{"id":5236,"date":"2011-06-16T01:52:36","date_gmt":"2011-06-16T01:52:36","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5236.htm\/"},"modified":"2011-10-02T20:05:39","modified_gmt":"2011-10-02T20:05:39","slug":"chest-drainage-systems","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/procedures\/chest-drainage-systems.htm\/","title":{"rendered":"Chest Drainage Systems"},"content":{"rendered":"<p><strong><\/strong><br \/>\n<strong> TRADITIONAL CHEST DRAINAGE<\/strong><\/p>\n<p>In 1967, Deknatel introduced the first integrated<br \/>\ndisposable chest drainage unit based on the threebottle<br \/>\nsystem. Now that we have reviewed normal<br \/>\nanatomy, physiology, and pathophysiology, let\u2019s<br \/>\ndiscuss each of the three chambers in detail.<\/p>\n<p><strong> COLLECTION CHAMBER<\/strong><\/p>\n<p>At the right side of the unit is the collection chamber<br \/>\n(figure 13, D). The patient tubing connects the<br \/>\ndrainage unit directly to the chest tube. Any drainage<br \/>\nfrom the chest flows into this chamber. The collection<br \/>\nchamber is calibrated and has a write-on surface to<br \/>\nallow for easy measurement and recording of the<br \/>\ntime, date, and amount of drainage.<\/p>\n<p><strong> WATER SEAL CHAMBER<\/strong><\/p>\n<p>The middle chamber of a traditional chest drainage<br \/>\nsystem is the water seal. The main purpose of the<br \/>\nwater seal is to allow air to exit from the pleural<br \/>\nspace on exhalation and prevent air from entering<br \/>\nthe pleural cavity or mediastinum on inhalation.<br \/>\nWhen the water seal chamber is filled with sterile fluid<br \/>\nup to the 2 cm line, a 2 cm water seal is established<br \/>\n(figure 14). To maintain an effective seal, it is<br \/>\nimportant to keep the chest drainage unit upright at<br \/>\nall times and to monitor the water level in the water<br \/>\nseal to check for evaporation.<\/p>\n<p>Bubbling in the water seal chamber indicates an air<br \/>\nleak. The patient air leak meter indicates the approximate degree of air leak from the chest cavity<br \/>\n(figure 14). The meter is made up of numbered<br \/>\ncolumns, labeled from 1 (low) to 7 (high). The higher<br \/>\nthe numbered column through which bubbling<br \/>\noccurs, the greater the degree of air leak. By<br \/>\ndocumenting the number, the clinician can monitor<br \/>\nair leak increase or decrease.<\/p>\n<p>The water seal chamber also has a calibrated<br \/>\nmanometer to measure the amount of negative<br \/>\npressure within the pleural cavity (figure 13, F). The<br \/>\nwater level in the small arm of the water seal rises as<br \/>\nintrapleural pressure becomes more negative.<br \/>\nIf there is no air leak, the water level should rise and<br \/>\nfall with the patient\u2019s respirations, reflecting normal<br \/>\npressure changes in the pleural cavity. During<br \/>\nspontaneous respirations, the water level should rise<br \/>\nduring inhalation and fall during exhalation. If the<br \/>\npatient is receiving positive pressure ventilation, the<br \/>\noscillation will be just the opposite \u2014 the water level<br \/>\nshould fall with inhalation and rise with exhalation.<br \/>\nThis oscillation is called tidaling and is one indicator<br \/>\nof a patent pleural chest tube.<\/p>\n<p>At the top of the water seal chamber is a high<br \/>\nnegativity float valve and high negativity relief<br \/>\nchamber (figure 13, C). These safety features maintain<br \/>\nthe water seal in the event of high negative pressures.<\/p>\n<p>Three situations can cause high negative pressure:<br \/>\n1. The patient in respiratory distress, coughing<br \/>\nvigorously, or crying;<br \/>\n2. Chest tube stripping;<br \/>\n3. Decreasing or disconnecting suction .<\/p>\n<p>High negativity is indicated by rising water in the<br \/>\nsmall arm of the water seal chamber. If the water rises<br \/>\nbeyond \u201320 cm, the high negativity float valve will<br \/>\nrise and impede the flow of water, allowing the<br \/>\npatient to develop as much negativity as needed for<br \/>\ninspiration. In instances of falsely imposed high<br \/>\nnegative pressure, such as stripping chest tubes,<br \/>\nwater will continue to rise, filling the high negativity<br \/>\nrelief chamber. The relief chamber automatically vents<br \/>\nexcessive negative pressure, thus preventing<br \/>\nrespiratory compromise from accumulated negativity.<\/p>\n<p>Vigorous milking or stripping can create dangerously<br \/>\nhigh negative pressures. Research has documented<br \/>\nnegative pressures as high as \u2013450 cm H2O. Pleurevac<br \/>\nprevents accumulation of excessive high<br \/>\nnegative pressure as discussed above; however, the<br \/>\ntransient high negative pressures created by vigorous<br \/>\nstripping can put the patient at risk for mediastinal<br \/>\ntrauma and graft trauma. Use extreme caution and<br \/>\nfollow your hospital policy.