as water moves up the drainage tube during deep inspiration) </li></ul>
  16. 16. Two bottle chest drainage system <ul><li>Collection bottle and water seal </li></ul><ul><li>Amount and rate of fluid drainage can be measured </li></ul><ul><li>Water seal remain fixed </li></ul><ul><li>Rely on gravity to create pressure gradient </li></ul>Tube from patient Tube open to atmosphere vents air 2cm fluid Fluid drainage
  17. 17. Three bottle chest drainage system <ul><li>Straw under 20cm H2O </li></ul>Tube to vacuum source Tube open to atmosphere vents air Tube from patient Fluid drainage
  18. 18. Contd.. <ul><li>The depth of the water in the suction bottle determines the amount of negative pressure that can be transmitted to the chest, NOT the reading on the vacuum regulator </li></ul><ul><li>Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) </li></ul><ul><li>Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest </li></ul><ul><li>Suction can improve the speed at which air and fluid are pulled from the chest </li></ul>
  19. 19. Draw backs of three bottle system <ul><li>Bulky with 16 pieces and 17 connections </li></ul><ul><li>Lot of time to set up </li></ul><ul><li>Potential for error or contamination high </li></ul><ul><li>Expense for hospital to clean ,sterilize and track the processing </li></ul>
  20. 20. Disposable chest drainage systems <ul><li>In 1967, a one-piece, disposable plastic box was introduced </li></ul><ul><li>The box did everything the bottles did – and more </li></ul><ul><li>Compact, sterile and disposable </li></ul><ul><li>Chambers corresponds to bottle in three bottle system </li></ul>
  21. 21. From bottles to a box To suction From patient Suction control chamber Water seal chamber Collection chamber from patient Collection bottle Water seal bottle Suction control bottle
  22. 22. Contd… <ul><li>Collection chamber :Amount and rate of fluid drainage </li></ul><ul><li>Water seal chamber :Asymmetric u tube,one way valve,used to measure IPP </li></ul><ul><li>Dry seal chest drain: mechanical one way valve </li></ul><ul><li>Suction control chamber: protect the pt from excess suction pressure </li></ul><ul><ul><li>wet: regulate by height of column of water </li></ul></ul><ul><ul><li>dry: mechanical screw type valve: varies the size opening to vaccum source </li></ul></ul><ul><li>calibrated spring loaded self regulating mechanism </li></ul><ul><li>Positive pressure relief valve-that vent accumulated pressure >2cmH2O </li></ul>
  23. 23. Heimlich valve <ul><li>Mechanical one way valve </li></ul><ul><li>Allow air to escape from chest and prevent air from entering chest </li></ul><ul><li>Adv : Does not require water to operate </li></ul><ul><li>Not position sensitive </li></ul><ul><li>Early ambulation of the patient </li></ul><ul><li>Disadv : Less patient assessment information </li></ul><ul><li>Cannot see changes in IPP </li></ul>
  24. 24. From box to bedside
  25. 25. Our drainage systems a b c d
  26. 26. Setting up a chest drain system <ul><li>Thoracostomy </li></ul><ul><li>Setting up a drainage unit </li></ul><ul><li>Making proper connecting and applying suction </li></ul>
  27. 27. Equipments <ul><li>Sterile gloves and gown </li></ul><ul><li>Skin antiseptic solution </li></ul><ul><li>Sterile drapes </li></ul><ul><li>Gauze swabs </li></ul><ul><li>Syringes and needles </li></ul><ul><li>Local anesthetic </li></ul><ul><li>Scalpel and blade </li></ul><ul><li>Suture (“1” silk) </li></ul><ul><li>Dressing </li></ul><ul><li>Curved Kelly clamps </li></ul>
  28. 28. Equipments <ul><li>Chest tube </li></ul><ul><li>Connecting tubing </li></ul><ul><li>Closed drainage system </li></ul>
  29. 29. Patient preparation <ul><li>Explain the procedure </li></ul><ul><li>Informed written consent </li></ul><ul><li>Verify the site of abnormality </li></ul><ul><li>Mark the site on patient’s chest </li></ul><ul><li>Premedication </li></ul><ul><li>Monitor O2 saturation and supplemental O2 </li></ul>
  30. 30. Patient position <ul><li>Supine ,slightly rotated with arm on side of lesion behind patient’s head to expose the axillary area </li></ul><ul><li>Or sit upright leaning over an adjacent table with a pillow </li></ul><ul><li>Or lateral decubitus position </li></ul>
  31. 31. Insertion site <ul><li>Triangle of safety(in mid axillary line) - 4 th or 5 th ICS </li></ul><ul><ul><li>Ant.border of latissimus dorsi </li></ul></ul><ul><ul><li>Lateral border of pectoralis major </li></ul></ul><ul><ul><li>Line superior to horzontal level of nipple </li></ul></ul><ul><ul><li>Apex below axilla </li></ul></ul><ul><li>Midclavicular -2 nd ICS </li></ul><ul><ul><li>Thick pectoralis major –difficult to penetrate </li></ul></ul><ul><ul><li>Scar-cosmetic </li></ul></ul>
  32. 32. Direction of tube <ul><li>Air :anterior and superior (towards apex) </li></ul><ul><li>Fluid :posterior and inferior (towards base) </li></ul><ul><li>Surgical </li></ul><ul><li>Any tube position can be effective at draining air or fluid </li></ul><ul><li>and an effectively functioning chest tube should not be repositioned solely because of position in CXR </li></ul>
  33. 33. Procedure <ul><li>Strict aseptic technique Skin preparation </li></ul>
  34. 34. Procedure contd..
