PRESENTED BY:

 Review of the pleural space

 Indications for chest tubes
◦ Pleural Effusions
 Types of pleural effusions
 Transudate
 Exudate
 Empyema
Pneumothorax
◦ Treatments
 Thoracentesis
 Tube thoracostomy
 Surgical thoracotomy
Chest Tubes
 How they work
Pleural Membrane
 Visceral Pleural
 Attaches to the lungs surface and doubles back at the hilard
region.
 Parietal Pleural
 Starts at the hilard region where the visceral pleural doubles
back.
 It covers the ribs, diaphragm and the mediasteinum.

The Pleural space

It is the space between the pleural membranes
It is about 10-20 mm in width and it is filled with serous fluid.
 Serous fluid is typically pale yellow and
transparent, and of a benign nature, that fill the
inside of body cavities such as the pleural space.
 Serous fluid is secreted by small blood vessels in

the pleural lining.

 The serous fluid between the two layers acts as a

lubricant and reduces friction from muscle

movement.
 The average amount of fluid in each hemithorax is
about 8ml
 The normal protein concentration is 1.3-1.4g/dl
◦ Pressure within the pulmonary capillaries and lymphatic
system.
◦ Bulk Flow
 Bulk flow is how fluid with proteins without “sorting signals”
travels from compartment to compartment.
 Once the fluid had reached the “ bulk” concentration of proteins,
the osmotic pressure changes allowing the fluid flow.
 The pleural fluid is then removed via bulk flow from the pleural
space to small holes in the parietal pleura called stoma.
 The fluid flows from the stoma to the intercostal lymphatic
vessels, to the mediastinum, lymph nodes, thoracic duct and
empty into the subclavian vein where the fluid is removed.

The System is continuously producing and reabsorbing pleural

fluid.
 Pleural Effusions
 Empyema
 Pneumothorax
◦ Definition
Excess fluid that accumulates in the pleural cavity
◦ How does fluid accumulate?
Production of excess fluid
 Transudative
 Exudative
Blockage of the drainage system
The excess fluid in the pleural space becomes
diluted.
◦ Protein level decreased by more than 50% and the
LDH (lactate dehydrogenase) drops more than 60%
◦ Hydrostatic and oncotic pressures of the serous
fluid in the pleural space decrease.
◦ Pleural fluid is unable to be reabsorbed
◦ Fluid accumulates
Definition: fluids of inflammatory origin and are
characterized by:
◦ Increased protein concentration ( > 3 g/dl)
◦ LDH Increases from damaged tissue and dead leukocytes
◦ Fibrinogen is present and fluid may clot
◦ Excess leukocytes
◦ Glucose concentration is decreased
◦ Bacteria may be present
◦ Blood may be present from hemorrhage or tumor

What can cause an exudative effusion?

◦ Bacterial pneumonia
◦ Cancer
◦ Pulmonary embolism
◦ Viral infection
◦ Tuberculosis
 Lungs or pleura become compromised
◦ The immune systems calls in the inflammatory
proteins and white blood cells to help defend
against pathogens.
 The excess proteins cause clotting
◦ Clots can form fibrin strands
◦ The strands can go between the visceral and
parietal membranes and cause clotting.
◦ Fluid is unable to be reabsorbed through the
parietal membrane.
 Thoracentisis
◦ This is a procedure that can be done bedside
◦ A needle is inserted in the pleural space
percutaneouly
◦ The needle is inserted superior to the rib.
◦ One syringe is enough to test the fluid.

A gram stain culture can be done on the fluid to

determine if pleural space has an infection.
Trasudate:
 Total protein = <3.0g/dL
 LDH <200 IU
 WBC <1000 uL
 Clear

Exudate:
 Total protien = >3.0g/dL
 LDH >200 IU
 WBC >1000/uL
 Cloudy
Definition: Infected pleural effusion: Pus in the
pleural space: Often secondary to bacterial
Pneumonia.
◦ Fluid can build to a pint or more.
◦ In severe cases the pus ball can develop a fibrotic
covering that can attach itself to the wall of the
pleural lining.
 Definition:
◦ Air in the pleural space
 Can enter from outside the body
 Blunt trauma, penetrating trauma
 Disruption of the visceral pleural which allows air from
the lungs to enter the pleural space.
 Spontaneous
 Too much positive pressure:
PNEUMOTHORAX
 Thoracentesis
 Tube Thoracostomy
 Surgical Thoracotomy
Thoracentesis
 Drainage of a pleural effusion or pneumothorax by
inserting a needle into the pleural space so that the
fluid and/or air can be aspirated (suctioned) out
into a container.
◦ This relieves the pressure on the lungs and makes
breathing easier.
 Thoracentesis is most appropriate for free-flowing
pleural fluid accumulations and mild
pneumothorax.
 The chest tube is inserted into the pleural
space between the ribs on the patient's side.
 The skin and underlying tissue to the pleural