<\/p>\n<p>A manual high negativity relief valve is located on top<br \/>\nof chest drainage systems (figure 15). Depressing the<br \/>\nhigh negativity relief valve allows filtered air into the<br \/>\nsystem, relieving negativity and allowing the water<br \/>\nlevel to return to baseline in the water seal. Use the<br \/>\nhigh negativity relief valve with caution. If suction is<br \/>\nnot operative, or if operating on gravity drainage,<br \/>\ndepressing the high negativity relief valve can reduce<br \/>\nnegative pressure within the collection chamber to<br \/>\nzero (atmosphere) with the resulting possibility of a<br \/>\npneumothorax.<\/p>\n<p><strong> WET SUCTION CONTROL<\/strong><\/p>\n<p>The chamber on the left side of the unit is the suction<br \/>\ncontrol chamber (figure 13, H). Traditional chest<br \/>\ndrainage units regulate the amount of suction by the<br \/>\nheight of a column of water in the suction control<br \/>\nchamber. Note: it\u2019s the height of water, not the<br \/>\nsetting of the suction source, that actually limits the<br \/>\namount of suction transmitted to the pleural cavity. A<br \/>\nsuction pressure of \u201320 cm H2O is commonly<br \/>\nrecommended. Lower levels may be indicated for<br \/>\ninfants and for patients with friable lung tissue, or if<br \/>\nordered by the physician.<\/p>\n<p>In a wet suction control system such as the Pleur-evac<br \/>\nA-7000\/A-8000 series, fill the suction control chamber<br \/>\nto the desired height with sterile fluid. Connect the<br \/>\nshort suction tubing to a suction source, and adjust<br \/>\nthe source suction to produce gentle bubbling in the suction control chamber. Increasing suction at the<br \/>\nsuction source will increase airflow through the<br \/>\nsystem, but will have minimal effect on the amount<br \/>\nof suction imposed on the chest cavity.<br \/>\nExcessive source suction not only causes loud<br \/>\nbubbling (which can disturb patients and caregivers),<br \/>\nbut also hastens evaporation of water from the<br \/>\nsuction control chamber. This results in a lower<br \/>\namount of suction applied to the patient as the level<br \/>\nof water decreases. Self-sealing diaphragms are<br \/>\nprovided to adjust the water level in this chamber.<\/p>\n<p><strong> NEW GENERATION CHEST DRAINS<\/strong><\/p>\n<p><strong> DRY SUCTION<\/strong><\/p>\n<p>The next step in the evolution of chest drainage units<br \/>\nwas the development of dry suction control<br \/>\nchambers. Dry suction control systems provide many<br \/>\nadvantages: higher suction pressure levels can be<br \/>\nachieved, set-up is easy, no continuous bubbling<br \/>\nprovides for quiet operation, and there is no fluid to<br \/>\nevaporate which would decrease the amount of<br \/>\nsuction applied to the patient.<\/p>\n<p>Instead of regulating the level of suction with a<br \/>\ncolumn of water, the dry suction units are controlled<br \/>\nby a self-compensating regulator. A dial to set the<br \/>\nsuction control setting is located on the upper left<br \/>\nside of each unit. To set the suction setting, rotate<br \/>\nthe dial until the red stripe appears in the<br \/>\nsemi-circular window at the prescribed suction level<br \/>\nand clicks into place. Suction can be set at \u201310, \u201315,<br \/>\n\u201320, \u201330, or \u201340 cm of water. The unit is pre-set at<br \/>\n\u201320 cm of water when opened (figure 16).<\/p>\n<p>Connect the short suction tubing or suction port to<br \/>\nthe suction source. Source suction must be capable<br \/>\nof delivering a minimum of 16 liters per minute<br \/>\n(LPM) air flow. Increase suction source until the<br \/>\norange float appears in the suction control indicator<br \/>\nwindow.<\/p>\n<p>The unique design of the Pleur-evac dry suction control<br \/>\nimmediately responds to changes in patient pressure<br \/>\n(patient air leak) or changes in suction pressure<br \/>\n(surge\/decrease at the suction source). The setting of<br \/>\nthe suction control dial determines the approximate<br \/>\namount of suction imposed regardless of the amount<br \/>\nof source suction \u2014 as long as the orange float<br \/>\nappears in the indicator window.<\/p>\n<p>Patient situations that may require higher suction<br \/>\npressures of \u201330 or \u201340 cm H2O include: a large air<br \/>\nleak from the lung surface, empyema or viscous pleural<br \/>\neffusion, a reduction in pulmonary compliance, or<br \/>\nanticipated difficulty in expansion of the pulmonary<br \/>\ntissue to fill the hemithorax.<\/p>\n<p>In the presence of a large air leak, air flow through<br \/>\nthe Pleur-evac may be increased by increasing source<br \/>\nsuction, WITHOUT increasing imposed negativity. It is<br \/>\nnot necessary to change the suction setting on the<br \/>\nPleur-evac unit to accommodate high air flows.