  35. 37. Suturing and sterile dressing
  36. 38. Improper chest tube fixation
  37. 39. Get a CXR done
  38. 40. Complications Wound infection Empyema Infective Drain failure(dislodgement,kinked,blocked) Re expansion pulmonary edema Bronchopleural fistula pneumothorax Positional Pain Placement outwith pleural cavity-( s/c,intra abdominal,solid organ) Puncture of solid organ (liver,spleen,heart,lung,oesophagus) Puncture of inter costal artery- hemothorax Insertion on incorrect side Inter costal neuralgia S/C emphysema Insertional
  39. 42. Patient care <ul><li>Respiration </li></ul><ul><ul><li>Rate, regularity, depth and ease </li></ul></ul><ul><ul><li>Breath sounds </li></ul></ul><ul><ul><li>Deep breaths and cough </li></ul></ul><ul><ul><li>Splintage of thoracic incision with pillow </li></ul></ul><ul><li>Knowledge level </li></ul><ul><li>Pain control </li></ul><ul><li>Vital signs </li></ul><ul><li>Patient position/movement </li></ul><ul><ul><li>Encourage movement </li></ul></ul><ul><ul><li>Gravity drainage v/s suction </li></ul></ul><ul><ul><li>If discontinued from suction tube should be open to air </li></ul></ul>
  40. 43. Patient care (contd …) <ul><ul><li>Keep drain below level of chest </li></ul></ul><ul><ul><li>High or semi fowler’s position </li></ul></ul><ul><ul><li>Avoid dependent loops in pt tubing </li></ul></ul><ul><ul><li>Chest tube should not be clamped during patient movement ambulation or trips </li></ul></ul><ul><ul><li>Clamp only to : </li></ul></ul><ul><ul><li>Locate air leaks </li></ul></ul><ul><ul><li>Simulate tube removal </li></ul></ul><ul><ul><li>Replace a drain </li></ul></ul><ul><ul><li>Connect and disconnect an inline auto transfusion bag </li></ul></ul><ul><ul><li>Milking with caution </li></ul></ul>
  41. 44. Patient care <ul><li>Chest tube site/dressing </li></ul><ul><ul><li>Dressing dry and intact </li></ul></ul><ul><ul><li>Palpate for s/c emphysema </li></ul></ul><ul><ul><li>If present ,take down the dressing and inspect site, look for the eyelets. </li></ul></ul><ul><li>Tubing </li></ul><ul><ul><li>Regular inspection for leaks, kink, dependent loops compression/occlusion </li></ul></ul><ul><li>Drain fluid </li></ul><ul><ul><li>Samples </li></ul></ul><ul><ul><li>Monitor volume, rate, colour and characteristics </li></ul></ul>
  42. 45. Patient care (contd…) <ul><li>Water seal </li></ul><ul><ul><li>Water seal is filled to appropriate level </li></ul></ul><ul><ul><li>Water level moves on patient breaths ( tidalling ) </li></ul></ul><ul><ul><li>If no : Kinked, clamped, lying on tubing </li></ul></ul><ul><li>Dependent fluid filled loop </li></ul><ul><li>Lung tissue or adhesions are blocking the eyelets </li></ul><ul><li>No more air leaking to pleural space and lung has re-expanded </li></ul><ul><li>To locate air leaks </li></ul><ul><li>Suction :check connections and tubing </li></ul><ul><li>typical suction level: -15 to – 20 cmH2O </li></ul>
  43. 46. Timing of chest tube removal <ul><li>Depends on indication </li></ul><ul><li>Pneumothorax </li></ul><ul><ul><li>Bubbling movement has ceased </li></ul></ul><ul><ul><li>Lung fully expanded in CXR </li></ul></ul><ul><ul><li>Controversial: Duration of observation </li></ul></ul><ul><ul><li>Clamping the tube </li></ul></ul><ul><ul><li>Get CXR 12-24 hrs after last air leak </li></ul></ul><ul><li>Pleural fluid drainage </li></ul><ul><ul><li>Volume < 100 ml in 24 hrs </li></ul></ul><ul><ul><li>Serous fluid </li></ul></ul><ul><ul><li>Lung re expanded and clinical status improved </li></ul></ul><ul><ul><li>No fresh or altered blood coming out of chest tube </li></ul></ul>
  44. 47. Removing the chest tube <ul><li>Explain the procedure to the patient </li></ul><ul><li>Prevent risk of pneumothorax </li></ul><ul><li>End expiration v/s end inspiration </li></ul><ul><li>If on MV :End expiration </li></ul><ul><li>Two people – Instruct the patient and pull the tube </li></ul><ul><li>_ Occlude the insertion site </li></ul><ul><li>Tighten the suture and occlusive dressing </li></ul><ul><li>CXR 12 -24 hrs after removal </li></ul>
  45. 48. Removing the chest tube
  46. 49. Looking towards future-mobile chest drains <ul><li>Facilitate early ambulation </li></ul><ul><li>Reduce hospital stay </li></ul><ul><li>Air alone-oneway valve:Heimlich valve </li></ul><ul><li>For both fluid and air :mini chest drain </li></ul>

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