membrane is anesthetized using a small

needle, very similar to thoracentesis.
 An incision is made into the skin, and the

underlying tissue is separated until the

pleural space is entered.
 A tube, is inserted in the pleural space.
 This tube is sutured into place.
 Tubes are generally placed in the “safe
Triangle”
◦ The anterior border of the latissimus dorsi
◦ Lateral border of the pectorals major muscle
◦ A line superior to the horizontal level of the nipple
◦ An apex below the axillary
 Want placement to be above where the
diaphragm rises on inspiration.
◦ Between the 4th-7th intercostal space
◦ Aim the tube apically for a pneumothorax
◦ Aim basally for fluid

Apical pneumonthorax
Second intercostal space in the mid clavicular
line, anterior.
Not done often due to patient discomfort and
ugly scaring.
Surgical Thoracotomy
◦ Procedure done to access the thoracic organs
 Heart
 Lungs
 Esopogus
 Aorta
 Anterior spine
 A surgical thoracotomy is performed through a
6- to 8-inch incision in the chest.
 A thoracotomy removes all of the fibrous tissue
and aids in evacuating the infection from the
pleural space.
 Patients will require chest tubes for 2 days to 2
weeks after surgery to continue draining fluid
 Tubes
◦ Long semi-stiff clear plastic tubes
◦ They are between 7 and 40 French
 Larger tubes are used to drain puss and blood .
 Single container
◦ Tube goes from the patient to a collection container
with an air vent.
 Problem: Air could be sucked back up the tube and
back into the pleural space.
 Solution: Need a one way valve on the distal end of the
tube.
 Add water to the container then place the distal end of a
long the tube into the container.
 This creates as seal and solves problem #1
 What happens if there is more then just air
draining from the pleural space?
 Second container

◦ The first container can now collect fluid.

◦ The second container now becomes the seal.
 A tube connects the first container to a second
container with a measured amount of water in it to
form the a seal.
◦ The air vent is now in the second bottle
 Now lets add some suction to the system.
 Problem: The suction from the wall, even with

a regulator may be way too much suction.

 Solution: Add a third bottle.

◦ The third bottle is connected by a tube to the

second container and connected to the wall suction.
In the middle of the container there is a tube that
vents excess suction.
◦ The third bottle is filled with a prescribed amount
of water.
◦ The weight of the water acts as a suction limiter.
 No matter how hard the wall suction pulls,
the actual suction delivered to the patient is
only as hard as the amount required to pull
air out past the fixed weight of the water.
 The unused suction then pulls air in from

outside the container through a vent.

 Only need enough suction for the water to

bubble gently. More then needed only makes

unnecessary noise.
 Chest tube collection container
 If a chest tube gets pulled out, never put it
back in, call the doctor.
 If there is not condensation on the inside of

the collection container then there problem

has been cleared.
 Never close the suction valve
 Never pull up on the tube
Chest tube care has been taken over by the
nursing staff however being that they are
used to clear up respiratory complications, it
is important for us to have an understanding
of when they are indicated, where they are
inserted and how the systems works.
I hope this has helped to give you a basic
understanding of the indications for chest
tubes and how the system works.
 www.icufaqs.org/ChestTubes.doc
 http://en.wikipedia.org/wiki/Pleural_effusion
  hhp://en.wikipedia.org/wiki/Serous_fluid
 http://my.clevelandclinic.org/disorders/pleural_effusion/ts_overview.aspx
  http://en.wikipedia.org/wiki/Thoracentesis
 http://www.trauma.org/archive/thoracic/CHESTdrain.html
 http://thorax.bmj.com/content/58/suppl_2/ii53.full

http://my.clevelandclinic.org/services/tracheostomy/hic_tracheal_suction_gu
idelines.aspx
 Eagans, Fundamentals of Respiratory care
 http://www.fpnotebook.com/ER/Procedure/ChstTb.htm