<br \/>\nThe suction control level can be changed at any time<br \/>\nas prescribed by simply rotating the dial to the new<br \/>\nsuction setting. Confirm that the orange float remains<br \/>\nin the suction control indicator window at the new<br \/>\nsuction setting. If suction setting is changed from a<br \/>\nHIGHER to a LOWER level, the patient negativity may<br \/>\nremain at the higher level unless the negativity is<br \/>\nrelieved. Use the manual high negativity relief valve to<br \/>\nreduce negativity to desired level.<\/p>\n<p>Both the wet suction and dry suction series of Pleurevac<br \/>\nhave a positive pressure relief valve that opens<br \/>\nwith increases in positive pressure, preventing<br \/>\npressure accumulation (figure 15). Normally, air exits<br \/>\nthrough the suction port. Obstruction of this route<br \/>\n(i.e. a bed wheel rolls on top of the suction tube, or<br \/>\nthe suction port is capped after suction discontinued)<br \/>\ncould cause accumulation of air in the system leading<br \/>\nto tension pneumothorax. This safety feature allows<br \/>\nventing of the positive pressure automatically, thus<br \/>\nminimizing the risk of tension pneumothorax.<\/p>\n<p><strong> ONE-WAY VALVE<\/strong><\/p>\n<p>In the Pleur-evac Sahara\u2122, (figure 17) a one-way valve<br \/>\nreplaces the traditional water seal. No water is<br \/>\nrequired to establish the one-way seal. Just connect<br \/>\nthe patient tube to the patient\u2019s thoracic catheter and<br \/>\nthe patient seal is established for patient protection.<br \/>\nThe one-way valve maintains the patient seal even if<br \/>\nthe unit is tipped over. Unlike a water seal system in<br \/>\nwhich the seal may be lost when the unit is tipped,<br \/>\nthe Sahara dry seal protects the patient from<br \/>\natmospheric air.<\/p>\n<p>If air leak diagnostics are desired, the patient air leak<br \/>\nmeter must be filled to the \u201cFill\u201d line. The fluid in the<br \/>\npatient air leak meter is used for air leak detection as<br \/>\ndescribed earlier and is not a water seal.<\/p>\n<p>In the Pleur-evac Sahara, negative pressure exists in<br \/>\nthe collection chamber when the YES can be seen in<br \/>\nthe indicator window (figure 18). During gravity<br \/>\ndrainage before normal negative pressure has been<br \/>\nre-established in the pleural cavity, the indicator may<br \/>\nintermittently indicate negative pressure with patient<br \/>\nrespiration. During suction drainage, the pressure<br \/>\nindicator should indicate a negative pressure<br \/>\ncontinuously. The negative pressure indicator does<br \/>\nnot confirm drainage tube patency. Routinely check<br \/>\nthe drainage tube patency.<\/p>\n<p>The Pleur-evac Sahara system also has an automatic<br \/>\nhigh negative pressure relief valve to limit the<br \/>\nnegative pressure to approximately \u201350 cm of H2O. A<br \/>\nmanual high negativity relief valve is also provided to<br \/>\nvent excessive negativity as described earlier.<\/p>\n<p><strong> GRAVITY DRAINAGE<\/strong><\/p>\n<p>Not all patients require suction. Suction may be<br \/>\ndiscontinued to transport a patient; it may also be<br \/>\ndiscontinued 24 hours before chest tube removal.<br \/>\nConsult hospital policy to determine if an order is<br \/>\nneeded to institute or discontinue suction. If suction is<br \/>\ndiscontinued, the suction tube or port should remain<br \/>\nUNCAPPED and free of OBSTRUCTIONS to allow air<br \/>\nto exit and minimize the possibility of tension<br \/>\npneumothorax.<\/p>\n<p><strong> TO CLAMP OR NOT TO CLAMP?<\/strong><\/p>\n<p>The decision whether to clamp a chest tube when<br \/>\nthe drainage system has been knocked over and<br \/>\ndisconnected or otherwise disrupted is based on your<br \/>\ninitial assessment of the water seal chamber and air<br \/>\nleak meter. If there has been no bubbling in the<br \/>\nwater seal, you can deduce there is no air leak from<br \/>\nthe lung. Therefore, the tube may be clamped for the<br \/>\nshort time it takes to reestablish drainage. If there has<br \/>\nbeen bubbling and your assessment has determined<br \/>\nthere is an air leak from the lung, you MUST NOT<br \/>\nclamp the chest tube. Doing so will cause air to<br \/>\naccumulate in the pleural cavity since the air has no<br \/>\nmeans of escape. This can rapidly lead to tension<br \/>\npneumothorax.<\/p>\n<p>The few times you should clamp a chest tube are<br \/>\nwhen: 1) You are performing a physician-ordered<br \/>\nprocedure such as sclerosing, 2) Assessing for a leak,<br \/>\nor 3) Prior to removing the chest tube to determine if<br \/>\nthe patient can do without the chest tube (with a<br \/>\nphysician order).<\/p>\n<p>You should never clamp a chest tube during patient<br \/>\ntransport unless the chest drainage system becomes<br \/>\ndisrupted during patient movement, and then only if<br \/>\nthere is no air leak.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Array<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","footnotes":""},"categories":[5],"tags":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v22.5 - 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